Caries diagnosis handout


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Clinical caries diagnosis and classification

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Caries diagnosis handout

  1. 1. 4/13/2010 1 Prepared by Dr Lea Foster 1 Dental Caries is a disease of the hard tissues, characterized by the decalcification of the inorganic portions of the tooth. Loss of the mineral content is the followed by breakdown of the organic matrix. This destructive process results from the metabolism of carbohydrates by microorganisms. 2 caries (ker´ēz), n in dentistry, the decay of a tooth. Colloquial term is cavity. Advanced caries. caries, arrested, n the state existing when the progress of the decay process has halted. It is noted by its dark staining without any breakdown of tooth tissues. Caries Assessment Tool (CAT), an analysis that examines the risk factors for the development of dental caries in infants and young children. Risk factors such as the environment, family history, and general health can be identified early, thereby reducing a patient's risk for developing dental caries and other diseases of the teeth and gingival tissues. caries, baby bottle, n See caries, early childhood (EEC). caries, cemental (root surface), n the decay of the caries, gross, n a form of caries with advanced dental decay that is easily seen clinically. caries, healed, n See caries, arrested. caries, incipient, n a decayed part of a tooth in which the lesion is just coming into existence. caries, nursing, n See caries, early childhood (EEC). caries, pit-and-fissure, n See cavity, pit and fissure. See also sealant, enamel. caries, plaque-related, n the caries associated with plaque formation. Most commonly located in the pits and fissures of the teeth, especially the molar and premolar teeth, and along the gingival tissue and also the margins associated with dental restorations. caries, proximal, n decay occurring in the mesial or, ( ), y cementum that occurs as a result of gingival recession and exposure of the root surface. See also caries, cervical (root surface). caries, cervical (root surface), n the decay that appears on the root at the cementoenamel junction or the neck as a result of gingival recession and exposure of the root surface. See also caries, cemental (root surface). caries, chronic, n a form of caries that occurs over time and demands regular dental intervention. caries, compound, n a type of caries that affects two or more surfaces of a tooth. caries, early childhood (EEC), n a form of severe dental decay occurring in young children that is caused by long and frequent exposure to liquids that are high in sugar, such as milk or juice. Because this form can damage the underlying bone structure, it may affect the development of permanent teeth. caries, enamel, n the decay that occurs in the enamel of a tooth because of a fissure or the collection of bacterial plaque. It appears first as white spots, which later darken to brown. distal surface of a tooth. caries, rampant, n a suddenly appearing, widespread, rapidly progressing type of caries. caries, recurrent, n the extension of the carious process beyond the margin of a restoration. Also called secondary caries. caries, residual, n (residual carious dentin), the decayed material left in a prepared cavity and over which a restoration is placed. caries, root, n tooth decay occurring on a portion of the root that is exposed. Root caries. caries, senile n older term for the decay noted particularly in the elderly when supporting tissues have receded; occurs in cementum, usually on proximal surfaces of the teeth. caries, smooth surface, n the decay that occurs on the smooth surfaces of the tooth. See also caries, proximal dental and S. mutans. 3 Cavity G.V. Black Class I Caries Mount and Hume Site: 1 – Pit and fissure 2 Approximal Class II Class III Class IV Class V 2 - Approximal 3 – Close to Gingival Margin Size: Minimum Moderate Large Extensive 4 Class I, II, III, IV,V 5 Class I – Originating in occlusal or buccal pits and fissures 6
  2. 2. 4/13/2010 2 Class II – Interproximal lesions – posterior teeth Mesio-occlusal (MO) Disto-occlusal (DO) Mesio-occluso-distal (MOD) 7 Class III – Interproximal lesions – anterior teeth 8 Class IV – interproximal anterior lesions involving the incisal edge 9 A Bit of EverythingA Bit of Everything 10 Pits and fissures InterproximalsInterproximals Cervical margins Root surfaces Restoration margins 11 12
