diag final

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Good morning

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Diagnosis of Caries

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CONTENTS INTRODUCTION DIAGNOSIS OF CARIES ASSESSMENT TOOLS IN DIAGNOSIS CLASSIFICATION OF CARIES REVIEW OF DIAGNOSTIC METHODS – TRADITIONAL - NEW METHODS GENERAL RECOMMENDATIONS FOR IMPROVEMENT IN CARIES DIAGNOSIS CONCLUSION REFERENCES

INTRODUCTION: 

INTRODUCTION

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Diagnosis : The translation of data gathered by clinical and radiographic examination into a organized, classified, definition of the conditions present. (Mosby’s Dental dictionary ) Diagnosis : is a determination and judgment of variations from normal. (Sturdevant)

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Objectives of caries diagnosis. Diagnosis: The art or act of distinguishing one disease from another

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Clinical Risk Assessment for Caries: A patient is at high risk for the development of new cavitated lesions if . 1) High MS counts are found 2) Any two of the following factors are present Two or more active carious lesions Large number of restorations Poor dietary habits Low salivary flow

IDENTIFICATION OF ACTIVITY STATE: 

IDENTIFICATION OF ACTIVITY STATE Possible Activity Status : Lower caries risk High caries risk Active slow caries Active rapid caries Arrested caries

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ASSESSMENT TOOLS : Patient history Clinical examination Nutritional analysis Salivary analysis Radiographic Assesment

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Patient History: Clinical Examination :

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Nutritional Analysis : Salivary Analysis :

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The Problem Of Diagnosis ? Sensitivity Vs Specificity Sensitivity: It is defined by the probability of the test giving a positive finding when disease is present. Specificity: It is the probability of a negative finding when disease is absent.

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False positive -- Questionable lesion False negative -- Lesion redetected The indications are that the use of the method of diagnosis gives sensitivities of the order of 60% and a specificity of 85%.

Classification of Dental Caries: 

Classification of Dental Caries Incipient caries: White spots, white opaque areas that are revealed only when the tooth is dessicated

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Pit and fissure caries smooth surface caries Forward – Backward Caries .

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Senile Caries: Aging process. Exposed root surfaces . Partial denture clasps Residual caries: Accident, neglect Intention.

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Simple, compound and Complex Caries.

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G.V. Black Classification of Caries:

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Site Size No cavity(0) Minimum (1) Moderate (2) Enlarged (3) Extensive (4) Pit & fissure (1) 1.0 1.1 1.2 1.3 1.4 Contact area (2) 2.0 2.1 2.3 2.4 2.5 Cervical (3) 3.0 3.1 3.2 3.3 3.4 Description of caries lesions according to newer classification of caries.

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According to WHO the shape & depth of carious lesion can be scored

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C. REVIEW OF DIAGNOSTIC METHODS AND CRITERIA IN USE TODAY : 1) Traditional Methods Clinical diagnosis Radiographic diagnosis Elective temporary tooth separation Dyes Bacteriologic tests Fibre optic transillumination 2) Newer Methods : Digital fibre optic transillumination. Qualitative light induced fluorescence (QLF) Electrical conductance measurements Direct digital radiography Near Infrared Transillumination .

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G.V.Black – “ a sharp explorer should be used with some pressure & if a very slight pull is required to remove it, the pit should be marked for restoration even if there are no signs of decay” CLINICAL EXAMINATION Dr. Nigel B. Kidds Sharp Eyes But Blunt Explorers

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BASCD & WHO: “ if in the opinion of the examiner after visual inspection a doubt exists, the surface should be investigated with a blunt probe & unless the point enters the lesion ,the surface will be regarded as sound. The blunt probe should have a tip of 0.5 mm” VALIDITY ???

