Diagnosis of dental caries / dental implant courses

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DIAGNOSIS OF DENTAL
CARIES
INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education

DIAGNOSIS OF DENTAL
CARIES
 INTRODUCTION
 DEFINITION
 OBJECTIVE
 IMPORTANCE OF DIAGNOSIS
 CRITERIA FOR DIAGNOSIS
 TRADITIONAL METHODS
 RECENT ADVANCES
 DIAGNOSTIC METHOD OF CHOICE

INTRODUCTION
 Diagnosis is derived from greek
word dia means-by and gnosis
means knowledge
 Dental caries is the most common
disease in the world

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DEFINITION
 Is the process of identifying a
disease by its signs and symptoms
and results of various diagnostic
procedure
 The conclusion reached by this
process is also called as diagnosis

OBJECTIVE
 The primary objectives of caries
diagnosis are to identify those
lesions that require surgical
(restorative) treatment, those that
require nonsurgical treatment, and
those persons who are at high risk
for developing carious lesions

IMPORTANCE OF DIAGNOSIS
 It is self evident that before
preventive means can be
intelligently instituted or before
curative or restorative procedures
can be restored to, it is first
necessary to make a thorough
diagnosis of a case .

 The examination of the patient is,
then, an important procedure and
should be considered carefully and
thoroughly.
 It should include not only a close
inspection of the teeth and
supporting structures, but also
general inspection of patient.

 In making the examination, the
most minute defects and most
obscure pathologic disturbances
should be detected and recorded in
order that they receive immediate
attention.

CRITERIA
 In order to measure the accuracy of
a diagnostic test its outcome should
be validated against a correct
diagnosis often called a gold
standard

 For a robust gold standard 3
criteria should be fulfilled
1. reproducible
2. Reflect the patho-anatomical
appearance
3. Be independent of the diagnostic
tests under assesment

 According to PITTS(1997)the ideal
method or for diagnosis of carious
lesions would be non-invasive and
provide simple, reliable, valid,
sensitive, specific, and be based on
biologic processes directly related to
the carious process

 It should also be affordable ,
acceptable, and allow early
implementation in both clinical
practice and research settings
 Its use should promote informed
and appropriate preventive
treatment decisions, enhancing long
term oral health

TRADITIONAL METHODS
 PATIENTS COMPLAINT
 METICULOUS CLINICAL
EXAMINATION
 TACTILE EXAMINATION
 RADOGRAPHIC EXAMINATION
 TOOTH SEPARATION
 DENTAL FLOSS OR TAPE
 FIBEROPTIC TRANSILLUMINATION

PATIENT’S COMPLAINT
 Patient complaining of sensitivity to
the thermal changes ,mild to
moderate toothache, etc may
provide a hint about the presence of
dental caries.

METICULOUS CLINICAL VISUAL
EXAMINATION
 Careful examination of the patients
teeth under clean and dry
conditions using good illumination
may reveal visual signs of caries
like
1. Brownish discolouration of pit and
fissure
2. Opacity beneath pit and fissures or
marginal ridges
3. Frank cavitation of the tooth
surfacewww.indiandentalacademy.com

 A major short coming of this
method is very limited for detecting
noncavitated lesions in dentine 0n
the posterior approximal and
occlusal surfaces.

 MAGNIFYING MOUTH MIRROR
 MAGNIFYING LENS
 Rainer haak michael et al

CLINICAL VISUAL TACTILE METHOD
 This method is based on a
combination of light, mirror, and
gentle probing and is used in most
epidemiologic surveys
 Caries is diagnosed if the tooth
meets the American dental
association criteria of softened
enamel that catches the explorer
and resists its removal

 Or allow the explorer to penetrate
proximal surfaces under moderate
to firm probing pressure.

I. Probing has been criticized for
several reasons
a. It may allow transmission of
cariogenic bacteria from infected
sites to uninfected areas
b. It can irreversibly traumatize
potentially remineralizable
noncavitated lesions of enamel
and dentine.

C. And it may provide no more
accuracy in diagnosis than visual
inpection alone particularly in
fissures and in posterior
approximal surfaces

RADIOGRAPHIC EXAMINATION
 Conventional, intraoral periapical
and bitewing radiographs are
employed for diagnosis of dental
caries.

Of two bitewing radiographs have
more diagnostic value because
 Interproximal caries
 Recurrent caries below proximal
restoration
 Both maxilla and mandible in one
film

ADVANTAGES
 It discloses sites inaccessible to
other diagnostic methods.
 The depth of the lesion can be
evaluated and scored.
 Radiographs provide permanent
record.
 Radiography is noninvasive.