  3. 3. 4/13/2010 3 A multi factorialA multi-factorial disease 13 1. Enamel lesion- no cavity 2. Enamel lesion – cavity 3 Dentine lesion Pit and Fissure Approximal Cervical margin Root caries S h f ( l 3. Dentine lesion 4. Dentine lesion with pulpal involvement Smooth surface (early childhood/ baby bottle) Recurrent Iatrogenic Arrested 14 History, Clinical Examination and Diagnostic aidsand Diagnostic aids 15 Pre-disposing factors Diet Fluid consumption Oral Hygiene habits Level of understanding and motivation Drug therapy impacting on saliva flow Mouth-breathing 16 17 18
  4. 4. 4/13/2010 4 Visual diagnostic features 19 Deep retentive fissure pattern Dark staining White enamel 20 21 Visual diagnostic features 22 Non-cavitated • Shadowing • White ‘reverse caries’ C it t d i l i d tiCavitated – involving dentine • Shadowing and reverse caries indicate the extent of the lesion Cavitated – involving pulp 23 24
  5. 5. 4/13/2010 5 Visual Diagnostic Features 25 White spot lesion – not cavitated Cavitated – involving dentine Extensive 26 27 28 Visual diagnostic features 29 May occur in conjunction with TBA/abfraction lesions Occurs below the level of the enamel 30
  6. 6. 4/13/2010 6 31 Includes Early Childhood caries (AKA Baby bottle caries) Visual diagnostic features 32 Affects primary upper anterior teeth As well as primary lower 4’s and 5’s 33 34 Secondary Caries Visual diagnostic featuresVisual diagnostic features 35 Affecting the margins of restorations May occur as a fuction of failure of the restorative material Or as a function of microleakage 36
  7. 7. 4/13/2010 7 37 38 Damage caused by the operator in the process of treating other teeth 39 Damage to the approximal surface of adjacent teeth during tooth preparation and the finishing of restorations can result in the formation of caries Various studies show the incidence of this type of damage being from 50 -90% (1-3) Scratching/pitting of the surface of sound enamel at the contactScratching/pitting of the surface of sound enamel at the contact will remove the fluoridated surface layer and leave a rough surface which retains plaque Flattening of the adjacent tooth results in the creation of flat contacts – makes it impossible to restore a natural rounded contact area between teeth Leads to food traps – new caries, recurrent caries in restorations & periodontal pocket formation 40 41 42
  8. 8. 4/13/2010 8 How does caries feel to the probe? 43 44 Probe may not stick – or there may be a catch 45 Probe may or may not catch. 46 47 Surface feels sound 48
  9. 9. 4/13/2010 9 Chalky feel Pitting of the enamel surface. Pits within the white spot lesion 49 Loss of overlying enamel Dentine is soft – probe tip can penetrate 50 Lesions are dark and feel hard or very ‘leathery’ P b ti d t t t il if t llProbe tip does not penetrate easily if at all 51 52 Not able to reach these with a probe Other diagnostic aids?g 53 Rather obvious – no mystery here 54
  10. 10. 4/13/2010 10 Radiography Laser induced fluorescence Fibreoptic transillumination 55 56 Descriptive Incipient Moderate Stages 1 2ORModerate Advanced Severe 2 3 4 OR 57 Incipent Up to half way through enamel Moderate More than halfway through enamel up to DEJ Stage 1 Stage 1 Stage 2 58 Advanced From DEJ up to halfway through dentine Severe More than halfway through dentiney g Stage 3 Stage 4 59 60
  11. 11. 4/13/2010 11 61 62 63 64 65 66
  12. 12. 4/13/2010 12 67 Diagnosis of interproximal caries 68 69 70 Laser- Stimulated Fluorescence 71 72
  13. 13. 4/13/2010 13 The tooth surface is illuminated by a red light (excitation wavelength at 655 nm, modulated) that is produced by a laser diode and transmitted by an optical fiber. The laser induces fluorescence in mineralized tooth tissues, at a greater intensity in carious than in sound tooth tissues Th i d b i l fib h di d i h lThen transmitted by an optical fiber to a photodiode with a long pass filter (wavelength >680 nm) in the detection device Numerical value of the digital display (in units related to a calibration standard) correlates quantitatively with the intensity of the fluorescence detected and thus indicates the extent of caries (colour graphics have been developed also) Lussi et al. (5) suggested that a score of 20 indicates caries extending into the dentin, and this reference has been used in other studies using DIAGNOdent (6,7) 73 11 74 11 75 General decline in the prevalence of dental caries owing to the increased use of fluoride in the form of fluoridated water, fluoride toothpaste, and fluoride agents that are applied professionally or at home. Pattern of caries has also changed: the proportion of caries found in occlusal fissures has risen and pit and fissure caries are now perceived as the predominant types main reason for these changes is that fluoride inhibits enamel breakdown, so caries reaching the dentin tend to progress beneath a clinically intact enamel surface difficulty in visually inspecting the fissures of molars - such cases of occlusal dentinal caries, known as “hidden caries”, are commonly missed on visual examination and carious cavities are seen only at a late stage of disease. Is regarded as a useful adjunct to other forms of conventional diagnosis Reproducible and therefore excellent aid to monitor changes (4,8,9,10,11) 76 Transillumination 77 CURING LIGHT Useful in the anterior region Can help to visualize the l l flevel of penetration of caries into dentine 78