VISUAL & TACTILE EXAMINATION : 

VISUAL & TACTILE EXAMINATION The Visual method- used by many General practitioners The Visual-Tactile method

VISUAL METHOD WITH TEMPORARY TOOTH SEPARATION : 

VISUAL METHOD WITH TEMPORARY TOOTH SEPARATION The visual method with temporary Elective Tooth Separation The Visual Method with Temporary Elective Tooth Separation and Impression of the approximal lesion

RADIOGRAPHY: 

RADIOGRAPHY ADVANTAGES : Discloses sites inaccessible to other methods Detects at early , reversible stage Depth of lesion can be evaluated and scored. Permanent record Non-invasive

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Suggested ranking for radigraphic diagnosis of dental caries (early proximal lesions) (Axelson) Lesion confined to outer half of enamel Lesion penetrating dej. No lesion Lesion spreading laterally in dentin. Lesion penetrating dentin with the possibility of pulpal involvement.

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LIMITATIONS Does not distinguish b/w sound, subsurface & cavitated lesions Underestimation of demineralization Proximal caries on the apical 3 rd of the restoration may not be detected Can’t detect buccal/lingual caries Occlusal caries not seen until it reaches the DEJ

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Direct: Direct images on computer screen. Indirect Scanning an existing radiograph Min resolution 300dpi DIGITAL RADIOGRAPHY

Digital Imaging: 

Digital Imaging Digital sensors : Charge couple device based sensors (CCD) Complimentary metal oxide semiconductors (CMOS) Photo stimulable phosphor plates (PSP) CCD and CMOS – computer – images are displayed immeditely. PSP – latent image in image plate – exposed to laser scanner .

Charge-Coupled device: 

Charge-Coupled device Egs: Durr Vista Ray Trophy RVG, Sens-A-Ray, Visualix/Vixa

Digora system: 

Digora system

COMPUTER AIDED RADIORAPHY: 

COMPUTER AIDED RADIORAPHY Trophy 97 system- AI system (Logicon caries detector) Unique histologic & pathologic database

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According to kantor et al (Am J Dent Aug 2005;18(5) 241 -244) who compared the conventional radiography with digital radiography and found no statistically significant difference in diagnosis of proximal caries.

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Dyes used for detection of Carious Enamel Procion dyes Calcein dyes Brilliant blue DYES

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Dyes for detection of Carious dentin. 0.5% basic fuschin in propylene glycol Demin r dentin – denatured collagen – stains Acid red & Methylene blue. Vista red, Vistadental

Fiber Optic Transillumination : 

Fiber Optic Transillumination Advantages: Patient can see the problems that the practitioner is addressing vital in patient education and motivation. Screening device to see if radiographs are necessary Used in anteriors, premolars ≥ bitewing radiographs Can detect enamel crazing, cracks

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Transillumination devices: Standard ENT examination light Some composite curing lamps that have filtered tips that change the wavelength of light to yellow-orange Some small light probes used in electronics. fiber optic light built into lighting hand pieces.

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Digital Fiber Optic Transillumination (DIFOTI ) is a relatively new methodology that was developed to reduce the shortcomings of FOTI by combining FOTI and a digital CCD camera.

DIFOTI (DCNA 2005): 

DIFOTI (DCNA 2005) Components: 2 handpieces Disposable mouth piece Foot control for selecting the images Computer

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Correct placement of proximal mouthpiece. Position the hand piece. Image review PROCEDURE

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ADVANTAGES Doesn’t need ionizing radiation Instant images for comparison to evaluate any changes Non invasive early caries ,hidden caries Difoti more sensitive than conventional radiographs

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Limitations: Cant determine the depth of lesion Learning curve required White spots can be mistaken for cavitations Interproximal caries

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In a invitro study (JADA dec 2005;136(12):1682 – 7) authors compared conventional bitewing radiograph and DIFOTI. Their findings were that DIFOTI was not able to measure the depth of samples But it can show surface changes as early as 2 weeks.

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LASER FLUORESCENCE METHOD (LF) : Measures the fluorescence of the tooth that is induced after light irradiation to discriminate between carious and sound enamel. What is florescence? Autoflorescence

DIAGNODENT: 

DIAGNODENT Hibst and Gall , 1998, showed that red laser light (655 nm )and 1 mW peak power floroscence Diagnodent pen

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0 and 99 and adjustable sound Readings (Tam & McComb, J Dent Res 2001): 0-5 : no caries 5-25: initial lesions 25-35:early dentinal caries > 35: advanced dentinal caries

