the association between cariescan pro readings and histologic dep

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University of Iowa

Iowa Research Online

Teses and Dissertations

2013

Te association between CarieScan Pro readingsand histologic depth of caries in non cavitated

occlusal lesion in vitroJoshua Eric CohenUniversity of Iowa

Copyright 2013 Joshua Eric Cohen

Tis dissertation is available at Iowa Research Online: hp://ir.uiowa.edu/etd/2463

Follow this and additional works at: hp://ir.uiowa.edu/etd

Part of the Other Dentistry Commons

Recommended CitationCohen, Joshua Eric. "Te association between CarieScan Pro readings and histologic depth of caries in non cavitated occlusal lesion invitro." thesis, University of Iowa, 2013.

hp://ir.uiowa.edu/etd/2463.
http://ir.uiowa.edu/?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://ir.uiowa.edu/etd?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://ir.uiowa.edu/etd?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://network.bepress.com/hgg/discipline/661?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://network.bepress.com/hgg/discipline/661?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://ir.uiowa.edu/etd?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://ir.uiowa.edu/etd?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPageshttp://ir.uiowa.edu/?utm_source=ir.uiowa.edu%2Fetd%2F2463&utm_medium=PDF&utm_campaign=PDFCoverPages


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THE ASSOCIATION BETWEEN CARIESCAN PRO READINGS AND HISTOLOGIC

DEPTH OF CARIES IN NON CAVITATED OCCLUSAL LESION IN VITRO

by

Joshua Eric Cohen

A thesis submitted in partial fulfillmentof the requirements for the Master ofScience degree in Operative Dentistry

in the Graduate College ofThe University of Iowa

May 2013

Thesis Supervisor: Associate Professor Justine L. Kolker


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Copyright by

JOSHUA ERIC COHEN

2013

All Rights Reserved


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Graduate CollegeThe University of Iowa

Iowa City, Iowa

CERTIFICATE OF APPROVAL

_______________________

MASTER'S THESIS

_______________

This is to certify that the Master's thesis of

Joshua Eric Cohen

has been approved by the Examining Committeefor the thesis requirement for the Master of Sciencedegree in Operative Dentistry at the May 2013 graduation.

Thesis Committee: ___________________________________Justine L. Kolker, Thesis Supervisor

___________________________________Gerald E. Denehy

___________________________________Fang Qian


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Dedicated to the loving memory of my mother,Linda Cohen(1956-2010)

I Love You Mom


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ACKNOWLEDGMENTS

I would like to sincerely thank my thesis committee members: Dr. Justine L.

Kolker, Dr. Gerald E. Denehy, and Dr. Fang Qian for their guidance and encouragement.

I would also like to thank Dr. James Wefel who allowed me to get a glimpse of his

infinite wisdom in Cariology. A special thank you is in order to Dr. Christopher

Longbottom, Dr. Woosung Sohn, Dr. Gail Douglas, Dr. Marcos A. Vargas, Dr. Rodrigo

R. Maia, Jeffrey Harless, and Maggie Hogan for taking time out of their busy schedules

to offer much needed technical expertise.

I am especially thankful to my wife Alison and my daughters Emily, Madeline,

and Sophia for their unwavering love and support. I simply could not have done this

without you.


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TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................. vi

LIST OF FIGURES .......................................................................................................... vii

CHAPTER I INTRODUCTION. .........................................................................................1

Purpose .............................................................................................................3Study Aims .......................................................................................................4

CHAPTER II LITERATURE REVIEW .............................................................................5

Introduction .......................................................................................................5History of Dental Caries .............................................................................6Caries Prevalence Post Water Fluoridation ................................................6Current Dental Diagnostic Techniques .......................................................7

Mechanisms Involved in Caries Process ..........................................................7Bacterial Involvement ..................................................................................7Sugar Consumption .....................................................................................8Oral Cavity Environment .............................................................................8Demineralization/Remineralization .............................................................9

Caries Presentation .........................................................................................10Non-Cavitated Lesions ..............................................................................10Cavitated Lesions.......................................................................................11Closed Lesions ...........................................................................................12Caries Activity ...........................................................................................12

Caries Detection Techniques ..........................................................................13Visual Detection ........................................................................................13International Caries Detection and Assessment System (ICDAS) ............14Nyvads System .........................................................................................14Visual/Tactile Detection ............................................................................18Radiographic Detection .............................................................................22

Caries Detection Devices ................................................................................28Fiber Optic Transillumination (FOTI) .......................................................28DIFOTI ......................................................................................................32Laser Fluorescence ....................................................................................33Quantitative Laser Fluorescence (QLF) ....................................................34Light Induced Fluorescence (DIAGNOdent) ............................................37Electrical Conductance ..............................................................................41Electronic Caries Monitor (ECM) .............................................................43CarieScan PRO ..........................................................................................47

CHAPTER III MATERIALS AND METHODS ..............................................................50

Tooth Selection ...............................................................................................50Digital Macro Photographs of Occlusal Surfaces ...........................................50Scoring Occlusal Lesions ...............................................................................51

ICDAS II Criteria Code .............................................................................52Caries Analysis Uisng CarieScan PRO ..........................................................53

Charging the CarieScan PRO ....................................................................53System Testing ...........................................................................................53


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Scoring Teeth with the CarieScan PRO .....................................................53Tooth Sectioning .............................................................................................55

Tooth Preparation for Sectioning ...............................................................55Mounting Teeth for Sectioning ..................................................................56Sectioning ..................................................................................................56Removing Sections ....................................................................................57

Polarized Light Microscopy ...........................................................................57Histologic Examination ..................................................................................58Ranked Scale .............................................................................................58

Statistical Analysis ..........................................................................................59Intra- and Inter-Rater Reliability for Visual Inspection ............................59Intra-Rater Reliabilityof Examination with the CarieScan PRO ...............60Intra- and Inter-Rater Reliability of Histologic Examination ....................60Association Between Visual Inspection and Histologic Findings .............60Association Between CarieScan PRO and Histologic Findings ................61Association Between Visual Inspection and CarieScan PRO ...................61Sensitivity and Specificity for ICDAS ......................................................61Sensitivity and Specificity for the CarieScan PRO ...................................63

Pilot Study ......................................................................................................65

Hypotheses ......................................................................................................65Operational Definitions ..................................................................................65

CHAPTER IV RESULTS ..................................................................................................91

Evaluations of Intra- and Inter-Observer Reliability for Measurements ........91Intra-Observer Reliability for ICDAS Scores ............................................91Inter-Observer Reliability for ICDAS Scores ............................................91Intra-Observer Reliability for CarieScan PRO Scores ..............................92Intra-Observer Reliability for Histologic Scores .......................................93Inter-Observer Reliability for Histologic Scores .......................................93

Evaluations of the Associations Between Histologic Consensus,ICDAS Consensus, and CarieScan Pro Mean ................................................94

Association of Histologic Consensus with ICDAS Consensus .................94Association of Histologic Consensus with CarieScan PRO Mean ............94Association of CarieScan PRO Mean with ICDAS Consensus .................95

Sensitivity and Specificity ..............................................................................97Sensitivity and Specificity of ICDAS ........................................................97Sensitivity and Specificity of CarieScan PRO ...........................................98

CHAPTER V DISCUSSION ...........................................................................................107

REFERENCES ................................................................................................................117


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LIST OF TABLES

Table

1. ICDAS vs Histo I. ....................................................................................................62

2. ICDAS vs Histo I Interpreted. ...................................................................................62

3. ICDAS vs Histo II. ...................................................................................................63

4. CarieScan vs Histo I. ...............................................................................................63

5. C.S. vs Histo I Interpreted. .......................................................................................64

6. CarieScan vs Histo II. ..............................................................................................64

7. ICDAS vs Histo I.....................................................................................................97

8 ICDAS vs Histo II. ..................................................................................................98

9. CarieScan vs Histo I. ...............................................................................................98

10. CarieScan vs Histo II. ..............................................................................................99

11. Nyvad et als description of diagnostic criteria from a 1999 paper in CariesResearch..................................................................................................................100