  14. 14. 4/13/2010 14 All our diagnostic techniques are aimed at early detectionare aimed at early detection 79 Accurate diagnosis is the first step in determining the proper course of action Preventive and minimum intervention strategies can then be applied 80 Is active caries present If so… what rate is it progressing 81 the risk of recurrent caries increases with marginal gap width caries always progresses rapidly restorations cure caries 13 82 d Prevention & remineralization size and location of white spot lesions and stained fissures active and arrested non- cavitated enamel lesions arrested non- cavitated lesions within the outer third of dentin slowly progressing lesions within the outer third of dentin rapidly progressing lesions within the outer third of dentin lesions in the inner two thirds of dentin secondary caries adjacent to restorations cavitated lesions 13 Intervention 83 rapidly progressing lesions within the outer third of dentin lesions in the inner two thirds of dentin secondary caries adjacent to restorations cavitated lesions Immediate interventive treatment 84
  15. 15. 4/13/2010 15 Subsequent decisions about whether to place or replace restorations at other sites should beat other sites should be delayed until the most conservative options have been considered 85 86 E0 – no caries, E1- outer enamel, E2 – Inner enamel D1 - outer 1/3 dentine, D2 – middle 1/3 dentine, D3 – inner 1/3 dentine 15 87 1. Qvist, V., L. Johannessen, et al. (1992). "Progression of Approximal Caries in Relation to Iatrogenic Preparation Damage." Journal of Dental Research 71(7): 1370-1373 2. Medeiros, V. A. F. and R. P. Seddon (2000). "Iatrogenic damage to approximal surfaces in contact with Class II restorations." Journal of Dentistry 28(2): 103-110 3. Lussi, A. and M. Gygax "Iatrogenic damage to adjacent teeth during classical approximal box preparation." Journal of Dentistry 26(5-6): 435-441 4. Chu, C., E. Lo, et al. "Clinical diagnosis of fissure caries with conventional and laser-induced fluorescence techniques." Lasers in Medical Science 5. Lussi A, Megert B, Longbottom C, Reich E, Francescut P (2001) Clinical performance of a laser fluorescence device for detection of occlusal caries lesions. Eur J Oral Sci 109:14–19. doi:10.1034/ j.1600- 722.2001.109001014.x 6. Reis A, Mendes FM, Angnes V, Angnes G, Grande RH, Loguercio AD (2006) Performance of methods of occlusal caries detection in permanent teeth under clinical and laboratory conditions. J Dent 34:89–96. doi:10.1016/j.jdent.2005.04.002y j j 7. Silva BB, Severo NB, Maltz M (2007) Validity of diode laser to monitor carious lesions in pits and fissures. J Dent 35:679– 682. doi:10.1016/j.jdent.2007.05.005 8. Attrill DC, Ashley PF (2001) Occlusal caries detection in primary teeth: a comparison of DIAGNOdent with conventional methods. Br Dent J 190:440–443 9. Baelum V, Nyvad B, Gröndahl HG, Fejerskov O (2008) The foundations of good diagnostic practice. In: Fejerskov O, Kidd E (eds) Dental caries. The disease and its clinical management, 2nd edn. Blackwell Munksgaard, Oxford, pp 104–118 10. Jonas A. Rodrigues & Michele B. Diniz & Érika B. Josgrilberg & Rita C. L. Cordeiro - In vitro comparison of laser fluorescence performance with visual examination for detection of occlusal caries in permanent and primary molars Lasers Med Sci (2009) 24:501–506 DOI 10.1007/s10103-008-0552-4 11. Hibst, R., R. Paulus, et al. (2001). "Detection of Occlusal Caries by Laser Fluorescence: Basic and Clinical Investigations." Medical Laser Application 16(3): 205-213 12. Small Cavities, Big Problems - Diagnosis and Treatment of Non-Cavitated Carious Lesions 13. Anusavice, K. (1995). "Treatment regimens in preventive and restorative dentistry." J Am Dent Assoc 126(6): 727-743 14. Evans, R. W., A. Pakdaman, et al. (2008). The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Australian Dental Journal, Blackwell Publishing Limited. 53: 83-92. 15. Anusavice, K. (2001). "Clinical decision-making for coronal caries management in the permanent dentition." J Dent Educ. 65(10): 1143-1146 88