DISADVANTAGES
 For accurate reproducibility,
standardized geometric angulation,
exposure time, processing
procedures and analyzing facilities
are necessary
 Only 2 dimentional image of a three
dimentional object.
 Does not reveal the earliest stages
of caries development

 Radiolucency may be due to caries,
wear, fracture or cervical burnout
 Radiographic diagnosis is
subjective, prone to observer bias
 Approximal caries on the more
apical part of a restoration may not
be detected
 Noncavitated lesions on the root are
difficult to diagnose.

TOOTH SEPARATION
 Temporary elective tooth separation
to detect the approximal smooth
surface caries.
 This method is acceptable to both
patients and dentists.
 Regular orthodontic elastomeric
separators, wedges or a mechanical
separator can be used for
separation.

DENTAL FLOSS OR TAPE
 Dental floss is sawed through the
contact areas between the teeth if it
frays or shreds then it is a sign of
proximal caries

FIBEROPTIC
TRANSILLUMINATION
 Fiber optic transillumination has
been designed for caries detection
by FRIEDMAN and MARCUS in 1970
 When teeth are examined with a
fiberoptic light source , caries
appears as a dark shadow

 The basis for FOTI is that the
decayed tooth material scatters
more light strongly, and thus has a
lower index of light transmission
than a sound tooth structure.

ADVANTAGES
 Non invasive method
 No hazards of radiation
 Comfortable to the patients
 Useful in patients with crowding

DISAVANTAGES
 Subject to observer bias
 Does not provide a permanent
record of findings
 Difficulty in placing the probe in
some areas

RECENT ADVANCES
 XERORADIOGRAPHY
 DIGITAL RADIOGRAPHIC METHODS
 COMPUTER AIDED RADIOGRAPHIC
METHOD
 DIGITAL SUBTRACTION
RADIOGRAPHY
 DIGITAL FIBER OPTIC
TRANSILLUMINATION

 CARIES DETECTOR DYES
 ELECTRICAL CONDUCTANCE
MEASUREMENTS
 ENDOSCOPIC FILTERED FLOURESCENCE
METHOD
 QUANTITATIVE LASER FLUORESCENCE
 ACIST
 ULTRASONIC IMAGING
 OPTICAL COHERENCE TOMOGRAPHY

XERORADIOGRAPHY
 Xeroradiography is a highly
accurate eletrostatic imaging
technique
 Here a photo conductive plate is
electrically charged and this plate is
coated with a layer of selenium and
is placed in a light proof cassette
and this is placed in patients mouth
and x-ray exposed.

 The latent image that is formed on
photoconductive plate is converted
in to a positive image by a process
known as development in a
processor unit
 Here the image is developed using a
liquid toner

 The toner image on the plate
surface is then dried and lifted off
the plate by means of transparent
adhesive tape
 Lamination of the tape to a
translucent backing material fixes
the image which is now ready to
view

 The plate is thereafter sterlized with
u-v radiation cleaned of residual
toner and exposed to light to erase
any residual charges.
 Once the plate is cleaned it can be
reused.
 THOMAS KATSANALAS et al –dental
traumatology vol 5 oct 1989.

ADVANTAGES
 “Edge enhancement” can demarcate
areas of varying densities especially
at margins.
 Less radiation exposure(1/3rd
)
 No wet processing
 Takes approximately 30 seconds to
develop an image

DISADVANTAGES
 Expensive
 Electric charge over the film may
cause discomfort to the patient

DIGITAL RADIOGRAPHIC METHODS
1. Digital radiographic methods offer
a more superior means of
detecting caries than coventional
methods
 Digital radiographs can be
obtained by two methods
1. Video recording and digitization of
conventional radiograph
2. Direct digital radiograph

 The first direct digital radiography is
Radiovisiography invented by
FRANCIS MOUYEN in 1989
 It uses a charged couple device
which works like a miniature video
camera

 This records the image produced by
conventional x-rays and stores it in
the computer memory for image
processing and viewing.
 ANN WENZAL journal of dental
research 2002 pgs 590-593

ADVANTAGES
 Reduced radiation dose
 Instant image visualization
 Elimination of processing chemicals
 Image enhancement
 Patient education utility
 Convenient storage

DISADVANTAGES
 Expensive
 Rigidity and thickness of sensor
 Decreased resolution
 Unknown sensor life span
 CCD cameras cannot be sterilized

 The digora image plate system is an
alternative to the CCD systems
 Here the radiographic information is
recorded on a phosphorus storage
screen called the image plate
 The essential components are the
image plate and the readout device
(scanner) which is connected to the
personal computer

