new technologies in caries diagnosis: the canary system in pediatric practice
DESCRIPTION
Shifting from a surgical approach in Dentistry to one of risk management and meaningful prevention because we know that when a lesion is left to extend until a filling is needed, the clinical opportunity for effective prevention is lost.TRANSCRIPT
NEW TECHNOLOGIES IN
CARIES DIAGNOSIS
The Canary System in
Pediatric Practice
Dr. Ian McConnachie AAPD Annual Session May 24-27, 2012
A couple of Gifts from the North
• No Commercial Interest or Reimbursement
from Quantum Dental Technologies
• Member of Unpaid Dentist Advisory Panel to
Quantum Dental Technologies
• Some slides provided by QDT
Disclosures
Acknowledgements
• DR. STEPHEN ABRAMS President and CEO of Quantum Dental Technologies • DR. MARIELLE PARISEAU Creator of www.ShapingTheFutureofDentistry.org Note: The current final version of this presentation will be available on the Shaping the Future of Dentistry website later this week. Look in Menu under Resources
Page 4
New Technologies in Caries Diagnosis
• Diagnodent by KaVo
• Caries ID by Dentsply
• Spectra by Air Techniques
• CarieScan by CarieScan Ltd
• The Canary System by Quantum Dental
Technologies
A Micro Review of Cariology Measuring and Recording Decay - The Current Reality The Shift in Dealing with Decay Newer Technologies Detecting Decay The Canary System Use of the Canary in Pediatric Dentistry – The 9 Month Story Canary-Ready for Prime Time?
Outline of the presentation
Early Carious Lesion in Enamel
ENAMEL SALIVA PLAQUE PLAQUE
Pathogenesis of Dental Caries (biological balances)
SUGARS
Polysaccharides
Bacterial Enzymes
Salivary buffers
Plaque buffers
Calcium Salts
Calcium Salts
ACID
mouth inside of tooth
Demineralization Re-mineralization
ENAMEL
THE CURRENT REALITY
• Visual Exam • Mirror and Explorer • Dental Radiographs • Transillumination • Dmfs/dmft
Measuring and recording decay
Methods for Caries Detection
Conventional methods
• Visual examination: + non-destructive + safe - poor resolution - unable to detect incipient demineralization - unable to detect subsurface caries
• X-rays: + non-destructive + can detect subsurface caries - limited safety - unable to detect incipient demineralization - low resolution
Radiographs • Radiographic imaging of pits and fissures is of minimal
diagnostic value because of the large amounts of surrounding enamel .
• Literature review by Dove: • “overall the strength of the evidence for radiographic
methods for the detection of dental caries is poor for all types of lesions on proximal and occlusal surfaces”.
• “it is beneficial only if the intervention is the surgical removal of tooth structure and detrimental if it is used for non-invasive remineralization methods.”
McKnight-Hanes C, Myers DR, Dushku JC, Thompson WO, Durham LC. Radiographic recommendations for the primary dentition: comparison of general dentists and pediatric dentists. Pediatr Dent. 1990 Jul-Aug;12(4):212-216 Flaitz CM, Hicks MJ, Silverston LM. Radiographic, histologic, and electronic comparison of basic mode videoprints with bitewing radiography. Caries Res. 1993; 27(1): 65-70. Lussi A, Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 27:409-16, 1993 Dove, S. B., “Radiographic Diagnosis of Dental Caries in Consensus Conference on Dental Caries Management Throughout Life, March 2001, Journal of Dental Education, 2001; 65 (10): 985 – 990
NO BIG DEAL
A VERY BIG DEAL
Lower body weight
Psychological impact
Caries is a transmissible bacterial infection and a multifactorial disease that reflects change in one
or more significant factors in the total oral environment.
(NIH Consensus Conference 2001)
A TRANSMISSIBLE BACTERIAL INFECTION
Diagnosis involves recogn i t i on o f t h e s e c h a n g e s rather than simply n o t i n g c a v i t i e s
TOOTH DECAY PREVENTABLE is
BECAUSE FILLINGS
D o n ’ t t r e a t u n d e r l y i n g d i s e a s e
D o n ’ t a d d r e s s p l a q u e b i o f i l m i s s u e s
D o n ’ t c h a n g e r i s k l e v e l
We need to from a surgical approach to a RISK management & preventive approach.
• Growing awareness of social determinants
• Newer recording of caries levels-ICDAS
• Risk-based care • A myriad of new products • New diagnostic devices
The SHIFT in Dealing with Decay
“ It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be”
Isaac Asimov
Product Decisions?
Fluoride CPP-ACP (Recaldent) NovaMin ProArgin Xylitol products Antibacterial rinses Salivary products Neutralizing agents Silver Diamine Fluoride Povidone Iodine CHX varnish (Prevora) Sealants ICON
• RISK Demand?
• Age and Ability?
• Buffering?
• Fluoride Uptake?
• Contact time needed?
• Desensitization?
• Antibacterial Activity?
• Salivary Stimulant?
• Compliance?