12. Criteria used for the visual, FOTI and radiographic examinations in Crtes etals 2000 paper in Caries Research........................................................................101

13. Descriptive statistics of mean differences between the first and secondmeasurements with the CarieScan PRO ................................................................102

14. Associations of ICDAS levels with histologic consensus categories (N=95).......103

15. Associations of CarieScan levels with histologic consensus categories(N=95)

...................................................................................................................104

16. Associations of CarieScan levels (0-50, 51-100) with ICDAS levels (N=95). .....105

17. Associations of CarieScan levels (0-30, 31-100) with ICDAS levels (N=95). .....106


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LIST OF FIGURES

Figure

1. Tooth Mounted for Photographs ...............................................................................67

2. Microsoft PowerPoint image of photographed teeth. Wet image on the left.Dry image on the right. Red circle denotes the area of interest ................................68

3. Photograph of the Excel spreadsheet used to randomize the photographedlesions to prevent any bias during second evaluation ...............................................69

4. ICDAS Codes 0 - 4. .................................................................................................70

5. CarieScan PRO fully charged in cradle per manufacturer's specifications. .............71

6. Sensor collar in place calibrating the CarieScan PRO per manufacturer's

specifications. ...........................................................................................................72

7. Proper placement of the CarieScan PRO sensor. ......................................................73

8. CarieScan color pyramid and corresponding numbers. ............................................74

9. With the lip hook in contact with the tooth and wrapped in a gauze saturatedin artificial saliva, the CarieScan PRO sensor is placed on the site of interestand a score is recorded. .............................................................................................75

10. Placing buccal (red) and lingual (green) marks to designate location of thelesion prior to covering occlusal surface with resin. ................................................76

11. Etching the occlusal surface prior to placing resin. ..................................................77

12. Frosted appearance in the enamel after acid etching. ...............................................78

13. Placing an adhesive prior to resin placement on the occlusal surface. .....................79

14. Placing composite resin on the occlusal surface. ......................................................80

15. Series 1000 Deluxe Hard Tissue Microtome. ...........................................................81

16. One of four cuts in the tooth to get three sections. ...................................................82

17. Mounting ring ready to be placed in microtome for sectioning. The tooth wasmounted high enough in the wax to expose the CEJ. ...............................................83

18. Serial sections in a buccal/lingual direction through the site of interest whichwas identified by the paint. .......................................................................................84

19. Sections cut into the pulp chamber so that the extent of caries into dentin canbe properly assessed..................................................................................................85

20. Separating the second of three sections using the Interproximal Carver (IPC). .......86


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21. Serial sections prepared for histologic exam with Polarized Light Microscopy(PLM). Sections placed on the slide in the order they were separated. Thered paint can be seen on the buccal surfaces of the middle and left sections. ..........87

22. Looking at sections using an Olympus BH-2 Polarized Light Microscope. ............88

23. Image taken from PowerPoint document used to score histologic lesions. Theimages from left to right correspond with the sections on the slide as seen inFigure 21. ..................................................................................................................89

24. Examples of histologic scoring using the Crtes ranked scale. ................................90


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CHAPTER I

INTRODUCTION

Since the implementation of wide spread water fluoridation and other fluoride

modalities in the last half century, the incidence and prevalence of dental caries in the

United States has decreased. Despite this decrease, dental disease is still a problem

today. Due to the complexity of the disease process, it is often difficult to diagnose

dental caries. In many circumstances, the presence of fluoride can help hide occlusal

caries by aiding in the initial mineralization and remineralization of enamel, making it

difficult for providers to effectively detect, manage, and treat the disease at the earliest

possible stage.

Studies have shown inconsistencies in the ability for dentists to uniformly detect

dental caries. Dentists generally rely on a few methods for diagnosis, including visual

and/or tactile, and radiographic. While radiography is a valuable diagnostic tool, its

usefulness at diagnosing occlusal caries is limited. By the time occlusal caries can be

detected radiographically, the disease process is already quite advanced minimizing the

opportunity for providers to treat at a minimally invasive level. Visual and tactile

methods of caries detection are often reported to be highly subjective (Pereira,

Eggertsson et al. 2009). Clinicians often have different perceptions of what is considered

soft tooth structure or what characteristics are indicative of tooth decay on a specific

tooth surface. This inability for dental professionals to consistently detect caries using

visual and tactile methods calls for a more objective method which could potentially

quantify levels of dental disease.

Additionally, a more quantifiable system of measuring decay would prove

extremely valuable in future research because higher levels of studies, such as systematic

reviews and meta-analyses, would be more feasible with the ability to compare scientific

literature based on a quantifiable system.


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To date, there have been multiple studies which have looked at various diagnostic

techniques/systems and have measured their correlation to disease presence (Bader JD,

Shugars DA et al. 2001, Bader JD, Shugars DA et al. 2002). Despite these studies, there

has been little success in predictably correlating disease progression with clinical

detection. Some systems such as the International Caries Detection and Assessment

System (ICDAS), while proving to be a good diagnostic tool, require extensive

calibration and training, and still have yet to show an improved ability to predict disease

progression.

The most exact way of measuring the spread of caries is to examine extracted

teeth histologically and compare the findings with predicted outcomes of various

diagnostic modalities. This experimentation has been performed with multiple

diagnostic tools including: Digital Image Fiber Optic Transillumination, Fiber Optic

Transillumination (DIFOTI, FOTI); Quantitative Light Fluorescence (QLF); Laser

Fluorescence; and Electrical Conductance Measurement (ECM) to name a few. In

general, these studies have found these diagnostic tools to have good sensitivity in that

they are good at locating dental caries. The problem is that they tend to lack good

specificity in that they identify an undesirable level of false positive readings, making

them less useful in the practice of minimally invasive dentistry.

Relatively new to the market is the CarieScan Pro, which relies on Electrical

Conductance. The CarieScan PRO system uses Alternating Current (AC) Electrical

Impedance, compared to its predecessor ECM, which used Direct Current (DC) as its

energy source, a method already deemed non-effective at caries detection (Bader JD,

Shugars DA et al. 2002). By determining the association of the CarieScan PRO readings

to histological lesion depth, we can potentially predict disease progression much more

effectively than ever before.


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Purpose

This study evaluated the association between CariesScan PRO readings and

histologic involvement measured using polarized light microscopy of non-dentinal

cavitated occlusal tooth surfaces classified according to ICDAS.

The study described herein is one of the first of its kind with this device, and has

the potential to change the way dental caries are detected, monitored, and diagnosed. A

strong association between CarieScan Pro readings and histologic involvement would

eventually enable clinicians to predictably determine the progression of dental disease

objectively. Removing subjectivity from the diagnostic process would be

groundbreaking in clinical dentistry, forever changing the way lesions are managed and

monitored. From a research standpoint, the effects of future dental materials,

antimicrobials, dental fluoride delivery systems, etc. on teeth could be measured

clinically without the use of invasive procedures.

As described fully in chapter 3, data for this study was collected from extracted

posterior teeth presenting with non-dentinal cavitated carious lesions, which were

deemed as such according to ICDAS criteria (Codes 0-4). The teeth were photographed

which was used to classify the lesions. Occlusal surfaces were then examined using the

CarieScan PRO device. The teeth were then sectioned and examined histologically. This

study then examined the association between CarieScan PRO readings and actual

histologic progression of dental caries.


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Study Aims

The aim of this study is to measure the association between CarieScan PRO

readings and histologic depth of caries on non-dentinal cavitated occlusal lesions in vitro.

Additionally, this study aims to measure the association between ICDAS scores and

histologic depth of caries on the same surfaces. The association between ICDAS scores

and CarieScan PRO readings will also be measured.

The CarieScan PRO manufacturer claims sensitivity and specificity greater than

.90. This study intends to compare sensitivity and specificity findings with manufacturer

claims.


