cariesdiagnosis

1. Dr.Basavan Gowda
Reader
Dept.Conservative Dentistry
&Endodontics
Navodaya Dental College
Raichur
CARIES DIAGNOSIS &
CARIES VACCINE

2. INTR
O
DUC
TIO
N
Dental caries - multi factorial disease of the calcified
tissues of the teeth, characterized by
demineralization of the inorganic portion and
destruction of the organic substances of the tooth.
progressive bacterial damage to teeth.
of
population
one of the most common diseases-95
& still a major cause of tooth loss.

3. Diagnosis isthe art oract ofidentifyingadiseasefromits
signsand symptoms.
The worddiagnosis(plural, diagnoses)-Greek ‘‘dia’’
meaning‘‘thorough’’ and‘‘gnosis’’ meaning
‘‘knowledge’’.

4. IDEAL R
E
Q
U
I
R
E
M
E
N
T
S
1. Accurate.
2.Sensitive.
3.Specific.
4.Reproducible.
5.Reliable.
6.Not transfer S. Mutants fromaffected area to
unaffected area
7.Cost effective

5. H
Ii
S
T
O
R
YO
FPATiIENT
History
Factors
Risk Increasing
(Observational)
Childhood,
Adolescence
Age
Senescen
ce
Women at slightly
greater
Gende
r risk
No fluoride in public
water
Fluoride
exposure
supply
Diet
Sugar containing foods, sticky
foods
Smoking
Risk
increases
General
Health
GIT disorders & H/O
Radiation
Medication
reduce salivary
flow

6. M
E
T
H
O
D
S F
O
R DIAGNOSING C
A
R
iI
E
S
VISUAL EXAMINATION.
TACTILE EVIDENCE OFCARIES-PROBING
TOOTH SEPARATION.
DENTAL FLOSS.
RADIOGRAPHIC
MODIFIED RADIOGRAPHIC TECHNIQUES
IOPA
CONVENTIONAL
BITEWING
XERORADIOGRAPHY
DIGITAL
ENHANCEME
NT
COMPUT
ER
IMAGE
ANALYSI
S
SUBSTRACTI
ON
RADIOGRAP
HY
CBC
T

7. INTRAORALCAMERA
ELECTRIC RESISTANCE ( CONDUCTANCE)
OPTICALDETECTION
DYES
FIBER OPTIC
TRANSILLUMINATION
DIGITAL IMAGING FIBER
OPTIC TRANSILLUMINATION
QUANTITATIVE LASER
FLUORESCENE
DIAGNODENT

8. R
E
C
E
N
TA
D
V
A
N
C
E
S
TERAHERTZ IMAGING
OPTICAL COHERENCE TOMOGRAPHY
CARIE SCAN
ULTRASONIC IMAGING

9. TRADITIONAL M
E
T
H
O
D
S
VISUAL EXAMINATION:
Encompasses – criteria - detection of whitespot,
discoloration andfrankcavitation.
Examiner detects caries - changeintranslucency o
f
enamel.
Clean, dry and well-illuminatedfield.
ICDAS – INTERNATIONAL CARIES DETECTIONANDASSESSSMENT
SYSTEM - improved version of visual methods.

11. DISADVANTAGES
Reliabilit
y
Caries
depth
Discoloratio
n
– pits –
healthy
tooth
– mistaken
–
caries

12. T
A
C
T
I
L
E E
V
I
D
E
N
C
E O
F CARIES:
E
X
P
L
O
R
E
R
Determiningroughnessor softnessof tooth surface withasharp
explorer.
Both penetration &resistance to removalof anexplorertip -
evidence of demineralization
The explorer can be of different varieties such as:
a) Rightangleprobe
b) Backactionprobe
c) Shepherds crook
d) Cowhornwithcurved ends

13. T
O
O
T
H
S
E
P
A
R
A
T
I
O
N
Electively and temporarily separatingapproximalsurfaces - examine them
Adjunct to C &R examination
It has goodpotential in validating other diagnostic methods of
detecting approximal lesions.
The method requires asecond brief visit after aperiodof 3-7 days.
LIMITATIONS:
Requires second visit
Discomfort to patient.