 After exposure the image plate is
placed in the scanner ,where the
laser beam is deflected across the
phosphorus screen.
 The released light energy is
collected in a photomultiplier and
converted in to a analog signal,
which is then digitized with the
digora system

ADVANTAGES
 Image takes less than 30seconds to
appear on the computer screen
 Wide exposure range
 Image brightness and contrast can
be adjusted
 Edge enhancement and is possible
 Different measurements can be
made

 Digital radiography linked to dental
unit offers an attractive design
 The kavo unit
 Durr’s vista ray mobile system

COMPUTER AIDED RADIOGRAPHIC
METHOD
 Computer aided radiographic
methods exploit the measurement
potential of computers in assesing
and recording the lesion size
 The new trophy 97 system, artificial
integrated intelligence software is
integrated provides size and
progression of the carious lesion
especially in approximal caries

 At both D1 and D3 thresholds,
computer aided method offers high
levels of sensitivity for approximal
caries
 Computer softwares have been
developed for automated
interpretation of digital radiographs
in order to standardize image
assessment.

ADVANTAGES
 Identifies small carious lesions
otherwise not perceptible by
radiographs or visual examination.
 Helps in monitoring the carious
process

DISADVANTAGES
 Time consuming
 More expensive

DIGITAL SUBTRACTION
RADIOGRAPHY
 RICHARD WEBBER was the first one
to introduce the digital subtraction
radiography
 Here the digitization is achieved by
taking a picture of the radiograph
using high quality camera.
 This is fed to a computer imaging
device called digitizer .

 Two standardized radiographs
produced with identical exposure
geometry are used.
 The first one is called the “reference
image” and the subsequent images
are taken for comparison.

 The reference image is displayed on
the screen over which the
subsequent images are
superimposed
 The difference between the original
and subsequent images can be seen
as dark areas

ADVANTAGES
 Superior to conventional
radiography for detecting recurrent
caries
 It is sensitive it can detect a
0.12mm change
 Approximal caries can be visualized
better
 Assesses the progression of the
carious lesion

DISADVANTAGE
 EXPENSIVE
 J.EBERHARD et al (caries research
2000, vol 34 pgs 219-224)

CARIES DETECTOR DYES

CARIES DETECTOR DYES
 Caries detector dyes were
developed in 1970s to help the
dentist to identify infected and
unremineralizable dentine during
caries excavation.

 Greame milicich- caries detector
dye simply follow the water present
in the voids that acid attack has
created with in the tooth structure
 Once the prism structure of enamel
has been degraded and has become
amorphous and porous the dye
follows the water present in the
microscopic voids

 The sound tooth structure does not
have porosities or voids to allow
staining .
 In 1972 a technique using a basic
fuschin red stain was suggested to
aid in the differentiation of the two
layers of carious dentin

 BASIC FUSCHIN-half percent basic
fuschin in propyl glycol.
 Because of the potential
carcinogenicity the basic fuschin
stain was sequentially replaced by
another dye ACID RED SOLUTION

 ACID RED SOLUTION –one percent
acid red in propylene glycol is used
in the diagnosis of carious dentine
due to its acidic ph it cannot be
used in lesions close to pulp
 Calcein –calcein dye remains in the
lesion as it makes complex with
dentine

 Procion- procion dye reacts with the
nitrogen and hydroxyl group of
enamel and acts as a fixative
 Brilliant blue –brilliant blue dye
increases a diagnostic quality of
fiber optic transillumination

 O brien et al used blue tracer dye to
increase the colour contrast of the
approximal incipient lesions by
FOTI
 Flourol 7GA-rijke et al used this dye
in conjunction with a fiber optic
illumination to detect proximal
caries and found the method to be
sensitive

 Pyrromethane 556 and sodium
fluorescein in conjunction with laser
fluorescence for detection of caries
 Pyrromethane dye can absorb the in
488nm to 515nm range and emit
the light in 540nm

 Snoop-  Snoop is the
propylene glycol
based detector
 Differentiates the
infected and
affected dentine
 technique

 Some of the non specific dyes will
stain food debris enamel pellicle and
any other organic matter trapped
in the occlusal fissures
 White and rainey indicated
procedure of sodium bicarbonate
prophylaxis followed by air abrasion

 dye uptake by enamel lesions
would be very advantageous since it
would allow lesion to be visualized
in the early stage
 Daniel (D C N A)-quoted that caries
detector dyes helps in detecting the
caries that may be missed.