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CHAPTER II

LITERATURE REVIEW

Introduction

Diagnosis of dental caries and deciding when to provide treatment is still

considered very subjective and continues to be widely debated to this day. There

continues to be considerable research regarding this subject matter in an attempt to better

understand the caries progression process and how it can be prevented. Researchers, in

an attempt to standardize the methods with which they collect data, have used the World

Health Organizations criteria for diagnosing caries (World Health Organization. Expert

Committee on Mental Health. 1962). Unfortunately, using this tool limits caries

diagnosis to teeth that are cavitated, a clinical sign that manifests itself after extensive

progression in the disease process. Other classification systems have come into use in

order to detect dental caries earlier. Unfortunately, there is inadequate evidence to

support that these systems can be used as universally as the WHO system. To complicate

the matter, dental caries have become increasingly more difficult to diagnose since the

widespread use of fluoride. Non-cavitated dentinal lesions are far more prevalent as a

result of little to no demineralization on occlusal surfaces making detection much more

difficult (Sawle RF, Andlaw RJ 1988, Weerheijm KL, van Amerongen WE et al. 1989).

Even when occlusal caries are detected, there is debate as to the extent of the caries

progression and whether or not it should be treated. The ability to quantitatively measure

the progression of caries would be a useful clinical tool in objectively identifying the

extent of the disease process. Additionally, a predictable quantitative measure could

improve caries research by ensuring uniformity in lesion progression without relying on

inter-rater reliability. The following literature review will address the current knowledge

of caries detection and the respective techniques used in this decision making process.


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History of Dental Caries

Dental caries is an ancient disease that can be traced back as far as the fifth

century. It is widely believed that the origin of dental caries may have occurred shortly

after agriculture replaced hunting and gathering as the primary source of food.

Examination of skulls in Britain suggests that the moderate caries experience found in the

Anglo-Saxon period (fifth to seventh centuries) had changed little by the end of the

Middle Ages, approximately the year 1500(Moore, Corbett 1971, Moore, Corbett 1973).

By the eighteenth century sugar was much more available as was the prevalence of food

refinement. By the end of the nineteenth century, dental caries was established as a

worldwide endemic disease in developed countries.

Caries Prevalence Post Water Fluoridation

The overall prevalence of dental caries has drastically declined over the last thirty

to forty years (Alwas-Danowska HM, Plasschaert AJ et al. 2002). Due to increased

preventive modalities such as the emergence of fluoridated drinking water and

toothpastes, there has been a dramatic decrease in smooth surface caries resulting in an

increased proportion of occlusal caries as a proportion of total caries prevalence (Alwas-

Danowska HM, Plasschaert AJ et al. 2002). Early occlusal caries detection has become

more difficult due to the absence of cavitation in and underneath fissures as a result of

frequent fluoride use (Alwas-Danowska HM, Plasschaert AJ et al. 2002). Because of this

fact, today there is a greater need for early occlusal caries diagnosis.


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Current Dental Diagnostic Techniques

Dentists have a number of ways of detecting occlusal caries. Some of these

methods include: visual, visual-tactile, radiographic, laser or light fluorescence, fiber

optic transillumination, and electrical impedance (Jablonski-Momeni, Stachniss et al.

2008). With all these options at their disposal, visual, tactile, and radiographic are

currently the most widely used diagnostic tools in caries detection (Adeyemi AA, Jarad

FD et al. 2008).

Mechanisms Involved in Caries Process

Bacterial Involvement

Bacteria are necessary for the occurrence of dental caries regardless of any other

factor. Caries cannot occur in the absence of bacteria (Emilson CG, Krasse B 1985,

Loesche 1982). The primary bacteria responsible for dental caries are mutans

streptococci and lactobacilli, which are naturally occurring in the oral cavity. Because of

the natural occurrence of these organisms, as well as others, it is widely accepted that an

imbalance in the number of these bacteria with respect to the total bacterial count plays

an integral role in the development of dental caries. However, bacterial counts by

themselves are a poor predictor of caries development. In order for caries to develop, an

environment must be created that is rich in bacteria, has an adequate substrate (teeth and

the oral cavity environment) and a food source. Caries have been described as a

carbohydrate-modified bacterial infectious disease, in which a cariogenic diet selectively

favors cariogenic bacteria (van Houte J, Lopman J et al. 1994).


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Sugar Consumption

Similar to bacterial involvement, diet plays an integral role in the development of

dental caries. This remains particularly true in regards to the intake of refined

carbohydrates and sugars. When these sugars have been refined prior to consumption,

they are broken down much easier in the oral cavity making them readily available for

consumption by cariogenic bacteria.

Sugars added to the diet seems to be the primary cause of caries, however, caries

can also occur in populations whose only sugar consumption is naturally occurring.

Despite the overwhelming evidence in the literature to support this claim, it is important

to note that sugars are not the only food source involved in the carious process. Cooked

or milled starches can be broken down to low-molecular-weight carbohydrates by the

salivary enzyme amylase and thus act as a substrate for cariogenic bacteria. (Bibby BG

1975, Firestone, Schmid et al. 1984). It has been argued that a mixture of sugars and

starches are more cariogenic than sugars by themselves. Conversely, foods containing

high molecular weight carbohydrates when lightly cooked, (i.e. vegetables) are not

considered cariogenic because they cannot be broken down completely by amylase in the

mouth and therefore not an adequate food source for cariogenic bacteria(Krasse B 1982,

Newbrun E, Hoover C et al. 1980).

Oral Cavity Environment

As alluded to earlier, the oral cavity is saturated with a diverse population of

resident microflora. These microflora, particularly bacteria, contribute to the normal

physiology of a host species in direct and indirect ways. Bacteria may colonize and

therefore occupy host sites preventing the colonization of other species which may be

harmful to the host. Additionally these bacteria may create microenvironments which


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prove to be unfavorable for the growth and development of invading species which may

be harmful to the host (Kuramitsu, Ellen 2000).

Microflora is not the only component in the oral cavity that affects the

development of dental caries. Saliva composition and volume are very important in

creating a symbiotic relationship between host and microflora species. One of the

important functions of saliva is to dilute and eliminate substances introduced into the

mouth. When sugar concentrations rise in the mouth, saliva production is increased.

This increase in volume will induce swallowing, thus clearing the mouth of sugar. The

remaining sugar is then gradually diluted by incoming saliva. Saliva also has the ability

to act as a buffer, keeping the pH of the oral cavity high enough to prevent

demineralization in tooth surfaces (Fejerskov 2009).

Demineralization/Remineralization

Normal tooth enamel is predominantly mineral in content. It consists of

hydroxyapatite crystals, primarily made up of calcium phosphate, tightly packed together

giving it a glass like appearance. Enamel exposed to the oral environment experiences

constant surface changes and modifications due to the recurring changes in pH generated

by diet and plaque accumulation. During acid exposures, calcium and phosphate are

precipitated out from the tightly packed hydroxyapatite lattice leading to demineralization

of tooth structure. As the acid is buffered and the pH levels begin to rise, Calcium and

Phosphate are re-incorporated into the Hydroxyapatite matrix causing the tooth to

remineralize. These phases of demineralization and remineralization, when in balance,

result in no net mineral loss, therefore preserving the structural integrity of the tooth

surface.

During remineralization, and in the presence of fluoride ion, small amounts of

fluoride are removed from solution during crystal growth. The hydroxyapatite molecules


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substitute a hydroxyl group with fluoride, creating a fluorapatite molecule. These

changes in ion content influence the physical and chemical properties of the mineral and,

most importantly with respect to enamel, change its solubility (Fejerskov 2009).

Fluorapatite is less soluble than hydroxyapatite rendering tooth enamel more stable

during periods of acid exposure. It is this process that is desired when implementing

fluoride into drinking water and toothpaste.

While fluoridation has had a profound effect on the caries prevalence, it must be

understood that increased fluoride concentrations in the mouth do not necessarily mean

that caries will not occur. Furthermore, fluoride does not prevent the initial carious

attack, which would be expected if its presence in the enamel crystal increased enamel

resistance to acid dissolution, but rather the fluoride in the oral cavity acts to inhibit

further demineralization of the lesion and to help promote remineralization (Burt,

Eklund 2005). Because of this, dental caries presents in a much different manner than it

did prior to the use of fluoride.