14. D
E
N
T
A
LF
L
O
S
S
Pickard(1961) - use of dental floss for
detection of caries.
If its shreads one can suspect
a proximal cavity.
Disadvantage- overhanging restorations- proximal
side –same features.

15. RADIOGRAPHICTECHNIQUES
CONVENTIONAL RADIOGRAPHS
2 dimensionalpicture of 3 dimensionalobject.
Net mineral lossmustexceed at least 40-60 - radio graphically visible.
IOPA-
primarily used for detecting changes around roots & in b/n teeth
Paralleling technique is superior to bisecting technique
Visualization of approx 3teeth

16. B
ITE
W
ING
To detect INCIPIENT CARIES AT CONTACT POINTS
8 teeth in one radiograph can be
visualized
Regarding…
incipient carious lesions,
cervical margins of restoration ,
alveolar crest height ,
pulp chambers.

17. PROBLEMS ENCOUNTER WITH RADIOGRAPHIC
METHODS
1. Overlappingof proximalcontacts.
2. Gagging sensation
3. False diagnosisdueto overestimation- increase lesiondepth -change -
angulations.
4. Radiolucency cannot bejudged- becauseof caries /resorption
5. Superficial demineralization - buccal &lingualsurfaces - imaged- approximal
caries.
6. Cervical burnoutmaymimiccervical caries.

18. RADIOGRAPHIC INTERPRETATION OF OCCLUSAL CARIES
LIMITATIONS
1.Caries in enamel - difficult -superimposition of
enamel over the fissures.
2. Lesions involving buccal grooves of molars are
superimposed over the occlusal area - simulate
occlusal lesions.
3. A thin radiolucency appears at the DEJ in occlusal
caries, which is missed -considering - normal
difference of radiolucency in enamel & dentin.

19. P
R
O
B
L
E
M
SINDIAGNOSISO
FS
E
C
O
N
D
A
R
YC
A
R
I
E
S
Lesions - occlusal surface, b/n restoration & tooth
cannot be visualized until - advanced stage.
It is often difficult to differentiate between
secondary caries & caries which have been left
during restoration (residual caries).

20. X
E
R
O
R
A
D
IOGR
APH
Y
It is complete drynonchemicalprocess
Imageis recorded onaluminiumplate coated -layer of seleniumparticles.
Selenium particles - uniform electrostatic charge &stored - conditioner.
When X-rays are passed – film selective discharge –Se particles.
POSITIVE IMAGE LATENT IMAGE
DEVELOPME
NT
C.F
.Carlson
1937

21. X
E
R
OR
A
D
IOGR
A
P
H
Y
• Later the procedure,Alplate - cleaned andusedagain .
• Xeroradiography istwice assensitive asconventional films
andaphenomenonof 'EdgeEnhancement'ispossiblewith
this technique.
• Nodarkroomfordeveloping.
• Nospeciallight source for view.

22. X
E
R
O
R
A
D
I
O
G
R
A
P
H
Y
ADVANTAGES
• Edge enhancement
• Less radiation
• Economical
DISADVANTAGES
• Electric charge-film – discomfort to
patient
• Development- 15 min

23. R
E
A
S
O
NF
O
RA
D
V
A
N
C
E
S
New diagnostic modalities allow early lesions of caries to be
quantified.
Advantages of early caries detection:
Opportunity to monitor caries progression by
remineralization.
Creates an opportunity for a preventive - outdated
“Drill and Fill” approach.

24. INTRAORALC
AM
ER
A
Camera placed inside oral cavity
to display
Intra oral images on a computer
• Improved visual access
• Improved lightening
• Improved magnification
• Demonstrate pt needs
for treatment

25. MODIFIEDRADIOGRAPHICTECHNIQUES
DIGITAL ENHANCEMENT
R/F recorded – digitalimagereceptors &enhanced– computer
processing.
Adigitalimage- imageformed&represented byaspatially
distributed set of discrete sensors&PIXELS.
Receptors-highly sensitive sensors- lessradiationexposurethan
film
It isthe Imagethat hasbeenrecorded withnon-film receptor.