Newer Technologies Detecting Decay
The Value of Early Detection
1. Is the ability to control the disease process in order
1. To contain, arrest or remineralize lesions, in
order
2. To avoid or delay the burdens or costs associated with a spiral of restoration and re-restoration
If a lesion is left to extend until a filling is needed, the clinical opportunity for
effective prevention is lost
New Technology Methods For Caries Detection
Fluorescence-based Technology • Diagnodent • Caries ID • Quantitative Light-Induced Fluorescence • Spectra (QLF Technology) Digital Fibreoptic Transillumination (DIFOTI) Electrical Impedance Measurement • Caries Scan
The Characteristics of an Ideal Caries Detection System
Primary
• High sensitivity & specificity for caries detection
• Detects & monitors de & re-mineralization
• Detects smooth surface, root surface, occlusal
surface & interproximal lesions
• Detects caries around restoration margins
• Non-invasive & safe
• Repeatable measurements
The Characteristics of an Ideal Caries Detection System
Secondary
• Imaging and or image capture
• System for recording & storing
measurements
• Patient Education and Motivation
• In-vitro and in-vivo data & publications
• Minimal or no preparation of the tooth surface
prior to taking a reading
• Ability to detect and monitor erosion lesions
The Characteristics of an Ideal Caries Detection System
The key is to understand what the device is measuring
Sensitivity and Specificity
Sensitivity
• The proportion of true positives correctly identified by the test
Specificity
• The proportion of true negatives correctly identified by the test
Therefore, an experimental test aims to achieve 100% sensitivity (no false positives) and 100% specificity (no false negatives)
Because these are proportions, can calculate confidence intervals
Closer the C.I. is to 1.0 the better
The Canary System
by Quantum Dental Technologies
Canary interactive software and printed patient reports
The Canary Console
Science Behind The Canary System
•Pulses of laser light hit the tooth surface.
•Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).
•PTR can provide a depth profile by varying the frequency of the laser beam.
Temperature increase < 1oC not harmful
•Detected signals reflect the tooth’s condition.
•Detects 50 micron lesion up to 5 mm below the surface.
What it is - Screenshot
Odontogram
Menu Options
Canary Number
Camera Image
Caries Mapping
Canary Number
Camera Image with
Grid
Canary Patient Report
• Customized patient report on dental practice letterhead
• Clear simple indication of problem areas
• Patient can track their progress
• Engages patient in their oral health care
Internet Connectivity
• The Canary System equipped with wireless connect to
the ‘Canary Cloud’. • Benefits for internet connectivity include:
– Back-up and storage of data – Seamless software updates – Data and risk analysis for report generation – Online access of patient reports via Canary Web Portal – Access to data even when the system is being serviced or
upgraded – Enables dentists to access all patient data among all dental
operatories – HIPPA and PIPEDA Compliant
VALUE PROPOSITION
Value to the Dentist
• Attract new patients: with state of the art technology and a minimally invasive approach
• More patient visits: more frequent visits for patients enrolled in remineralization programs
• Reduce costs: scans can be performed by lower cost staff (hygienists, assistants)
• Affordable: flexible leasing options provide immediate profitability
Value to Patients & Insurers
• Reduce costly & painful restorations
Healthy Tooth
Early Enamel Decay
Advanced Enamel Decay
Demineralization
The Life Cycle of Tooth Decay
Remineralization
Remineralization Therapies The Canary System Scan X-Ray, Drill Fill & Bill
• Between teeth
(interproximal areas)
• Around the edges of fillings
• Enamel and root surfaces
Canary detects small lesions from 50 microns in depth and up to 5 mm below the tooth surface.
• Biting Surfaces (occlusal pits and fissures)
Caries Detection on ALL Surfaces
Sensitivity and Specificity
Sensitivity
• Overall measurement in vitro 97% Specificity
• Overall measurement in vitro 82%
*Bench study Dr. B Amaechi UTSA
Integrating into Dental Practice
• Scanning done by lower cost staff (dental assistant)
• Applying remineralizing therapies
• Return for repeat monitoring of suspect lesions
• Good practice management tool
THE 9 MONTH STORY Our questions at the start
• How easy to measure • How reproducible • How accurate • Canary Scale 21-70 • Specificity and Sensitivity
The Canary in Pediatric Practice –
The Canary in Pediatric Practice –
THE 9 MONTH STORY Lesions evaluated clinically Pit and fissure Interproximal Facial Under sealants ICON Under and around restorations
Pit and Fissure Caries
Pit and Fissure Caries
Pit and Fissure Caries
Pit and Fissure Caries
Interproximal lesions
Issues at Outset
• How easy to learn
• How reproducible the numbers
• Canary Scale 21-70
• Sensitivity and specificity
Houston, We Had a Problem
Range of Measurements Verified by Treatment
Surface ICDAS # Canary # Permanent Occlusal 2 13-19 3 17-34 4 24-53 Interproximal (Pre-Adjustment) 2 24-26 4 21-29 (Post Adjustment) 3,4 32-40 (small sample size)
Interproximal lesions
The key is to understand what the device is measuring
• Canary number will under report lesion size
• Intervention decisions
remain based on CAMBRA
Detecting Caries under a Sealant
Detecting Caries under a Sealant