Caries Presentation

Non-Cavitated Lesions

Non-cavitated lesions can appear in a number of ways. Ekstrand et. al.(1995)

introduced a visual ranked scale which included two types of presentations of non-

cavitated lesions. Ekstrand reported that non cavitated lesions can be identified by no or

slight change in enamel translucency after prolonged air-drying for five seconds

(Ekstrand, Ricketts et al. 1998). This is the earliest detectable presence of the caries

process visually. More involved would be an opacity or discoloration to the enamel

barely detectable on a wet tooth surface, but visibly noticeable upon air drying. Still

more involved, they can present as distinctly opaque or discolored visibly without air


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drying of the tooth surface. Most involved, non-cavitated lesions present as localized

areas of enamel breakdown in opaque or discolored enamel and/or a grayish discoloration

from the underlying tooth structure.

It is important to mention that not all opacities and/or discolorations are

attributed to dental caries. These presentations are indicative of a lower mineral content

within the enamel, however it is highly possible that these manifestations are attributed to

a number of different mechanisms during enamel formation or even after tooth eruption

(Fejerskov 2009).

Theoretically, non-cavitated lesions can be managed by non-operative

interventions. Without cavitation, there is no indication for operative intervention based

on presentation alone. All non-cavitated lesions should, at the very least, be treated

preventively by toothbrushing with a fluoridated toothpaste. In some cases, further

preventive methods may be necessary such as fluoride varnish applications. These

determinations are ultimately based on an individuals overall risk level.

Cavitated Lesions

Cavitated lesions, as one would expect, present with a cavitation in either opaque

or discolored enamel, exposing underlying dentin (Ekstrand, Ricketts et al. 1998). It is

generally concluded that cavitation results from the demineralization of underlying dentin

causing the overlying enamel to fall upon itself resulting in cavitation. Size of cavitation,

however does not always reflect the degree to which the underlying dentin has been

affected. It is entirely possible for a tooth to present with fairly substantial

demineralization into dentin and have only minimal cavitation.


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Closed Lesions

To understand closed lesions, one must apply the concepts of

demineralization/remineralization and non-cavitated carious lesions to one another.

Generally, the non-cavitated lesion only progresses to cavitation upon the complete

breakdown of overlying enamel. Bjorndal describes this phenomenon occurring only

after the communication of bacterial invaded enamel with hypermineralized dentin. It is

after this communication that dentin begins to demineralize (Bjrndal L 2008). No

serious microbial invasion takes place in the dentin as long as the highly organized

enamel layer (even though being demineralized) separates the biofilm from the dentin.

The bacteria are not able to penetrate through the enamel rod structure. The microbial

invasion is related to the gradual structural breakdown of the enamel layer (Bjrndal L

2008). The presence of fluoride has had a major impact on the prevention of enamel

breakdown as a result of: antibacterial properties; ability to prevent demineralization;

ability to aid in remineralization (Burt, Eklund 2005). As a result these lesions present

themselves with lesions into dentin, despite the appearance of intact enamel due to the

presence of fluoride.

Caries Activity

A lesion is considered to be active when the tooth undergoes mineral loss due to

the metabolic activity of the biofilm adhered to the tooths surface. When biofilm

activity does not result in mineral loss of tooth structure, the lesion is considered inactive.

Activity may change status multiple times over the lifetime of a lesion. Nyvad et al.

developed a visual tactile caries diagnostic system to determine caries activity (Nyvad,

Machiulskiene et al. 1999). The philosophy behind the system is that surface

characteristics of enamel are affected by biofilm activity. Therefore, when the biofilm is

in a state where its activity results in mineral loss, it can be concluded that the caries


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process is active. Nyvads system focuses on surface characteristics rather than the depth

of the lesion. The surface texture is an indicator of actual caries activity. The surface

integrity is dependent on the presence of any cavitations or activity within the enamel.

An active non-cavitated lesion is characterized as a whitish/yellowish opaque

surface with a loss of luster, exhibiting a chalky or neon-white appearance (Fejerskov

2009). The surface feels rough when explored. The inactive version of this lesion

conversely is shiny and feels smooth when explored. The color can vary from whitish to

dark in color, however it is generally considered a non-reliable indicator. An active

cavitated lesion appears soft and leathery, while an inactive lesion appears shiny and is

hard on probing.

Caries Detection Techniques

Visual Detection

Visual examination is the most commonly used method for detecting caries

lesions, because it is an easy technique that is routinely performed in clinical practice

(Pitts NB 1993). Traditionally, visual inspection has presented with levels of high

specificity, but low sensitivity and reproducibility. It is believed the levels of low

reproducibility are attributed to the subjective nature of caries detection (Braga M.M.,

Mendes F.M. et al. 2010, Braga MM, Martignon S et al. 2010). As a measure to improve

on low sensitivity and reproducibility values, several indices have been created. Two

such indices discussed in this section are the International Caries Detection and

Assessment System (ICDAS) and Nyvads System.


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International Caries Detection and Assessment System (ICDAS)

In an attempt to propose an internationally accepted caries detection system, an

index for caries diagnosis, the ICDAS, was created in 2002 by a group of cariologists and

epidemiologists, based on visual examination aided by a WHO probe (Pitts NB 2004).

The teeth are cleaned and air dried for five seconds prior to examination. All

examinations are performed with a dental light, a mirror, and a WHO probe as needed.

Teeth are scored on an ordinal scale ranging from 0 6. The score and criteria are listed

as follows:

0 No or slight change in enamel translucency after prolonged air drying (5s)

1 First visual change in enamel (after air drying or restricted to pit and fissure)

2 Distinct visual changes in enamel

3 Localized enamel breakdown in opaque or discolored enamel

4 Underlying dark shadow from dentin

5 Distinct cavity with visible dentin

6 Extensive distinct cavity with visible dentin (involving over half of a surface)

Initially, ICDAS was devised as a detection system for primary caries. Adjunct

criteria have recently been devised for activity assessment.

Nyvads System

Due to the decreasing prevalence of dental caries in children and adolescents,

Nyvad et. al. (1999) predicted the need for a more sensitive method of detecting caries as

a result of a better understanding of the complexities involved in the dental caries process

(International Conference on the Declining Prevalence of Dental Caries, Glass 1982,

Marthaler, O'Mullane et al. 1996). It was concluded that the WHO method of measuring


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caries at a cavitated stage is no longer adequate in reflecting the changes in incidence of

dental caries. Currently, it is better understood that the caries process is highly dynamic,

and significant caries activity occurs far before the clinical manifestation of cavitation.

The use of a caries diagnostic system which includes non-cavitated caries has the

distinct advantage that all stages of lesion formation development of cavitation through

non-cavitated stages of caries may be reflected in the recordings (Nyvad,

Machiulskiene et al. 1999). The aim of Nyvads study was to describe a set of clinical

diagnostic criteria differentiating between levels of caries activity in cavitated and non-

cavitated lesions. It was also important that they could assess the inter- and intra-rater

reliability of examiners over the three year study as well as compare degrees of

agreement with the commonly used WHO criteria (Table 11).

Eight hundred eighty-nine, 9-14 year-old children with a high caries prevalence

were selected. These children participated in a clinical caries trial and were available for

repeated caries examinations for 3 consecutive years. Each year, 50 children were

selected for assessment of inter- and intra-rater reliability (Nyvad, Machiulskiene et al.

1999). Two examiners independently examined each patient. Each patient was re-

examined with an interval of 1-2 weeks.

The percentage agreement of the caries diagnoses varied between 94.2 and 96.2%.

The kappa values ranged between 0.74 and 0.85 for intra-examiner examinations and

between 0.78 and 0.80 for inter-examiner examinations (Nyvad, Machiulskiene et al.

1999). The results of the study demonstrated that when the new criteria were applied to

the site-specific diagnosis of caries lesions in a clinical trial, they could be reproduced by

the same examiner or by another examiner with significant agreement (Nyvad,

Machiulskiene et al. 1999).