 Dyes do not stain the bacteria but
instead they stain collagen
associated with less mineralized
organic matrix.

 Dorothy mc coomb - the sound
circumpulpal dentine and sound
dentine at amelodentinal junction
took up the stain because of the
higher proportion of the organic
matrix normally present in these
sites which leads to over treatment

 Am Lennon et al (car res 2003)-
caries detector dyes had a
significantly lower specificity than
other methods.

ELECTRICAL CONDUCTANCE
MEASUREMENTS
 Another method of non interventive
caries detection is the use of
electronic résistance measurement.
 This method is first proposed by
MAGITOT and became popular in
nineteen eighties.

 The principle behind the electric
resistance measurements is that sound
enamel has a high resistance to electric
current flow,
 whereas carious enamel with its
micro porosities filled with conducting
media (i.e water and ions from saliva )
has an increasingly lower reistance and
therefore higher conductance as lesion
progresses and enlarges.

 CARIES METER L
 VANGUARD ELECTRONIC CARIES
DETECTOR
 ECM I
 ECM II
 ECM III
 ECM IV

CARIES METER L
 was manufactured by 2 companies
i.e. GC international and onuiki
dental
 400 Hz current was used
 The display was in the form 4
colored lights reflecting the status
of the tooth

-
 Green-no caries
 Yellow-enamel caries
 Orange- dentine caries
 Red – pulpal involvement
 The values were recorded each time
the light color changed

 The measurement were taken
between a probe tip and a clip
attached to an oral electrode
 The teeth were dried by three in
one syringe and isolated by cotton
rolls and then required re moistened
with a drop of saline

 The information obtained from this device
was insufficient for many reasons
1. Restricting and standardizing the flow of
air to dry the tooth
2. The area of saliva contact medium made
the technique less favorable
3. Transformation of continuous scale to an
Ordinal scale display of four categories
presented by colour

VANGUARD ELECTRONIC CARIES
DETECTOR
 The Conductance measurement
were made between a specially
designed probe tip and a hand held
connector
 The frequency of the device was of
25 Hz which was able to produce a
low current of 3 micro amperes
 The readings were site specific

 The machine displayed a frowning
face that indicated extensive
demineralization or smiling face
indicated a sound site
 Reading of (0-9) were inversely
related to resistance and indicating
increasing degree of
demineralization, thus it was an
ordinal conductance scale

ECM PROTOTYPE I
 The First prototype used a design
close to vanguard machine
 An air flow gauge was included in
the device, the air flow through the
tip was at changeable rate, which
could be changed from 5-10 l/min.

 The frequency employed was a
21hz
 ECM reading appeared on the
screen in a range of about -1to13
representing increasing electrical
conductance

Clinical interpretation
Range Clinical
interpretation
1-3 Sound enamel
or early stages
of caries
3.1-6 Caries up to
DEJ
6.1 -8 Dentinal caries
8.1 -13 Deep dentinal
caries

 In this method the surface was to
be measured at more than one
point was found to be time
consuming
 Have to apply conducting gel before
use of the instrument

ECM II
 This was a battery driven
 An audible beep indicated that the
circuit was completed between the
probe tip and the hand held
connector
 A double beep indicated the stable
conductance measurements

 Cut-off points
1. Dentinal caries-0.000-0.390
2. Enamel careis-0.391-0.0501
3. Sound tissue >0.501

ECM III

Factors affecting electrical
measurements
 Porosity- pore volume and its
depth
 Surface area-site specific and
surface specific
 Hydration of the enamel- use of
contact medium
 Temperature
 Concentration of the ions

 En verdonschot et al (1995)-did a
research on validity of electrical
conductance measurements in
evaluating the marginal integrity of
sealent restorations and found that
ECM is efficient in finding the
dentinal caries due to the loss of
marginal integrity of the sealant and
the composite restoration.

 Lussi et al (1995)-diagnosis of
fissure caries using ECM – and
concluded that ECM -78% in
detecting the fissure caries

 Huysmanss et al(1995)-siad that there is
a linear relationship the area of between
electrical conductance and the electrode
area on the sound enamel in extracted
teeth .
 If the electrode area is sufficiently large
the sound enamel may reach the
conductance level above the threshold for
the dentinal caries

 Ricketts et al (1997)-the effect of
air flow on site specific ECM used in
diagnosis of pit and fissure caries in
vitro-
 Minimum air flow of 7.5 L/min is
required to eliminate false positive
readings.

