Early diagnosis of dental caries

1. EARLY Diagnosis Of Dental
Caries

2. What is Dental caries?
 Microbial disease of
calcified portion of
teeth characterized by
demineralization of
inorganic & destruction
of organic portions of
teeth.
-Shafer 1958

3. Acc to Sturdevant
1968
According to WHO
1979
Infectious
microbiological disease
of the teeth that results
in localized dissolution
and destruction of
calcified tissues
Caries is defined as a
localized post eruptive,
pathological process of
external origin involving
softening of the hard
tooth tissue and
proceeding to the
formation of a cavity .

4. WHAT IS DIAGNOSIS

5.  Diagnosis (Plural-diagnoses )
 Greek ‘‘dia’’ meaning ‘‘through’’ and ‘‘gnosis’’
meaning ‘‘knowledge’’.
 Thus, ‘‘to diagnose’’ implies that it is only through
knowledge about the disease that a diagnosis can be
established.

6. Importance of diagnosis
 To identify etiological factors
 Determine nature of the disease involved
 To determine treatment planning
 To access prognosis

7. 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.
True diagnosis (Attia 2003)
Disease present Disease absent
A
True positive
B
False positive
C
False negative
D
True negative
Sensitivity= A/(A+C)
Specificity= D/(B+D)

8. Requirements of Ideal
diagnostic test
 Accurate & Cost effective
 Sensitive and Specific
 Reproducible and Reliable
 Should not transfer bacteria from one site to other

9. VARIOUS
DIAGNOSTIC
AIDS

10. TRADITIONAL
METHODS
Visual & tactile inspection
Caries indices
Caries detector dyes
Radiographic methods

11. ADVANCED METHODS
Digital radiographs
FOTI
DIFOTI
QLF
DIAGNODent
Vistaproof
Soprolife
Canary system
Midwest Caries I.D.
CarieScan
Carivu
Electronic caries monitor (ECM)

12. Visual diagnosis
 Most commonly because it is an easy technique that is
routinely performed in clinical practice.
 Permits early caries signs to be detected and recorded
in a reliable and accurate way by using visual indices
 Indices may also describe the characteristics of all
clinically relevant stages in the caries disease
process, making them a cost-effective method of
recording caries lesions.

13. • Teeth should be cleaned and/or dried before the
examination process, which if not included will
increase the risk of missing lesions
• Some indices recommend tactile examination to be
performed in conjunction with visual examination,
and this has been considered questionable.
• Another recommend using the WHO probe, which is
ball-ended with a sphere presenting 0.5 mm in the
extremity, allowing this kind of evaluation.

14. Tactile diagnosis
 GC Black 1924
 Simon1956
 Gilmore 1982
 Marzouk 1985
 Sturdevant 1985
 Ekstrand et al., 1987
Probing with
Sharp Explorer

15. Disadvantages of Probing with Sharp
Explorer
 Traditional probing with a sharp explorer has come into
question as the ultimate determinant of caries activity.
 Further increase in cavity
Bergmann and Linden, 1969; Ekstrand et al., 1987; Imfeld et
al., 1990;Yassin, 1995
 Transfer of bacteria (3 to 7 ×106 cultivable bacteria)
Loesche et al., 1973, 1979
 Unreliable in deep fissures
Lussi,1991; Penning et al., 1992

16. Examples showing the benefit of cleaning and drying to
detect caries (A–C) and harmful effect of probing with
a sharp explorer

17. Internationally accepted
caries detection system
DMFT/S index (Klein, Palmer, Knutson
1938, 1987,1997)
Nyvad’s System (Nyvad et al.,1999)
Significant caries index(Sic) (Bratthal D
2000)

18.  International and Caries Detection Assessment
System (2002,2005 Baltimore, Maryland, USA)
 Universal Visual Scoring System (UNIVISS)
(2008)
 Pulpal Ulceration, Fistula, Abscess Index (PUFA)
(Monse et al 2010)
 Caries Assessment and Treatment Instrument
(CAST) (Frencken JE 2011)

19. Detection with chemical
dyes
 Fusayama introduced a technique in 1972 that used a
basic fuchsin red stain to aid in differentiating layers of
carious dentin.
 Fuchsin was replaced by another dye, acid red 52,
which showed equal effectiveness.
 Caries-detecting stains differentiate mineralized from
demineralized dentin in both vital and nonvital teeth.

