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  1. 1. Lecture 6Lecture 6 Measuring dentalMeasuring dental cariescaries.. Prof. AhmedProf. Ahmed AbdelrahmmanAbdelrahmman
  2. 2. EXAMINATION OF DENTALEXAMINATION OF DENTAL CARIESCARIES:-:- TYPE I :-TYPE I :- complete examinationcomplete examination.. TYPE II :-TYPE II :- limited examinationlimited examination.. TYPE III :-TYPE III :- mirror & explorer andmirror & explorer and source of illuminationsource of illumination.. TYPE IV :-TYPE IV :- screening procedures,screening procedures, using only a tongue depressor andusing only a tongue depressor and available illuminationavailable illumination..
  3. 3. Diagnostic criteria of cariesDiagnostic criteria of caries:-:-  According to the WHO ( 1997 ) :-According to the WHO ( 1997 ) :-  any signs that precedeany signs that precede cavitationscavitations asas well as other conditions similar to thewell as other conditions similar to the early stage of caries areearly stage of caries are excludedexcluded as itas it can be treated incan be treated in noninvasivenoninvasive way.way.  White or chalky spots.White or chalky spots.  Discolored or rough spots that are not softDiscolored or rough spots that are not soft to touch with probeto touch with probe  Stained pits or fissures with no underStained pits or fissures with no under mined enamel.mined enamel.  Dark, shiny, hard pitted areas of enamel.Dark, shiny, hard pitted areas of enamel.
  4. 4. Decayed crownDecayed crown:-:- dental caries is recorded asdental caries is recorded as presentpresent whenwhen a lesion in a pit or fissure or on smootha lesion in a pit or fissure or on smooth surface hassurface has:-:- A cavity, undermined enamel or detectablyA cavity, undermined enamel or detectably softened floor or wallsoftened floor or wall.. A tooth with temporary filling should beA tooth with temporary filling should be included in this categoryincluded in this category.. Missing teeth:-Missing teeth:- as a result of cariesas a result of caries should be only recordedshould be only recorded
  5. 5.  Measurement of the intensity ofMeasurement of the intensity of dental caries have been useddental caries have been used since the early 20since the early 20thth century.century.  ProportionProportion of 1of 1stst molar lost through caries.molar lost through caries.  PercentagePercentage of permanent teeth affected.of permanent teeth affected. Both methods were not sensitive.Both methods were not sensitive.
  6. 6. DMF IndexDMF Index..  Attributed toAttributed to Klein, PalmerKlein, Palmer andand  KnustonKnuston in the 1930in the 1930’’s. Since then,s. Since then,  DMF index has received practicallyDMF index has received practically  universal acceptance and probablyuniversal acceptance and probably the best known of all dental indexes.the best known of all dental indexes.
  7. 7. Characteristics of DMFCharacteristics of DMF Index:-Index:-  The DMF, anThe DMF, an irreversibleirreversible index,index, applied only to permanent teeth. Andapplied only to permanent teeth. And always significant by upper casealways significant by upper case letters.letters.  DD was decayed teethwas decayed teeth, M, M, teeth, teeth missing due to caries, andmissing due to caries, and F,F, teethteeth that had been previously filled.that had been previously filled.
  8. 8.  DMF score for any one individual canDMF score for any one individual can rangerange from 0 to 32from 0 to 32 in whole whole number.  A mean DMF score for a group, beingA mean DMF score for a group, being the total of individual values dividedthe total of individual values divided by the number of subjects examined,by the number of subjects examined, can havecan have fractional valuesfractional values..
  9. 9.  The DMF index can be applied toThe DMF index can be applied to whole teethwhole teeth (designated as(designated as DMFTDMFT) or) or to surfacesto surfaces ((DMFS)DMFS) which is morewhich is more sensitive, used in the clinical trials.sensitive, used in the clinical trials.  ToTo save timesave time in a large survey, DMFin a large survey, DMF can be usedcan be used half-mouthhalf-mouth and theand the score doubled, an approach thatscore doubled, an approach that assume the bilateral nature of caries.assume the bilateral nature of caries.
  10. 10. Modification.Modification.  Teeth that have been filled and haveTeeth that have been filled and have redecayedredecayed on another surface, soon another surface, so better to use DMFS.better to use DMFS.  Secondary cariesSecondary caries around an existingaround an existing restoration.restoration.  Crowned teethCrowned teeth and bridge pontic.and bridge pontic.
  11. 11. Indexes for primary teeth:-Indexes for primary teeth:- The equivalent index for theThe equivalent index for the primary dentition is theprimary dentition is the defdef andand its modifications, signified byits modifications, signified by lower caselower case letters.letters.