 Y.l le et al (1995)-electrical conductance
of fissure enamel in recently erupted
molar teeth as related to caries status.
 ECM can aid in detection of fissure caries
in recently erupted molar and ECM can be
used to predict the probability that a
sealant will be required with in 18-24
months after eruption

 The main disadvantage of this ECM
is difficult measuring procedure.
 Enamel cracks and hypo mineralized
areas can give false positive
readings

 BENNEDICT-first person to observe
the fluorescence in human teeth
 He noted a differential in
fluorescence between sound and
carious enamel
QUANTITATIVE LASER
FLOURESENCE

 The visible light with in the blue
green region has been used for the
development of a sensitive method
for the detection of caries at an
early stage
 The tooth is illuminated with a
broad beam of a blue green light of
488nm wave length from an argon
ion laser

 The fluorescence in the enamel
occurring in the yellow region
(540nm) is observed through a
yellow high pass filter to exclude
the tooth scattered blue laser light
 Sound enamel gives fluorescence
with a yellowish light

 The light scattering in the enamel is
primarily due to the hydroxyapatite
crystals and tubules in the dentine
 ANGAR MANSSON-natural lesions
of(diameter >1mm) with a lesion
depth as small as 5-10micron m can
be detected

 Incipient as well developed caries in
enamel were clearly visible as dark areas
which contrasted with the fluorescent
surrounding
 Microradiographic analysis of the
longitudinally ground section of the tooth
confirmed that the dark area in the laser
fluorescence corresponded to a
demineralization of the enamel

 Longitudinal monitoring of lesions with the
QLF analysis software can be used to
Quantitatively measure mineral loss

technique
 The QLF device consists of the light source
and the intraoral camera
 The QLF technique is a 2-stage process.
First, an image of the toothmust be
acquired with the intraoral camera (ccd)
held in the hand.
 Then, both qualitative and quantitative
assessments of mineral loss areobtained.
 The enhanced contrast between sound and
demineralized enamel enables the clinician
to identify areas of concern.


 Dorothy McCoomb-QLF can be
affected to some extent by a the
wet or dry state of the fissures ,by
the stains in the fissures and by
fissure morphology
 The use of air polishing to remove
plaque improved the diagnosis

 E.de josseline de jong et al-did a
study on detection of initial enamel
caries with laser flourescence and
concluded that QLF is suitable for in
vivo measurement of mineral
change in natural enamel lesions on
smooth surface and might be useful
in clinical trials and evaluation of
preventive measures

 W.Buchalla et al-interproximal
caries lesions at D2 andD3 level can
be visualized using QLF when
applied from both buccal and lingual
directions and observed presence of
lesion depends upon the position of
the camera rather than on the
direction of the illumination.

 Emmami et al – QLF can detect the
early enamel lesions observed in
orthodontic patients during
treatment and after de-bracketing

ADVANTAGES
1. Increased contrast between caries
and sound enamel makes earlier
detection of lesion possible
2. Depth of lesion can be estimated
to a certain extent .
3. Possibility exist for a diagnosis
without a probe even on occusal
surfaces

4. The examination represents no
danger to a patient or operator
since the excitation light is both
with in the visible range of
relatively low intensity.

DISADVANTAGES
1. There is no differentiation between
active and arrested caries
2. The method does not differentiate
between caries and developmental
defects with lower mineral content
3. Secondary caries lesion associated
with metal fillings cannot be
detected
4. Equipment is expensive

DIAGNODENT

 This device makes use of laser auto
fluorescence technology, but
instead of using blue light it uses
red light of wavelength 655nm. Out
put <1mw

 This red light identifies caries as
having an increased fluorescence
over sound tooth, whereas blue
light highlights caries as a reduced
fluorescence compared to sound
tooth

 These differences are attributable to
the characteristics of the light of
different wave length, and the
effects of the light of different
wavelength in teeth and lesions of
the caries.

 A reading is provided on a digital
display accompanied by an audible
tone
 Higher the digital reading and pitch
of the audible tone, greater the
potential for caries involvement of
the amelodentinal junction and
underlying dentine

 The science behind this
phenomenon appears to be the
increased fluorescence exhibited by
cariogenic bacterial metabolites with
in the lesion ,as well as the changed
fluorescent nature of the lesion
itself

 Diagnodent unit comprises a pen
like with a detachable tips of
different diameter
 The central core fiber running
trough the pen grip and the tip is
the red laser, with surrounding fiber
being detectors to measure the
returned fluorescence light from the
tooth surface

 Scores above 25 are considered to
suggest a high probability of caries

 It can detect the lesions up to
2oomicron m

 Lussi et al (2004)- did a study on
extracted teeth
 Values 0-13=no caries,
14-20=enamel caries
,>20=dentinal caries
 Device is useful in longitudinal
monitoring of carious process.