It was also found, as would be expected, that there were misclassifications. The

majority (~80%) of these misclassifications involved disagreement between sound tooth

surface and non-cavitated caries lesions (either active or inactive). Approximately 10%


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higher than those of the Nyvad system at the D1 threshold, but not at the D2 or D3

thresholds. There were no statistically significant differences found between the two

systems for specificity or percent agreement at any of the thresholds. This study

concluded that there were some differences between the two systems, however they were

both considered reliable in estimating the caries lesion depth on occlusal surfaces on

primary teeth. Despite the strong correlation, the inability to look at plaque accumulation

on extracted teeth was discussed, a key component to the Nyvad index, creating an

obvious flaw to the study. It was acknowledged that the comparisons of the two systems

were incomplete and that further studies were needed.

Braga et. al. (2010) also compared Nyvads system with ICDAS-II LAA in vivo.

The overall aim of the study was to compare the performance of the two systems in

detecting and assessing caries activity of occlusal lesions. Similar to the invitrostudy

described earlier, two examiners examined selected tooth surfaces using both indices.

One hundred sixty-four children were screened. One hundred thirty-nine children

completed the examination and 763 teeth were sampled. A small subsample of teeth

from this population were extracted, hemi-sectioned and examined histologically by the

same two examiners. The same statistical analyses were used to examine inter and intra-

rater reliability, correlation, sensitivity, specificity, and accuracy as were used in the in

vitro study.

Again, both indices were found to have excellent inter and intra-rater reliability.

It is important to note that for inter-rater reliability, the disagreements were related to

non-cavitated caries lesions using both sets of criteria. Similar to the previous study, the

initial stages of caries led to most of the disagreements between examiners, as expected,

and, according to previous studies, accurate assessment and strong reliability demands

more training and examination time (Braga, Mendes et al. 2009). It was also interesting

to note that the ICDAS-LAA index scored more lesions as active compared to the Nyvad

index. Additionally, it was found that neither index was able to accurately detect


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differences between lesions in the outer and inner half of enamel. It is important to note

this observation. Despite the conclusion that both indices were found to be comparable,

giving high reproducibility and validity to detect and estimate overall caries lesion depth

in primary teeth, there was still difficulty determining the extent of enamel only

involvement (Braga MM, Martignon S et al. 2010). It is possible that this outcome would

not be found in permanent dentition, and that either index may be an excellent tool in

predicting caries spread in enamel. Ultimately, similar to the in vitrostudy, it was found

that both scoring criteria were comparable. There was high reproducibility and validity

to detect and estimate caries depth in primary teeth.

Visual/Tactile Detection

It has been concluded in the literature that the diagnosis of occlusal caries is indeed

very difficult. In 199l Lussi looked at the validity of both clinical and diagnostic

treatment decisions on occlusal pits and fissures using visual and visual/tactile methods.

In this in vitrostudy, 61 human teeth were examined by 34 dentists. Twenty-six of these

dentists were asked to examine the occlusal surfaces of extracted teeth without the use of

an explorer. The remaining 8 dentists were arbitrarily assigned to use a probe to look at

the same teeth. All examiners were told that the teeth were from teenagers with an

average caries experience, and were given 50 seconds per tooth for examination. The

examiners were responsible for diagnosing in a designated fissured area whether that

fissure had (1) no caries; (2) a subsurface lesion; (3) caries confined to enamel; (4) caries

beyond the dentinal-enamel junction (Lussi 1991). The examiners were also asked to

assign a treatment based on their diagnosis. Their treatment options were: (1) no

treatment; (2) fissure sealing; (3) preventive resin restoration; (4) composite or amalgam

(Lussi 1991). Each participant was invited to repeat their examination after a minimum

of one weeks time. Twelve dentists accepted this invitation.


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Upon completion of the second examination, all teeth were sectioned into three slices

which encompassed the lesion in question. The assessment of the sectioned area was the

validating criterion for the evaluation of the percentage of teeth correctly diagnosed,

and of sensitivity and specificity (Lussi 1991). For the sake of the study it was

assumed that caries confined to enamel did not require a restoration. Based on this

assumption, no treatment or fissure sealing was the correct treatment when there

was either no caries, a subsurface lesion, or enamel caries. When there were dentinal

caries, a composite or amalgam restoration was the treatment of choice. It was also

assumed that a dentist planning to do a preventive resin restoration would switch to an

amalgam or composite restoration once caries extension was revealed during treatment

and therefore acceptable treatment decision when caries were found to be in dentin

(Lussi 1991).

It was found that the specificity of dentists using an explorer was slightly higher

(87.4%) than the specificity of dentists who did not (82.5%). The sensitivity however,

was slightly less (60.5%) with the explorer than without (65%) (Lussi 1991). These

findings were not found to be significantly different, contributing to the idea that there is

no net benefit in using tactile methods to diagnose caries. Additionally, there is adequate

literature to support the disadvantages of probing fissures such as transfer of cariogenic

bacteria and/or damage to the integrity of surface enamel (Lussi 1991). The results

showed that the percentage of correctly diagnosed teeth in this study was rather low

(approximately 42%). After removing the probability of correct diagnosis by chance

alone, the proportion of correctly classified teeth beyond chance ranged between 21%

(dentists using explorers) and 25% (dentists using a visual technique) (Lussi 1991). This

difference was not found to be statistically significant. More importantly it reaffirms the

idea that diagnosis of occlusal caries is difficult to diagnose.

Penning et al. looked at the validity of probing for fissure caries diagnosis in 1992. In

this in vitrostudy, 100 extracted molars (50 upper and 50 lower), which presented with


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discolored fissures but no visible cavitation were selected.Each tooth was probed with a

sharp sickle explorer with 500g of force. If the tooth was lifted after retracting the

explorer, it was deemed to have a stick and the area was marked on the tooth with red

paint. All teeth were photographed and sectioned bucco-lingually. These sections were

then radiographed and examined for caries. The radiographic scores were compared with

the sticks and analyzed statistically (Penning, van Amerongen et al. 1992).

The results found that throughout the 100 teeth there were 1,140 probings, resulting

in 41 sticks (Penning, van Amerongen et al. 1992). Upon radiographic examination, it

was found that 36 of the 41 sticks were caries (true positives) with 5 being sound (false

positives). Of the 1,009 non-sticking probes, 112 of them presented with caries

radiographically (false negatives), while 987 of them presented as sound (true negatives).

Of the 148 lesions, only 36 were marked by a sticking explorer resulting in a sensitivity

of 24.3%. A false positive was found 5 out of 992 possible instances resulting in a

specificity of 99.5% (Penning, van Amerongen et al. 1992).

There were several limitations in this study as discussed in the paper. Some of these

limitations include: the study was performed in vitro; force of probing and withdrawal on

the probe, and incomplete picture of total caries under a designated fissure. Regardless,

Penning found specificities comparable to previous studies. The sensitivities were found

to be significantly lower than that of previous studies cited in the paper, yet all

sensitivities were found to be no better than 62% (Penning, van Amerongen et al. 1992).

Penning reports that one clinical study revealed a sensitivity of 82% with a specificity of

100%, however failed to mention how these were calculated .

In 1993, Lussi compared different methods of diagnosis for non-cavitated fissured

surfaces. In this in vitrostudy, 100 human teeth with no caries on smooth surfaces were

selected (Lussi 1993). Of the original 100 teeth, 63 (52 molars, 11 premolars) were

found to have macroscopically intact occlusal surfaces. Dentists were informed that all

teeth came from teenagers with average caries experience. They were given 20 seconds


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to examine each tooth, and to make a specific diagnosis for a designated spot on the

occlusal surface. Each tooth was inspected using either: visual inspection; visual

inspection with a magnifying glass; visual inspection combined with conventional

bitewing radiography; visual inspection combined with light pressure probing; and

conventional bitewing radiography. Each dentist was asked to diagnose each specified

spot as either: having no caries; caries confined to enamel; or caries beyond the dentino-

enamel junction (Lussi 1993). After all examinations were completed, the teeth were

sectioned and examined histologically.