26. Twotypes of nonfilmreceptors for recordingdigital
images :
Digital imagereceptor (DIR)-collects x- rays
directly(DDI) Direct digital imaging
Scanning device -forming digitalimages- radiograph(IDI)
Indirect digitalimaging

27. DIRECTR
E
C
E
P
T
O
R
S
Direct receptors communicate- computer -electronic
cable-transfers data -radiofrequency transmitter.
charged coupledevice (CCD)-connected to computer.
CCD isasemiconductor- metal oxides(silicon) that i
s
coated withx-ray sensitivephosphorous.
CCD issensitive bothto X-rays andvisiblelight.

28. displayed for viewing.
x-rays strike the screen
light photons are
produced, detected -
CCD.
stored in the computer- image
processing
The intraoral DIR is placed in the
mouth

29. INDIRECTR
E
C
E
P
T
O
R
S
When x-rays interact - phosphor,
latent image is formed & stored
plates - transferred & inserted -
scanning device
digitized, using laser light
scanning.
Digitized images -
stored- displayed-
computer
Photostimulable phosphorplates(PSP)

30. ADVANTAG
E
S
• Darkroom isnotrequired
• Instant imageisviewed
• The quality of imageisconsistent
• Eliminationof the hazards of filmdevelopment
• Radiation doseisdecreased
• Capability for teletransmission.
D
I
S
A
D
V
A
N
T
A
G
E
S
• High cost of system
• life expectancy - not fixed
• Detection of occlusal caries: performed almost equally well.
• No value in detection of initial enamel lesions / proximal dentinal
lesions

31. Madeit possibleto useautomated
procedures-overcome-
shortcomings-human eye - caries
detection.
Softwares - developed for
automated interpretation of digital
radiographs.
This technique isbasedonthe
“EXPERT SYSTEM”
programme gives us the
diagnosis.
programme compares the
patient’s data with the basic
knowledge of the pathology.
clinician enters the
patient’s data
C
O
M
P
U
T
E
RIMAGEANALYSIS

32. A
DV
A
NT
A
G
E
S
• provide sensitive and objective observation- small
lesions
• possible to monitor the lesion
• Quantification of small lesions - possible
D
IS
A
D
V
ANT
A
GES
• Always need-standardization of exposure geometry
• Sensitivity is higher but specificity is lesser
• Time consuming and less economical.

33. SUBTRACTIONRADIOGRAPHY
PRINCIPLE: Optimally, all unchanged anatomical background structures will
cancel and unchanged areas will be displayed in a neutral grey shade in the
subtraction image.
Areaswithmineralloss- darkershadesof grey
Structured noiseisreduced- to increasethe detectability o
f
changesinthe radiographicpattern.

34. Structured noisesare the images, whichare not of diagnosticvalue a
n
d
interfere inroutine interpretation of radiographs.
Disadvantages:
Inability to produce correct projection
geometry
Improper density and
contrast

35. C
O
N
EBEAMC
T
Chief limitation- conventional intra-oral radiographs-
(2D) image- structure (3D).
CBCT - three dimensionalimaging(3D) system
This method- constructs radiographicslices, cross-
section throughteeth

36. Slices - viewed for radiolucencies
Specifically useful for the detection of RECURRENT
CARIES.
CBCT - utilizes least amount of radiation- cost
effective for patients.
Radiation dose = quarter panoramic image / five
dental x rays- high-speed film.

37. O
P
T
I
C
A
LD
E
T
E
C
T
I
O
N
Principle: carious lesion - low index- light transmission,
-
appears- dark shadow.
Evolved due -growing concerns about ionizing radiations
Vaarkamp et al(1997): early enamel lesions can be detected.
Fiberoptic - halogen lamp +rheostat ------> lightof variable
intensity
FIBRE OPTIC TRANSILLUMINATION

38. For examination, tip - probe - Embrasure
immediately
beneath the contact point
Shadow - beneath -marginal ridge may be
evident -
break - integrity -enamel
This can detect Enamel– crazing, cracks in tooth.