  12. 12. Characteristics of def index:-Characteristics of def index:-  TheThe dd stood for decayed teeth,stood for decayed teeth, ee means indicated for extraction, andmeans indicated for extraction, and ff was filled teeth.was filled teeth.  Teeth missingTeeth missing for caries are notfor caries are not recorded coz of the difficulty ofrecorded coz of the difficulty of distinguishing betweendistinguishing between extractedextracted andand naturallynaturally exfoliatedexfoliated primary teeth.primary teeth.
  13. 13. Modifications of def:-Modifications of def:-  TheThe dmfdmf index for use in childrenindex for use in children beforebefore ages of exfoliation.ages of exfoliation.  It applied only to primary molars.It applied only to primary molars.  TheThe dfdf index in which missing teethindex in which missing teeth are ignored.are ignored.
  14. 14.  TheThe dfdf andand defdef should beshould be numericallynumerically the same.the same.  Both understate the true extent ofBoth understate the true extent of carious attack.carious attack.
  15. 15. Limitations of DMF index:-Limitations of DMF index:-  DMFDMF values are not related to thevalues are not related to the number ofnumber of teeth at risk.teeth at risk.  It hasIt has no denominator.  Have little meaning unlessHave little meaning unless ageage isis also stated.also stated.
  16. 16.  It can beIt can be invalidinvalid in older older adults.  It can beIt can be misleadingmisleading in childrenin children……  It can beIt can be over estimateover estimate cariescaries experience in teeth withexperience in teeth with PreventivePreventive RestorationsRestorations……....DMF score will beDMF score will be inflated.inflated.
  17. 17.  DMF cannot used forDMF cannot used for root caries.root caries.  DMF cannot account forDMF cannot account for sealed teethsealed teeth..
  18. 18. Criteria for diagnosing RootCriteria for diagnosing Root Surface Caries:-Surface Caries:-  DiscreteDiscrete well defined &well defined & discoloreddiscolored soft area.soft area.  Explorer enters easilyExplorer enters easily displays somedisplays some resistanceresistance to withdrawal.  The lesion is located either at theThe lesion is located either at the CEJCEJ OR wholly on theOR wholly on the root surfaceroot surface..
  19. 19. Root caries index ( RCI ) :-Root caries index ( RCI ) :-  As described byAs described by Katz,1980,Katz,1980, a tooth isa tooth is considered to be at risk of root cariesconsidered to be at risk of root caries if--->if--->  EnoughEnough gingival recessiongingival recession hashas occurred to expose part of theoccurred to expose part of the cement surface to thecement surface to the oraloral environment.environment.
  20. 20.  RCI =RCI =  Root surface :decayed + filledRoot surface :decayed + filled  Root surface :d+ f+ soundRoot surface :d+ f+ sound x100x100
  21. 21.  A communityA community RCI of 6.91RCI of 6.91 means thatmeans that all teeth withall teeth with gingival recessiongingival recession, 6.9%, 6.9% were decayed or filled on the rootwere decayed or filled on the root surface.surface.
  22. 22. DT = 1 DS = 2 DT = 1 DS = 3 DT = 1 DS = 1
  23. 23. Following theFollowing the ingestion ofingestion of fermentable carbohydratesfermentable carbohydrates, the pH of, the pH of the plaque drops rapidly to a pointthe plaque drops rapidly to a point where demineralization begins;where demineralization begins; usually in a range betweenusually in a range between pH 5.5 andpH 5.5 and 5.05.0.. pH 5.5 pH 5.0 pH Time Normal plaque pH
  24. 24. Demineralization: calcium & phosphate ions leaching out at the plaque enamel interface at pH 5 . Ca Ca CaCa CaPO4 PO4 PO4 PO4 PO4PO4 Enamel Demineralized area Dental plaque Saliva pH = 5 Ca (1)(1)
  25. 25. Inward flow of calcium and phosphate ions (remineralization) favoured by fluoride ions at pH 7. F F F F PO4 PO4 PO4 PO4 PO4 Ca Ca Ca Ca Ca EnamelRemineralized area Saliva pH = 7 (2)(2)
  26. 26. Demin. DeminRemin. Remin When demineralization exceeds remineralization dental caries occurs Dynamic equilibrium = no caries Demin. Exceeds remin. = caries occurs
  27. 27. Carious lesionCarious lesion beginsbegins as a clinicallyas a clinically undetectableundetectable subsurfacesubsurface demineralization of enamel visible onlydemineralization of enamel visible only at microscopic levelat microscopic level..