 Dorothy Mc Coomb-(2001)-said that
occlusal area to be diagnosed was
to be clean as presence of plaque
and calculus gives the false positive
readings

 Dc.Attrill et al (2001) BDJ- said that
Diagnodent is the most accurate in
detecting the occlusal caries in the
primary teeth.

 Dr Milicich argues that the DIAGNOdent
can return a false-positive value as a
result of the organic plug in the fissure
surface.
 False positive values can also be
associated with remineralised caries that
has had chromogenic material
incorporated into the remineralised caries
porosities, developmental hypocalcific
enamel and naturally fluorescent enamel.

 Dr Milicich also argues that since caries
can develop at the base of the fissure
pattern, it can remain undetected by the
DIAGNOdent due to the ‘overhang’ of
sound enamel, which ‘shadows’ these
small lesions.
 It is important to remember that the
DIAGNOdent is only effective in reading
2mm into tooth structure. This is
illustrated in the diagrams below.

 Does not correlate with the
demineralization of the tooth

DIGITALDIGITAL FIBEROPTIC
TRANSILLUMINATIONTRANSILLUMINATION

 Digital fiber optic transillumination
is relatively new methodology that
was developed in attempt to reduce
the short comings of FOTI by
combining FOTI and digital CCD
CAMERA

 The principle behind
transilluminating teeth is that
demineralized areas of enamel or
dentine scatter light (in this case a
high intensity white light) more
than sound areas. Incipient caries
appear as darker areas in the
resultant images.

 DIFOTI system consists of 2 hand
pieces (one for occlusal surfaces
and one for smooth and
interproximal areas), a disposable
mouthpiece, a foot pedal for
selecting the image of interest from
the live pictures, and a computer
system to capture and store the
resulting image

TECHNIQUE
 The appropriate hand piece is
selected and placed over the tooth,
and a live image appears on the
screen.
 The software detects when the
image is focused, and the operator
selects images to be captured.

 A Schneiderman et al(1997)-
assessment of dental caries with
digital imaging fiber optic
transillumination in vitro
 DIFOTI is reliable for detection of
early caries lesions, its values for
sensitivity are significantly higher
than those of radiological imaging.

 S.traneus et al(2006)-observer
reliabity in approximal caries
detection using DIFOTI
 He selected 6 observers for his
study and he concluded that DIFOTI
showed good qualitative method but
weaker quantitative method

 Digital fiber optic transillumination
is very efficient in detecting the
early carious lesions which helps in
prevention of further progression of
caries
 No radiation exposure so no
radiation hazards

 It is non invasive
 very much helpful in
1. cancer patients
2. Pregnant women

 It does not measure the depth of
the lesion
 expensive

Difeerences between diagnodent and
DIFOTI
DIAGNODENT
Diagnodent is a
portable laser diode
based device(665nm
DIFOTI
Visible light via fibro
optic
transillumination
It detects the
bacterial by products
It detects the
demineralization
Lesions appears as
red flourescence
It is seen as dark
areas in the
illuminated tooth
surface

once the lesion is
detected it gives a
digital read out
It is obtained as a
picture on the
computer
It leads to over
treatment
It does not leads to
over treatment

ULTRASONIC SYSTEM
 The use of ultra sound for caries
detection has been proposed for
past 30 years
 Transmission of ultrasonic waves
were discovered by lord rayleigh in
1885.

 Sound waves are longitudinal or
pressure waves which travels
through gases ,liquids ,and solids .
 Ultrasound waves have a frequency
of >20,000 Hz
 The speed of the sound wave
depends upon the medium they
travel in air it is 330m/sec

 The principle of the ultrasonic
system is that a high frequency
waves produced by probe are
spread in to the tooth material and
transmitted back to the probe
following reflection at any
discontinuity

 The waves detected by the probe
are transmitted in to electric
impulses and seen as echoes
 These echoes contain information
about the about the depth of the
lesion

o The ultrasonic caries detector
contains a
1. Probe
2. Transductor
3. Cathode ray tube (monitor)
4. Amplifier
5. timer

 Defects are identified easily when
the ultra sonic beam has been
directed perpendicular to the
surface
 Pulse generated in the transducer is
transmitted in to the tooth and then
reflected back to the transducer if it
strikes any discontinuity

 Sound enamel and demineralized
enamel can be diferentiated from
their echo position on the CRT and
gives the display on the monitor.