Detecting Caries under a Sealant
Lab study on extracted teeth comparing Canary and Diagnodent
Sensitivity • Canary 0.83 • Diagnodent 0.64 Specificity • Canary 0.79 • Diagnodent 0.46
• ORCA Abstract from QDT 2012
Detection Around ICON
Issues With ICON
• Newer technology with limited in-vivo
data
• Caries development around and within
material unknown
• Longevity of material unknown
• Potentially a very useful material
• How to monitor for early change
Detection Around ICON
Detection Around ICON
Anomalous Lesion
Anomalous Lesion
Characteristics
• No surface breakdown (ICDAS 1 or 2)
• Evident radiographically, often for a year or
longer
• Once through enamel you “drop” into defect
• Lesion tends to be reddish-brown and “mushy”
• Does not exhibit typical carious texture
• Suspicion is the histological picture is distinct
from traditional caries picture
Anomalous Lesion
Anomalous Lesion – Preliminary Observations
• Canary does not accurately measure defect • Lesion appears to have a different
pathology and suspected different
histological picture • More information required
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Preliminary Observations on Canary Overall
Occlusal Surface • Highest ease of measurement and
predictability Facial surface • Highest ease of measurement and
predictability Interproximal Permanent Teeth • Significant learning curve • Lesion will be at least as deep as
measurement indicates
Preliminary Observations on Canary (cont’d)
Interproximal Primary Teeth • Greater accuracy of Canary number
compared to permanent teeth Under Sealants • Very good indicator of what lies beneath ICON • Likely good indicator of change with
repeat scans Under and Around Restorations • Good indicator of restoration failure
Orthodontic Treatment – A Unique Opportunity
Facts on Orthodontic-Related Decalcification and
Caries
• Approximately 50% of ortho cases end with “white
spot lesions”
• Lesions can commence within 1 month of bracketing
• Braces can preclude bitewing radiographs for 3
years or longer
• Risk-based preventive strategies exist
• Canary System an excellent diagnostic tool
Orthodontic decalcifications and caries
Slide courtesy of Reliance Orthodontics
Orthodontic Treatment – Recommended Canary Protocol
• Collaboration and communication triad established
pre-orthodontics
• Baseline risk assessment
• Baseline bitewing radiographs
• If moderate or high risk then full Canary scan at
baseline
• Rescan of interproximal and facial surfaces at 3-6
months based on risk
• Customized preventive strategy for home, primary
care office and orthodontic office
Dear Dr. Re: Patient Our mutual patient was in recently for regular care. You will recall that he/she demonstrates a higher risk for dental caries. As a result, we have initiated a customized preventive programme for him/her while undergoing the orthodontic care under your supervision. Specific components of this preventive programme include: ___ Higher fluoride toothpaste used at bedtime ___ More frequent dental hygiene visits for scaling, prophylaxis ___ More frequent dental hygiene visits for additional fluoride varnish application ___ Review of home hygiene techniques including use of floss and proxybrush ___ Scanning of at risk sites on teeth with the Canary System The current review of ________’s oral hygiene and caries status reveals: ___ Oral hygiene is under control ___ Adjustments to the preventive programme are required and involve the following: ___ A rescan of the at risk sites is planned for ___ months We appreciate your collaboration in the oral care for _______. Please contact our office if you have concerns about anything for him/her. Sincerely yours, Ian McConnachie B.Sc., D.D.S., M.S., F.R.C.D.(C )
The Canary: Clinical Indications
• Complementary to bitewing radiographs – may
reduce frequency need
• Monitor of remineralization therapy
• Monitor of margins of existing restorations
• Monitor of pre-cavitated lesions on all surfaces
• Complement to Caries Management by Risk
Assessment
• Part of collaboration triad in orthodontic care
Office Integration Recall or Specific Exam •Identify White Spots •ICDAS or Measure •Risk Assessment •Apply Remineralization Therapy •Oral Hygiene Instruction •Provide Home-based Therapy
Reassess 3 Months •Assess lesion •ICDAS or Measure •Apply Remineralization therapy •Dispense Home-based therapy
Reassess 6 Months •Assess Lesion •ICDAS or Measure •Apply Remineralization Therapy •Dispense Home-Based Therapy
The Characteristics of an Ideal Caries Detection System - How Does Canary Rate?
Primary
? - High sensitivity & specificity for caries detection
YES - Detects & monitors de & re-mineralization YES BUT- Detects smooth surface, root surface, occlusal surface & interproximal lesions YES - Detects caries around restoration margins YES - Non-invasive & safe YES BUT - Repeatable measurements
The key is to understand what the device is measuring.
The Characteristics of an Ideal Caries Detection System
Secondary YES - Imaging and or image capture YES - System for recording & storing measurements YES - Patient Education and Motivation YES but More Needed - In-vitro and in-vivo data & publications YES BUT - Minimal or no preparation of the tooth surface prior to taking a reading
? - Ability to detect and monitor erosion lesions
The key is to understand what the device is measuring.
MAYBE – BUT DEFINITELY WORTH CONSIDERING
Is This the Motherlode In Caries Diagnosis?