Examination by dentists resulted in: 6 teeth with no caries; 19 teeth with caries

confined to enamel; and 38 teeth with caries into dentin. Histologic examination

revealed: 22 teeth with no caries; 13 teeth with caries confined to enamel; and 28 teeth

with caries into dentin. Radiographic examination revealed: 21 teeth with no caries; 9

teeth with caries confined to enamel; and 33 teeth with caries into dentin (Lussi 1993).

Statistical analysis revealed that visual inspection with or without probing had the

lowest sensitivities with .12 and .14 respectively. Visual inspection with magnification

improved sensitivity to .20, yet it was not a significant difference. Significantly higher

values for sensitivity were found only when radiographs were involved, with bitewing

radiography and visual inspection with bitewing radiography yielding sensitivities of .45

and .49 respectively (Lussi 1993). Conversely, examinations which included radiographs

presented with the lowest specificities, although none of them significant. All

specificities ranged from .83 to .93 with bitewing examination being the lowest and

visual inspection and visual inspection with probing being the highest (Lussi 1993).

Once again this study is consistent with the aforementioned studies, which all result in

visual/tactile examinations having strong specificity with poor sensitivity. It can be

concluded that visual examination may not reliably find caries, but will likely minimize

over diagnosis. Lussi suggests that a more objective means of caries detection, e.g. caries


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detection devices may be the most suitable tool in detecting occlusal caries with higher

sensitivity.

In 2004 Ismail did a comprehensive review of the literature. This was not a

systematic review for all evidence published on visual and visuo-tactile methods of caries

detection, rather his review was focused on the content validity of a sample of caries

detection criteria reported in MEDLINE and the Cochrane Collaborations Oral Health

Group (CC-OHG) (Ismail AI 2004). One hundred thirty six articles were selected from

PUBMED and 35 articles from CC-OHG. One of the more important conclusions drawn

from this paper is that there is a huge difference in philosophies between Europe and the

United States. European researchers have been more progressive including early signs of

dental caries in their caries detection criteria, where the USA have focused on measuring

the cavitated stage of caries, when the explorer sticks with visual signs of caries

demineralization (Ismail AI 2004). This review confirms the lack of consistency

regarding explorer use, and again confirms that explorer use adds little caries detection

while posing a possibility of detriment to enamel surfaces. The paper concluded that,

this paper underscores the need to define a criteria system for visual and visuo-tactile

detection of dental caries that has content validity based upon current scientific evidence

and the consensus of experts in the fields of cariology and restorative sciences. (Ismail

AI 2004)

Radiographic Detection

Radiographs are one of the most common methods used by providers to aid in

diagnosis of dental caries. The most common radiograph used is the bitewing technique.

Bitewing examinations are widely used to detect caries that may not be noticed during a

visual clinical examination (Kidd EA, Pitts NB 1990). Bitewing radiographs are also

used to determine the depth of caries involvement. Most often, bitewing examination is


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affiliated with the diagnosis of interproximal caries. It is strongly recommended that

these radiographs be used in the diagnosis of occlusal caries into dentin (Pitts NB 1991).

Ricketts et. al. compared the diagnostic yield in caries diagnosis from traditional D

speed and E speed films for occlusal and interproximal caries (Ricketts DN, Whaites EJ

et al. 1997). In this in vitrostudy, 96 extracted molars and premolars (48 premolars and

48 molars) were collected with a range of carious appearances ranging from sound to

frank cavitation on occlusal and interproximal surfaces. The teeth were examined and

classified into one of the following categories: sound; white spot lesion; brown spot

lesion; stained; undermining discoloration of dentin; cavitation less than 0.7mm; or

cavitation greater than 0.7mm (Ricketts DN, Whaites EJ et al. 1997). The teeth were

positioned in acrylic arch trays to simulate a normal intra-oral anatomical relationship.

Four teeth (2 molars and 2 premolars) were placed in their respective anatomical order

within the four quadrants of the mouth (16 teeth total) and mounted into an articulator.

Six pairs of jaws were fabricated and used for radiographic examination (Ricketts DN,

Whaites EJ et al. 1997).

Bitewing radiographs were made using D speed and E speed films. Five examiners

interpreted the radiographs. All radiographs were viewed using a view box under optimal

settings. The films were examined in two separate sittings in an attempt to minimize

evaluator fatigue. Each proximal and occlusal lesion was scored as: sound; radiolucency

confined to outer half of enamel; radiolucency into inner half of enamel; radiolucency in

outer half of dentin; radiolucency into inner half of dentin. This evaluation process was

repeated at a later time to assess intra-rater reliability.

After radiographic examination/interpretation, all teeth were serially sectioned and

examined. Histologic findings were scored according to the following: sound; enamel

caries in outer half of enamel; enamel caries into inner half of enamel; dentinal caries in

outer half of dentin; dentinal caries into inner half of dentin (Ricketts DN, Whaites EJ et

al. 1997). The largest recorded depth amongst the sections served as the gold standard


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for validating radiographic examination. The sensitivity values at all diagnostic

thresholds and all tooth surfaces were low. In general, the specificity values were high

showing few false positives. However, specificity values for occlusal caries diagnosis in

molars were lower than for other surfaces (Ricketts DN, Whaites EJ et al. 1997). The

findings of low sensitivity are consistent with the works of others (Russell, Pitts 1993,

Ricketts DN, Whaites EJ et al. 1997). Ricketts points out that this may reflect the

difficulty of diagnosing demineralized tooth tissue when x-rays have to pass through

intact buccal and lingual enamel, and that there is histological evidence to support that

lesions are actually larger than they appear radiographically (Gwinnett AJ 1971).

Ricketts also pointed out that in this study the sensitivity of occlusal caries diagnosis in

premolars was so poor that radiographic diagnosis is practically useless.

Wenzel et. al. studied the comparison of visual examination, conventional film, and

digital radiographic enhancement on the assessment of occlusal caries depth, and in

comparison to histologic appearance of the same lesion (Wenzel, Fejerskov et al. 1990).

Forty seven extracted premolars and molars were selected for this study. The clinical

appearance of these teeth ranged from appearing to be non-carious to having a large

cavitation due to caries. Four observers examined these teeth visually and scored them

according to the following rank scale: 0) no caries; 1) caries in enamel, not cavitated; 2)

caries in enamel, not cavitated, presents with broad dark line in fissure; 3) small

cavitation; 4) large cavitation; 5) very large cavitation, likely reaching the pulp (Wenzel,

Fejerskov et al. 1990).

Dental radiographs were made. The teeth were also digitized. The radiographs were

examined and scored according to the following rank scale: 0) no caries; 1) caries in

enamel; 2) caries reaching the dentino-enamel junction; 3) caries in outer half of dentin;

4) caries in inner half of dentin (Wenzel, Fejerskov et al. 1990). The depths of the lesions

were also quantified on the digital images by counting the number of pixels in an

occlusal-pulpal direction. The process was then repeated after a minimum time of one


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month. The teeth were then hemi-sectioned, and the extent of the caries was scored

according to the following rank scale: 0) no caries; 1) caries in enamel; 2) caries reaching

the dentino-enamel junction; 3) caries in outer half of dentin; 4) caries in inner half of

dentin.

Forty five of the initial 47 teeth were used. The histologic findings revealed that 5

teeth were caries-free (score 0), 8 teeth had caries confined to enamel (score 1), 7 had

caries reaching dentino-enamel junction (score 2), 7 had caries in the outer half of dentin

(score 3) and 17 had caries in the inner half of dentin (score 4) (Wenzel, Fejerskov et al.

1990). This study found statistically significant correlations between clinical and

histologic examinations, radiographic and histologic examinations, and digital

radiographic and histologic examinations, with the latter having the strongest

correlations. It is important to note that there was less agreement between traditional

radiographs and histologic depth when compared to the correlation between clinical

examination and histologic depth. It was largely due to the fact that some teeth were

scored as caries free radiographically, when the lesion was actually deep into dentin

(scores 3 or 4) (Wenzel, Fejerskov et al. 1990). It was found that the depth of the lesion

measured through digital radiography was in good accordance with the lesion as it was

found histologically. This reinforces Wenzel et. al.s idea that digital processing may be a

good aid in accurately quantifying occlusal caries depth in a clinical setting.