 Angmar-mansson (1993)-described
the styudy done to detect the
smooth surface caries using
ultrasound caries detector and
found that the artificial lesions less
than 57% mineral content could be
differentiated from sound enamel
surface.

 A.hall AND Girkin (2004)- said that
the ultrasound may be quick reliable
method for detection of dental
caries in the enamel
 The use of longitudinal waves to
measure the demineralization in
relation to the ADJ is very useful, as
is the potential for surface sound
wave to detect the cavitation .

 Caliskan yanikoglu – did a study on
detection of natural white lesions by
an ultrasonic system and concluded
that ultrasonic system using
longitudinal waves has been able to
detect natural caries lesions in
human enamel and it might be used
as a diagnostic tool for detection of
tissue changes in caries related
studies.

 Shlomo et al (2007)-detecton of
cavitated carious lesions in
approximal tooth surfaces by
ultrasonic caries detector
 UCD can be used for clinical
evaluation of cavitated carious
lesions in proximal areas

DRAWBACKS
 low specificity
 inability in evaluating the depth of
the carious lesions

OPTICAL COHERENCE
TOMOGRAPHY
 OCT, creates cross sectional images
of biological structures using
differences in the reflection of light
 It was first proposed by Huang et al
for imaging the biological tissue
 OCT uses reflections of near infra-
red light to determine not only the
presence of decay but also the
depth of caries progression.

 OCT uses light the wavelength of
which dictates the scattering and
therefore the depth of penetration
of the imaging technique
 Most of the OCT techniques
described for imaging the dental
tissue have used wavelength 842-
1310 nm. this gives the imaging
depth of 0.6 -2mm

 OCT is based on the interference of
light
 When a light beam is spilt into two
and recombined , interference
produces a pattern , the intensity of
which is determined by the level of
light in each beam

 OCT systems use super luminescent
diodes as a light source , this type
of source produces light with a
broad range of wavelength ,each of
which produce it’s inference pattern

 The intensity of the interference is
a function of scattering caused by
the changes in tissue structures of
the tooth
 variation in scattering measured in
relation to the depth from a single
point on the tooth surface is called
an A- scan

 As two beams are produced from a
light source
 1. sample beam
 2. reference beam

 Sample beam goes into the tooth
and scattered according to the
nature of tissue so caries teeth
scatters light to a greater extent
than sound tooth structure

 Reference beam travels to the
moveable mirror and reflected back
and recombined with a sample
beam
 The recombined reference and
sample beam are focused on a
photo detector where any degree of
interference between the beams
can be observed

 In this way changes in the
scattering properties of the tooth as
a function of depth can be recorded
at a single point

 Sahar shafi-(2002)- that OCT is well
suited for the imaging of
interproximal and occlusal caries,
early root caries, and for imaging
decay under composite fillings

 Benetton et al- said that OCT could
detect incipient enamel and root
caries and quantitatively monitor
the demineralization of the tissue.

 Hall and girkin –said that OCT is a
non invasive method useful in
detecting secondary caries

CARIES RISK ASSESSMENT
o RISK- “the probability that some
harmful event will occur”
o Caries risk-caries risk is the
probability that caries risk will
develop or progress

 Assessment of caries risk is
performed to predict if an individual
will develop caries lesions during a
specified period of time.

 The assesment is based on a
particular exposure status of
etiological factors, supposed to
remain stable during the period in
question thus, caries risk relates to
the likelihood of a person
developing caries lesions for a
subsequent period of time.

 The importance of properly
predicting the occurrence of lesions
is obvious; targeted preventive
actions can be directed to those
persons ,or teeth , with a high risk
of caries

 Factors contributing to caries risk include
 Amount of plaque
 Type of bacteria
 Type of diet
 Frequency of carbohydrate intake
 Saliva secretion
 Saliva buffer capacity
 flourides

 Indirect factors to be considered in
caries risk assessment are
 Socioeconomic circumstances
 General health
 Epidemiological circumstances
 Clinical findings

 Formal caries risk assessment has
been described by BECK as 4 step
process
 The first two steps involve
identification of risk factors and
development of a multivariate
assessment tool or model that uses
the risk factors in the way that
weighs them according to their
statistical influence.