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According to Nelson et al (caries research mar – apr2000;34(2):151 – 8) diagnostic accuracy was excellent to KaVo DIAGNOdent when compared with radiography. According to seeds et al (QI feb 2003;34(2) 109 -116) DIAGNOdent was able to determine secondary caries under composite restorations when compared with a gold standard of histologic examination

QUANTITATIVE LASER/LIGHT FLUORESCENCE: 

QUANTITATIVE LASER/LIGHT FLUORESCENCE Bejelkhagen & Sundstrom (1981)

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Tooth appears yellow-green &Demineralized areas-dark ADVANTAGES: Incipient lesions – 25 μ m De Josselin De Jong (1992)-amt of mineral loss Monitor changes in lesions Red fluorescence-plaque, leaky margins

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LIMITATIONS: On accessible smooth surfaces only Lesion depth of about 400 µ m Cant discriminate between enamel & dentin lesions Not suitable for dentin demineralization Cant differentiate between decay , hypoplasia Wet/dry state, presence of plaque , calculus

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DYE ENHANCED LASER FLUORSCENCE Procion dyes Calcein dyes 10 % brilliant blue Other fluorescent dyes Fluorol 7GA Pyrromethane556-can detect only 2 hr of demineralization Sodium Fluorescein

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Ultra-Sound Imaging. Adv Dent Res 7(2):70-79, 1993 Introduced Ng et al (1988) Detecting early caries of smooth surface. Ultra sound pulse echo technique. Minereal content of body lesion relative echo amplitude changes

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Ultrasonic probe White spot lesion No/ weak surface echoes Visible cavitation High amplitude echo Tooth surface

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Endoscope/Videoscope Based on fluorescence — 400-500nm Viewed through a specific broad band gelatine filter—caries lesion – dark spots. White light endoscopy Integrated camera --- Videoscope

ELECTRICAL CONDUCTANCE (FIXED FREQUENCY) METHOD: 

ELECTRICAL CONDUCTANCE (FIXED FREQUENCY) METHOD Vangaurd caries detector 0 to 9 Indicators for Caries L meter are 4 coloured lights (DCNA, 1999) Green- No caries Yellow- Enamel Orange- Dentin caries Red - Pulpal involvement

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Indications: Pit and fissure caries Failure of fissure sealants False +ve results: Immature teeth Cracks in enamel

IMAGING WITH NEAR-INFRARED LIGHT (Daniel Fried, DCNA, 2005): 

IMAGING WITH NEAR-INFRARED LIGHT (Daniel Fried, DCNA, 2005) Visible light Radiography NIR image PRINCIPLE : Enamel is highly transparent in the near infrared (NIR). Demineralized areas appear dark due to attenuation DISADVANTAGES : FOTI, QLF, Diagnodent

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NIR systems InGaAs focal plane array - operates from 1000-1600 nm Low cost CCD camera - 830 nm- not very high contrast as with 1310 nm LIGHT SOURCES NIR laser diodes Tungsten-halogen lamps Superluminescent Diodes (SLD)-uniform illumination, better images

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ADVANTAGES: Lesion more clearly seen than with bitewing Better image contrast at NIR wavelengths than by X rays Can differentiate from stains , pigmentation, fluorosis & demineralization Can examine defects, cracks in enamel

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Can detect incipient lesions not seen in radiographs

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Detection of subsurface decay hidden under the enamel.

CARIES ACTIVITY TESTS: 

CARIES ACTIVITY TESTS DEFINTION The increment of active lesions (new and recurrent lesions) over a stated period of time. Caries activity is a measure of the speed of progression of a carious lesion. (Soben Peter)

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Various tests are Lactobacillus colony count. Snyder test The swab test. Buffer capacity test. Enamel Solubility test Reductase test. Alban test. Streptococcus Mutans Screening test Plaque / tooth pick method Saliva / Tongue Blade method. Fosdick calcium Dissolution test. Dewar test.

References: 

References Hidden and incipient carious lesions: DCNA 49,2005. Cariology: Newburn Diagnosis of Caries: Axelsson Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis. J.Dent may 2002;30(4):129-134. In Vitro evaluation of Diagnodent for detecting secondary carious lesion associated with resin composite resin. Q.I 2003;34(2):109-116

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Conclusion

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THANK YOU