Wenzel and Fejerskov examined the accuracy of visual inspection, conventional

radiography, and digital radiographic methods in the diagnosis of non-cavitated occlusal

lesions (Wenzel, Fejerskov 1992). Additionally, the study investigated whether two or

more of the previous methods provided an additive effect in the detection of occlusal

caries . One hundred twenty-four fully erupted third molars were radiographed and

extracted. This extracted sample was screened for the presence of cavitated lesions

leaving 78 teeth which met the criteria for this study. All teeth were examined by visual

inspection using air to dry the teeth, but without the use of a probe, and scored according


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to the following scale: 0) no caries; 1) chalky/and occasionally stained fissure indicative

of an early enamel lesion; 2) chalky and dark-stained fissure and a greyish shadow,

indicative of a dental lesion, but with no evidence of cavitation along the fissure entrance;

3) same criteria as 2, but with small surface defects (Wenzel, Fejerskov 1992).

The conventional film radiographs taken prior to extraction were examined using a

light-box and viewer. The scoring criteria were as follows: 1) no caries or changes

confined to enamel; 2) caries reaching dentin, but involving just the outer half; 3) deep

dentinal caries, half-way or more to the pulp. The images were then digitally recorded

and enhanced and scored using the same criteria that was used for scoring the

conventional film radiographs.

The teeth were then serially sectioned, with each section ranging between 500-600

!m in thickness. The sections were scored using the following criteria: 0) no caries; 1)

enamel caries; 2) caries reaching dentin, but involving just the outer half; 3) deep dentinal

caries, half-way or more to the pulp.

The histologic examination revealed 4 teeth to be completely caries-free, 22 teeth

with enamel caries, 24 teeth with shallow dentinal lesions, and 28 teeth with deep

dentinal lesions. By comparison, visual inspection indicated that there were 33 teeth with

dentinal lesions (5 of these were false-positive). Of the 28 teeth with deep dentinal

lesions, visual inspection only made the same diagnosis for 15 of them.

Conventional radiography (CR) indicated that 30 teeth had caries into dentin (5 of

these were false-positive). CR only indicated deep caries in 8 of the 28 teeth with deep

dentinal lesions, however 14 of them were indicated to have lesions into dentin.

Digital enhancement indicated that 34 teeth were carious (6 of these were false-

positive). Fifteen of the 28 deep dentinal lesions were indicated as such through

histological verification.

When conventional radiographs were added to visual inspection results, the true

positive detection rate increased by 11% with an increase in false positives to 7%. When


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digital enhanced radiographs were added to visual inspection there was a gain of 33% in

true positive detection with an increase in false positives of 11%. The results of this

study indicated that visual inspection with digital radiographic examination may provide

better accuracy in occlusal caries diagnosis than the other methods being tested(Wenzel,

Fejerskov 1992).

Russel and Pitts did a preliminary in-vitrostudy where they looked at the sensitivities,

specificities, predictive value positives, and diagnostic accuracies of conventional

bitewing radiography (D speed and E speed) and Radiovisiographs (Russell, Pitts 1993).

One hundred twenty extracted posterior teeth were collected and mounted into silicone

blocks. Four teeth were mounted per block (two molars and two premolars) in an attempt

to mimic a posterior quadrant. Two blocks of four teeth were mounted in a relationship

that mimiced an opposing upper and lower jaw, creating 15 artificial patients. Bitewing

radiographs were made using: conventional D speed film; conventional E speed film; and

Radiovisiographic images. For the conventional film, film settings were modified to

optimize the results for the respective films (Russell, Pitts 1993). The radiographs were

scored accordingly: R0) Sound tooth; R1) Outer half enamel lesion; R2) Inner half

enamel lesion; R3) Outer half dentin lesion; R4) Inner half dentin lesion (Russell, Pitts

1993).

The teeth were serially sectioned and examined independently. The histological

scoring criteria is as follows: 0) no caries; 1) carious lesion in outer half of enamel; 2)

carious lesion in inner half of enamel, but not in dentin; 3) carious lesion into outer half

of dentin; 4) carious lesion into inner half of dentin (Russell, Pitts 1993).

The results seem to indicate a slightly higher sensitivity with radiovisiography than

with conventional radiography for the diagnosis of occlusal caries, however it was not

found to be significant, nor were there any differences between either conventional

radiograph or radiovisiography with regards to specificity, predictive value positive, or

diagnostic accuracy. It is important to note that the sensitivity was found to be quite low


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for all methods with regards to diagnosing occlusal lesions. The author notes that by

using histological appearance to validate the accuracy of carious lesion detection, very

early carious lesions are the likely cause of the low sensitivity (Russell, Pitts 1993). This

article reinforces Wenzels notion that digital processing of radiographic images may

lend to a more accurate estimation of occlusal caries depth than conventional

radiography.

Caries Detection Devices

Fiber Optic Transillumination (FOTI)

As discussed earlier, the presence of lesions is influenced by changes in enamel

structure. Enamel that has been disrupted due to the demineralization process will

scatter photons of light differently than sound intact enamel. It is this scattering of light

that creates the clinical presentation of white spots on the tooth surface.

Fiber Optic Transillumination (FOTI) is used to enhance the clinical presentation of

these white spots due to scattered light. By concentrating a high intensity light on the

tooth surface, the light is permitted to shine through the tooth, highlighting changes in

enamel and dentin. The devices strength is its ability to help discriminate between early

enamel and early dentin lesions (Pretty 2006).

It has been noted in some studies that FOTI diagnosis by eye can be subject to

considerable intra- and inter-observer variation (Sidi AD, Naylor MN 1988, Verdonschot,

Bronkhorst et al. 1992, Verdonschot EH, Wenzel A et al. 1993). To overcome these

difficulties with FOTI, Digital Imaging Fiber-Optic Transillumination (DIFOTI) records

images with a Charge-Coupled Device (CCD) imaging camera, instantaneously. This

enables findings to be controlled and repeatable (Schneiderman, Elbaum et al. 1997).


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Cortes, et. al. compared the performance of visual examination using fiber optic

transillumination to traditional visual examination, and bitewing radiographs to detect

and estimate the depth of occlusal caries (Crtes, Ekstrand et al. 2000). In this study, 59

unrestored molars were selected. The occlusal anatomy of each tooth was diagramed,

and a selected site was identified and marked on the drawing. Each examiner scored the

occlusal surface with respect to the area marked in the drawing on a rank scale as

follows: 0) no or slight change in enamel translucency after prolonged air drying (5

seconds); 1) opacity or discoloration hardly visible on the wet surface, but distinctly

visible after air drying; 2) opacity of discoloration distinctly visible without air drying; 3)

localized enamel breakdown on opaque or discolored enamel and/or greyish discoloration

from underlying dentin; 4) cavitation in opaque or discolored enamel exposing dentin

(Crtes, Ekstrand et al. 2000).

After four hours the same teeth were examined using FOTI and scored according to

the following ranked scale: 0) no shadow or stained area; 1) thin grey shadow appears

when transilluminated; 2) wide grey shadow appears when transilluminated; 3) orange

brown shadow appearing to be in dentin, 2mm or less in diameter; 4) orange brown

shadow appearing in dentin greater than 2mm in diameter (Crtes, Ekstrand et al.2000).

Radiographs of the teeth were made and examined by one examiner, who was not

involved in the visual scoring. The ranked scale used to score the teeth was: 0) no

radiolucency; 1) radiolucency visible in enamel; 2) radiolucency visible in the dentin but

restricted to the outer 1/3 of dentin; 3) radiolucency extending to the middle 1/3 of

dentin; 4) radiolucency in the pulpal 1/3 of dentin.