  28. 28. Non-cavitated lesion Cavitated lesion
  29. 29. Initial stagesInitial stages of dental caries areof dental caries are reversiblereversible.. As long as the lesion is still incipientAs long as the lesion is still incipient i.e. with no cavitationsi.e. with no cavitations remineralization is possibleremineralization is possible.. The early identification of such earlyThe early identification of such early carious lesion iscarious lesion is extremelyextremely importantimportant because it is during thisbecause it is during this stage that the carious process can bestage that the carious process can be arrested or reversedarrested or reversed..
  30. 30. Treatment is by primaryTreatment is by primary preventivepreventive practices such aspractices such as plaque controlplaque control andand topical fluoridetopical fluoride applicationsapplications..
  31. 31. On the other handOn the other hand,, the overtthe overt cavitations stage iscavitations stage is anan irreversibleirreversible oneone.. It may be calledIt may be called ““ thethe point of nopoint of no returnreturn" as it is no" as it is no longer expectedlonger expected thatthat remineralizationremineralization can occurcan occur..
  32. 32. Criteria from WHO guidelinesCriteria from WHO guidelines;; Caries is recorded as present when a lesion in aCaries is recorded as present when a lesion in a pit or a fissure or on a smooth surface haspit or a fissure or on a smooth surface has:: 11--Obvious cavityObvious cavity 22--Undermined enamelUndermined enamel 33--Softened floor or wallSoftened floor or wall 44--On a proximal surfaces , the examiner must beOn a proximal surfaces , the examiner must be certain that the explorer entered a lesioncertain that the explorer entered a lesion.. 55--AA tooth with temporary filling should be includedtooth with temporary filling should be included in this categoryin this category.. Where anyWhere any doubtdoubt exists, the surfaceexists, the surface is recordedis recorded asas soundsound..
  33. 33. Scored as sound by WHO criteria
  34. 34. Thus,Thus, a tooth with the followinga tooth with the following criteria should be coded ascriteria should be coded as soundsound:: 11--White or chalkyWhite or chalky spotsspots.. 22--Discolored or rough spotsDiscolored or rough spots that arethat are not soft to touch with a blunt probenot soft to touch with a blunt probe.. 33--Stained pits or fissuresStained pits or fissures in thein the enamel that do not have visual signsenamel that do not have visual signs of undermined enamel, or softeningof undermined enamel, or softening of the floor or wallof the floor or wall..
  35. 35. Diagnostic Criteria for non-cavitatedDiagnostic Criteria for non-cavitated lesionslesions TheThe first visual evidencefirst visual evidence of an incipientof an incipient lesion on enamel surface the appearancelesion on enamel surface the appearance of aof a white spotwhite spot.. By time it may become aBy time it may become a brownbrown spotspot..
  36. 36. OnOn buccal & lingualbuccal & lingual surfaces, thesurfaces, the white spot may bewhite spot may be localizedlocalized or it canor it can extendextend parallel to the gingivalparallel to the gingival marginmargin..
  37. 37. TraditionallyTraditionally visual-tactile methodvisual-tactile method is used ( used (i.e. explorer as well as visionexplorer as well as vision( .( . –Mouth mirrorMouth mirror –ExplorerExplorer –Good illuminationGood illumination RecentlyRecently, method for diagnosing caries have, method for diagnosing caries have moved more towardmoved more toward exclusively visualexclusively visual methodmethod (i.e. without probing(i.e. without probing(( –Mouth mirrorMouth mirror –Good illuminationGood illumination
  38. 38. Explorer should not be usedExplorer should not be used for several reasonsfor several reasons:: 11--thethe use of exploreruse of explorer ,even gentle,even gentle probing with a sharp explorer, isprobing with a sharp explorer, is likely tolikely to damage the surfacedamage the surface zonezone ofof non-cavitated lesionsnon-cavitated lesions..
  39. 39. Even gentle probingEven gentle probing with a sharp explorerwith a sharp explorer turnedturned non-cavitated lesion intointo cavitationcavitation.. thusthus turningturning what could have been awhat could have been a reversiblereversible lesion (non-cavitated)lesion (non-cavitated) intointo one that isone that is irreversibleirreversible..
  40. 40. 22--It may provideIt may provide no more accuracyno more accuracy in diagnosisin diagnosis becausebecause the surfacethe surface enamel of non-cavitated lesionsenamel of non-cavitated lesions feelsfeels hardhard and give no indication forand give no indication for demineralizationdemineralization.. 33--It may allowIt may allow transmission oftransmission of cariogeniccariogenic bacteria from infectedbacteria from infected sitessites..