39. DIGITALIMAGINGFIBEROPTICTRANSILLUMINATION
shortcomings of
FOTI
- FOTI - digital
DIFOTI -
overcome CCD
camera.
tooth
FOTI - proximalandocclusal caries
DIFOTI - Both incipient &frank caries – all
surfaces
It was developed by Schneiderman et al
1997

40. MECHANISM:
Light propagates -optical fiber - tooth .
During Transillumination, - area of demineralization scatter
light and incipientlesionsappear darker - image.
Image - digital electronic CCD camera -
eliminate inter/intra examiner variability.
Image - analyzed-computer.
It can not only detect the early lesions but also monitor
-
progress of lesion.

42. A
D
V
A
N
T
A
G
E
S
• Detect fractures, integrity -
restorations
• Instant images – obtained
• Non invasive
• detects early & hidden caries
• No film, film processing
LIMIT
A
TIONS
• It cannot indicate - depth of lesion penetration.
• Cannot be used to detect caries in subgingival area.
• Cannot image -tooth completely covered by
restoration

43. QUANTITATIVEL
A
S
E
RO
R
LIGHT– INDUCEDF
L
U
O
R
E
S
C
E
N
C
E
Quantitative assessment of dental caries.
1st investigation-Bejelkhagen &Sundstrom (1981).
In QLF method, tooth - irradiating -visible light - blue
green region.

44. Tooth- fluorescent green - Demineralized - as dark
spots.
Fluorescent filtered images - CCD video camera.
Data - collected, stored and analyzed by custom-made
software.
Clinical applications:
clinical trials, patient education, and preventive clinical
practice.
Monitor demineralization of teeth.
early secondary caries beneath restorations

45. Advantag
es:
• Incipient lesions - detected.
• Sometimes red fluorescence-porphyrins - indicates presence
of dental biofilm, or high caries activity
• Quantification – enamel lesions -depth -400 µm
Limitations:
• Cannot discriminate b/n enamel lesions & dentin
• Cannot differentiate b/n decay, hypoplasia & unusual anatomical
features

46. L
A
S
E
R F
L
U
O
R
E
S
C
E
N
C
E
M
E
T
H
O
D
Measures the fluorescence - tooth that is induced after
light irradiation to discriminate between carious and
sound enamel.
DIAGNODENT:
It is a portable diode laser device.
It operates- infra red light from a diode laser
light- transmitted - descendent optic fiber to a hand-held
probe-
surface of tooth

47. Emitted fluorescence measured- photo-diode detector.
control unit displays digital representation - wavelength
detected
The signal is finally processed & display an integer b/n 0 and 99
and also acoustically.

48. If the reading is 21-100 - definite area of decay -
require operative intervention.
5-25: initial lesions
25-35: early dentinal caries
> 35: advanced dentinal
caries Clinical applications:
The device performs best on smooth surfaces
and inocclusal pits and fissures

49. D
I
A
G
N
O
D
E
N
T
P
E
N
Improved version -diagnodent.
It has improved tips (less prone to breakage) &
new small tip for detection of interproximal caries.
Better digital display and audible caries indicator
are also included .

50. D
Y
E P
E
N
E
T
R
A
T
I
O
N METHOD:
In caries diagnosis, qualitative examination-
prior
requirement.
observation of coloured dye signifies presence
of caries.
Dyes should fulfill the following criteria :
Dyes
should be
absolutely
safe for
intra oral
use.
Dyes should
be
specific
Dyes -easily
removed & not
lead to permanent
staining.

51. DYES-C
A
R
I
O
U
SE
N
A
M
E
L
'Procion' dyesstain enamel- irreversible andacts as
a fixative.
'Calcein' dyemakesacomplexwithcalcium- boundto
the lesion.
'Brilliant blue‘- enhance the diagnosticquality of FOTI

52. DYES-C
A
R
I
O
U
SD
E
N
T
IN
carious dentin- twolayers- outer layer-soft -cannot b
e
remineralized &inner- hard&canberemineralized.
0.3 Basic Fuschininpropylene glycol– demineralized
dentinwhichthe collagenisstained- inneroneremains
unstained– outer dentin removed clinically.
The staining by the dye is the result of denaturation
of collagen.