 The third step is the assessment
process that entails application of
the caries risk models o individual
to identify their risk profiles.
 4th
step is targeting the application
of a disease-prevention regimen or
treatment procedure that matched
to the risk profile of each individual

 Buffering capacity test
a. Ericssons test
 Fosdict test
 Dewar test
a. Lactobacillus count
 Snyder test
 Mutans streptococci screning
 Reductase test
 Rickles test

CARIOGRAM
 Cariogram was first presented in
1996
 The cariogram is computer program
that serves as a new risk
assessment model

 This program assesses and
graphically illustrates the caries risk
for a patient, expressed as the
“chance to avoid new caries” in the
coming year
 The cariogram also demonstrates
how and to what extent the various
caries causing factors may affect by
chance

 Illustrate the chance to avoid caries
 Illustrate the interaction of caries-
related factors
 Express caries risk graphically
 Recommended targeted preventive
actions
 Motivate patients in clinical setting
 Provide an educational program

CLINICAL DILEMMA
 Difficulty in diagnosis of dental
caries due to observer bias
 A web based study of more than
400 dentist has confirmed the
difficulty in diagnosing stained
occusal fissure based on visual
appearance alone

 It was concluded that web based
evaluation of stained occusal
fissures yielded diagnosis that had
moderately high sensitivity and low
specificity

 If these judgments had been
pursued clinically they would result
in large no of un needed restorative
intervention.
 Because of these causes many
advanced diagnostic devices are in
demand as they detect the caries in
the early stage.

DIFFICULTY IN DIAGNOSING
DENTAL CARIES
 Dentist often comment about
increasing difficulty of diagnosing
pit and fissure caries in permanent
posterior teeth, citing examples of
so-called “hidden lesions”
 Visual methods
 Radiographic methods
 Advanced caies detection devices
 Clinical evaluation-fissure biopsy

 Apart from the occult fissure lesion
penetrating deeply in to the dentine
difficulties in clinical detection and
registration arise not with the
advanced lesion but primarily with
the early lesion ,the non cavitated
lesion of dentine ,recurrent caries
and sub gingival root caries .

CARIES DETECTION VERSUS
CARIES DIAGNOSIS
 With the implementation of new
highly sensitive technologies that
“detect” caries lesions at earlier
stage, it is critical that clinicians
understand that these devices
detect and do not make a diagnosis.
 Clinicians make a diagnosis.

 We must gather information from
variety of sources, including some
of the new technologies that
provide important assistance;
however, only the practitioner can
make the decision , based on all
available data, that requires specific
interventions.

REVIEW
 D.c attrill and ph ashley –
comparison study of diagnodent
with conventional methods
 Conventional methods he choosed
were visual and radiographic
examination

 He concluded that diagnodent was
the most accurate system tested for
the detection of occlusal dentine
caries than conventional methods

 Q.shi et al (2001) comparision of
QLF and DIAGNODENT for
quantification of smooth surface
caries
 He concluded that though
DIAGNODENT performed better
than QLF in detecting natural
smooth surface caries in vitro,

 She concluded that DIAGNODENT
better than other conventional
methods and concluded that
Diagnodent device is helpful in
longitudinal monitoring of the caries
and thus also for assessing the
outcome of preventive
interventions.

 Qlf showed closer correlation with
mineral changes and is preferable
for scientific purposes, such as
monitoring de-or remineralization .

 A.m.lennon et al (2002)-
comparision study between
diagnodent and caries detector
dyes in detecting residual caries
 Caries detector dyes had
significantly lower specificity than
the other methods

 And he said that use of fluorescence
methods is improvement over
currently available methods for
detection of residual caries

 Lussi and p. francescut(2003)-
performance of conventional and new
methods in detecting occlusal caries in
deciduous teeth
 Conventional methods included in the
study were visual method,visual method
with magnification and visual inspection
with gentle probing and new method as
diagnodent

 Klas ahlund-Klas ahlund- approximal cariesapproximal caries
detection using digital radiographs anddetection using digital radiographs and
digital fibre optic transillumination, DIFOTidigital fibre optic transillumination, DIFOTi
 DIFOTI tends to detect more caries
lesions both in enamel and dentine
than digital radiographs.

DIFFERENT DIAGNOSTIC METHODS
 Patients complaint
 Clinical visual and tactile
examination
 Dental floss
 Tooth separation
 Fiber optic transillumination
 Radiographic examination

 Caries detector dyes
 Xeroradiography
 Digital subtraction radiography
 Digital radiographic methods
 Computed radiographic methods
 Electrical conductance
measurements

 Quantitative laser fluorescence
 Diagnodent
 Digital fiberoptic transillumination
 Ultrasound
 Optical coherence tomography

CONCLUSION
 As Caries is the dynamic process it
is important to diagnose caries in
the early stage as it helps in
preventing further progression of
the lesion
 Along with different caries detecting
methods, caries risk assessment
plays an important role in diagnosis
of dental caries.

THANK
YOU

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