The teeth were then sectioned into three 250 !m sections. The most extensive

changes were used to score according to the following ranked scale: 0) no

demineralization; 1) outer !enamel demineralized; 2) inner !enamel demineralized; 3)

outer 1/3 dentin demineralized; 4) middle 1/3 dentin demineralized; 5) inner 1/3 dentin

demineralized (Crtes, Ekstrand et al. 2000).


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Cortes et. al. examined the 59 teeth and found histologically that: 6 teeth were caries

free, 10 had caries in outer half of enamel, 24 had caries in inner half of enamel, 13 had

caries in outer third of dentin, 4 had caries in the middle third of dentin, and 2 had caries

in the inner third of dentin. It was found that the highest correlation was found between

visual detection and histological scores, followed by FOTI with histological, and

radiographic detection and histological respectively. These differences were not

statistically significant, however it was noted that the major significance was the poor

ability to detect enamel lesions radiographically. All methods were quite good at

detecting deeper lesions located into dentin, but had difficulties with determining depth

of a lesion in enamel or outer third of dentin (Crtes, Ekstrand et al. 2000). The study

confirmed that FOTI is as accurate as a detailed visual inspection, however it is important

to note from the previously cited literature in this thesis, that visual inspection is not a

great indicator for small lesions due to its poor sensitivity and inconsistent

reproducibility.

In another study, Cortes et. al. compared the combination of FOTI and traditional

visual inspection to traditional visual inspection by itself, FOTI by itself, DIAGNOdent

and Electrical Caries Monitor (ECM) (Crtes, Ellwood et al. 2003). This section will

focus on the visual examinations, while the other caries detection devices will be

addressed in subsequent sections. In this study, 152 sites were used from 111 extracted

molars. The occlusal surfaces of the 111 teeth were photographed and the sites of

interested were indicated on a drawing of the tooth. The visual assessments were scored

according to the criteria seen in (Table 12).

The teeth were then serial sectioned and evaluated by one evaluator. The caries

involvement was scored on a seven point scale based on depth of carious lesion. The

seven categories were: Sound; Outer!of enamel; Inner !of enamel; At the Dentino-

Enamel Junction (DEJ); Outer 1/3 of dentin; Middle 1/3 of dentin; Inner 1/3 of dentin.

The histological assessment found that, of the 152 sites, 34 (22%) were sound; 18 (12%)


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were in the outer half of enamel; 24 (16%) were in the inner half of enamel; 38 (25%)

were at the DEJ; 15 (10%) were in the outer third of dentin; 12 (8%) were in the middle

third of dentin; and 11 (7%) were in the inner third of dentin. Of the 34 sound sites, only

13 (38%) were scored sound using only the visual method and only 17 (50%) using the

FOTI and combined FOTI and visual. The visual method identified 21 (55%) of dentin

lesions correctly and the FOTI and combined FOTI and visual 25 (66%) and 26 (68%)

respectively. The highest correlations with the histological scores were seen for the

combined FOTI and visual and FOTI at (0.66) and (0.64) respectively (Crtes, Ellwood

et al. 2003).

FOTI, Visual and combined FOTI and visual showed high sensitivity and low

specificity for enamel lesions and high specificity and low sensitivity for dentin lesions.

It was concluded from this study that FOTI/visual combined method may be superior to

visual assessment, and that the effectiveness of all methods of assessment were reduced

when in the presence of stain and brown spot lesions (Crtes, Ellwood et al. 2003).

Similar to Cortes et. al., Ashley et. al. did an in vitrostudy where they compared the

Electronic Caries Monitor (ECM), FOTI and traditional and digital bitewing radiography

to one another using histological findings to validate findings (Ashley PF, Blinkhorn AS

et al. 1998). We will focus on the findings related to the methods previously covered and

discuss ECM in a subsequent section. One hundred and three permanent teeth(68

premolars and 35 molars) were selected for this study. The visual assessment was

performed after drying the tooth with compressed air and scoring according to the criteria

developed by Downer, 1975. Similar to the visual assessment, examination was done

using FOTI after drying the tooth with compressed air. Caries was evaluated and

recorded according to the criteria adapted by Houwink et. al in 1970. Radiographs for

each tooth were made using standard radiographic film and direct digital imaging.

After completion of all examinations, each tooth was serially sectioned at

approximately 0.4 mm intervals. All sections were examined under stereomicroscope


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and classified using the criteria developed by Downer, 1975. The histological

examination revealed 41 teeth had sound occlusal surfaces, 25 had evidence of occlusal

caries extending into enamel only and 37 had occlusal caries extending into dentin

(Ashley PF, Blinkhorn AS et al. 1998). The prevalence of disease in the extracted teeth

was 60% with only two teeth having caries which extended beyond 1/3 the total depth of

dentin.

The results illustrated that visual diagnosis had one of the lowest specificities along

with the ECM (0.73) but a slightly lower sensitivity (0.60) and lower positive (0.77) and

negative predictive value (0.55) for enamel lesions. FOTI and both radiographic

techniques both had higher specificities (0.80-0.88) than visual diagnosis and ECM, but

lower positive (0.60-0.72) and negative predictive values (0.40-0.42), and much lower

sensitivities (0.19-0.24 (Ashley PF, Blinkhorn AS et al. 1998)).

For lesions into dentin the ECM provided the highest combination of sensitivity

(0.78) and specificity (0.80) and the highest negative predictive value (0.87). Visual

diagnosis had the highest positive predictive value (0.82) and specificity (0.97). The

ECM had the lowest specificity (0.80) than the other systems (0.89-0.95), but the other

systems had much lower sensitivities (0.14-0.24). FOTI had the lowest combination of

sensitivity and specificity. Visual diagnosis was the least repeatable measurement with a

low value of kappa (0.42). Overall, FOTI and radiographs performed poorly in this

study. The sensitivities and specificities were significantly different from those for the

ECM at both diagnostic levels (Ashley PF, Blinkhorn AS et al. 1998).

DIFOTI

Fifty extracted teeth including: 16 incisors, 8 canines, 12 premolars, and 14 molars

were collected and mounted in modeling stone. Each tooth was inspected clinically by 2

experts using x4 magnification and an explorer, and histologic sections were used as the


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gold standard. These teeth were all scored systematically using DIFOTI. Radiographs

were made of all 50 teeth and examined as well. Five clinicians did the radiological

examinations with four of them having training in DIFOTI. Each of the five clinicians

used radiographic interpretation and DIFOTI techniques. These were scored and

compared to the gold standard in order to determine sensitivity and specificity. For

occlusal lesions this study found the sensitivity of DIFOTI to be over 3 times higher than

radiographic examination with a specificity approximately 10% lower. It was concluded

that DIFOTI had superior diagnostic capabilities when compared to radiographs,

particularly in early, incipient lesions, however it has a greater tendency to over diagnose

when no disease is in fact present.

Laser Fluorescence

Laser light is composed of electromagnetic waves with equal wavelengths and

phases (Fejerskov 2009). Materials, including tooth structure, possess the characteristic

of fluorescence. In fluorescence, emitted light has certain properties (wavelength) which

increases as it is absorbed within the material. The larger wavelength is caused by loss of

energy incurred during the absorption process. By using filtering techniques, this

wavelength can be measured. The measurement recorded is proportional to the physical

properties of the material. When the properties are known, for example sound enamel

and dentin, it can be used as reference. Any change from this reference value can imply a

deviation from normal tissue. Phenomena such as demineralization or bacterial presence

can influence this change. Change in fluorescence radiance and lesion area can be

followed in time to measure lesion development. The amount of fluorescence radiance

loss is related to the mineral loss in the lesion. Therefore, change in fluorescence can be

used as a diagnostic tool to identify the change in surface properties of tooth structure.


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Quantitative Laser Fluorescence (QLF)

De Josselin de Jong et. al. looked at the development of laser fluorescence

methods in an attempt to assess initial enamel caries lesions in vivo. Young teenagers

scheduled for orthodontic therapy were selected for this study. In each patient, two intact

premolars were selected. In each case these teeth were previously treatment

the association between cariescan pro readings and histologic dep

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