53. Basic Fuschindye– carcinogenic- replaced- acidred&
methylene blue.
Methylene blueisalsoslightlytoxic soacidred i
s
preferred.
Acid red is specific and more reliable

54. M
O
D
I
F
I
E
DD
Y
E
P
E
N
E
T
R
A
T
I
O
NM
E
T
H
O
D
'The Iodinepenetration method'-enamel porosity-
incipient caries- Bakhoset al. (1977).
Potassium iodide- specific periodof time -
well-defined area of enamel- excess is removed.
The iodine,whichremainsinthe micropores, is
estimated andthat indicates the permeabilityof
enamel.

55. TERAHERTZ IMAGING
Terahertz pulse imaging (TPI) - new imaging
technique
Terahertz freq 1012HZ / wavelength of 30µm.
Although, the TPI - new technique - imaging caries -a
hope in future it could indicate caries in all areas of
teeth
For an image to be obtained by terahertz irradiation
the
object is placed in the path of the terahertz beam.
R
E
C
E
N
T
A
D
V
A
N
C
E
S

56. Also possible - record terahertz images -CCD detector
.
Longitudinal sections through 3 teeth have
demonstrated
increased terahertz absorption by early occlusal caries
Work in progress to image intact teeth with early
carious
lesions.

57. Advantages:
• TPI system uses only micro-watts - non-ionizing
• more safer than those employing X-rays
• Adverse thermal effects are unlike
Disadvantages:
• Relatively expensive
• Needs more researches to make it possible to be
used in OC

58. OPTICAL COHERENCE
TOMOGRAPHY (OCT)
Method of measuring transparent and
semitransparent
structures
Based on interference of light- & measures -
light scattering
OCT can be defined as optical infer metric technique
tocreate cross sectional images of scattering media.

59. OPTICAL COHERENCE
TOMOGRAPHY (OCT)
OCT provides high resolution - imaging of
incipient caries.
With OCT, early lesions can be readily identified as
regions ofhigh light backscattering with depth into
the enamel as compared to healthy sound
enamel.

60. Clinicalapplications:
• Imaging -
interproximal
& occlusal
caries
• Early root
caries
Advantages
•quantitatively
monitor-
mineral
changes -
lesion.
• Can determine
depth of the
lesion.
Disadvantages
•Regions of high
light
backscattering
- not related to
caries
development can
lead to false
positive results.

61. CARiiiIES
CA
N
Cariescan offerrs earliest possible detection of caries.
Unique device provides accurate & repeatable
data tomonitor caries over time.
Mechanism:
It utilizes AC impedance spectroscopy (ACIST).
The impedance- healthy tooth -very high due to
relatively low ionic conduction.

62. As a tooth demineralizes – increase- larger pores.
As lesion progresses, pores -connect & tooth becomes a
mix of high & low conductive parts -
impedance decreases.
As the decay progresses, dentin involved- impedance falls
further.
As a result the sensitivity and specificity of the ACIST
system in distinguishing these different stages is very high .

63. 0-100
scale
0-50 = low probability of
caries
51-90 = medium probability of
caries
91-100 = high probability of caries
Used for the detection of EARLY AND HIDDEN LESIONS
92.5 accurate in detecting both sound and carious teeth,
minimizing false positive or false negative results.

64. A
DV
A
N
T
A
G
E
S
• Highest proven accuracy of all caries detection methods
• No ionizing radiation risk
• Easy to record and compare progress
C
O
N
T
R
A
I
N
D
I
C
A
T
I
O
N
S:
patients with cardiac pacemakers fitted.
D
I
S
A
D
V
AN
T
A
GES:It cannot be used to assess:
Secondary caries
Integrity of a
restoration Dental
root caries
It should not be used when tooth surfaces - plaque and or

65. U
L
T
R
A
S
O
N
I
CI
M
A
G
I
N
G
Introduced - detecting early carious lesions -
smooth surfaces.
PRINCIPLE:
The demineralization of natural enamel is
assessed byultrasound pulse echo technique
It is observed -definite correlation b/n mineral content
of
lesion & relative echo amplitude changes.

66. Ultrasonicprobe - longitudinal waves - surface - tooth & also serves
the
function of receiving the Waves.
Application: To find lesions on smooth
surfaces &
detecting
RECURRENT
CARIE
S
Sound wave with frequency 1.6 to 10 MHz
Initial white spot lesions ─ no or weak echo
Cavitated lesions ─ echo with high
amplitude
To be
continued………