20.  Outer carious dentin is stainable because the
irreversible breakdown of collagen cross-linking
loosens the collagen fibers.
 Inner carious dentin and normal dentin are not stained
because their collagen fibers are undisturbed and
dense.
 Dyes do not stain bacteria but instead stain the
organic matrix of poorly mineralized dentin.

21.  Yip et al .,1994
 Dyes neither stained bacteria nor
delineated the bacterial front but did stain
collagen associated with a less mineralized
organic matrix.

22. Commercially available caries
detector dyes
 Caries check (CC), containing 1% acid red in
polypropylene glycol has been recently introduced.
 Cd dyes caries detector (cad),
 Caries marker (cam),
 Seek (see),
 Sable seek (ses) ,
 Carbolan green,
 Coomassie blue
 Lissamine blue ,
 Snoop

23. RADIOGRAPHIC
METHOD

24.  Bitewing radiographs
 IOPA radiographs
 Digital radiography
 Digital subtraction radiography

25.  Radiographic examination is useful in Monitoring
caries lesion development, in view of the fact that
non-cavitated lesions can be reversed by non-
invasive intervention, providing changes in mineral
content of dental tissues.
 Ratledge et al. (2001)
 50-90% of dentin caries lesions radiographically
observed on the approximal surface might present
cavitation.

26.  Krick R et al., (2009)
 Caries are not visible on radiographs until they
penetrate more than one half the enamel
thickness and enamel lesions are usually not
visible until 30 - 40% of the lesion has become
demineralized.
 E Onem (2012)
 40-60% of tooth demineralization required for a
lesion to be seen raiographically.

27.  (Ricketts et al., 1997),
 Clinically "sound” and apparently intact occlusal surfaces,
however, may develop lesions which penetrate into the dentin,
which can be observed only through radiographic examination.

28.  Wenzel, 1995, 2004
 The performance of bitewing radiography, have
found a high sensitivity (50-70%) to detect caries
lesions in dentin of both approximal and occlusal
surfaces, compared to clinical visual detection.
 The validity of detecting enamel lesions is limited
on the approximal surfaces and low for the
occlusal surfaces.

29.  Espelid et al., 1994; Neuhaus et al., 2009
 Validity of detecting enamel lesions is limited on
the approximal surfaces and low for the occlusal
surfaces
 This difference can be explained by the fact that
radiography is a 2-dimensional image of a 3-
dimensional anatomy of the tooth structure. So,
the superimposed cuspal tissues obscure initial
changes in occlusal surfaces.

30.  Dove 2011
 There are great chances to occur false-negative
diagnosis in the presence of caries than false
positive diagnosis in the absence of disease i.e
high specificity and low sensitivity

31. DIGITAL
RADIOGRAPHY

32.  Advantages of digital radiography compared with
conventional radiography:
1. Image acquisition process in real time.
2. Reductions in radiation dose.
3. Time savings.
4. Digital manipulation of the image to enhance
viewing.
5. Avoiding unnecessary or repeated radiographs.

33. 6. Facilitate communication and case discussion among
dental professionals.
7. Visual aid to be shown to the patient on the computer
screen, increasing the confidence and credibility in
the treatment-decision making process.
8. Primary disadvantages include the rigidity and
thickness of the sensors, the high initial system cost
and unknown sensor lifespan.

34. Principal
digital image consists
of a set of cells that
are ordered in rows
and columns, forming
a table.
Each cell is
characterized by
three numbers: the
x-coordinate, the
y-coordinate and the
gray value.

35. Gray value is a number that
corresponds with the Xray
intensity at that location
during the exposure of the
digital sensor.
Individual cells are
called “picture elements”,
which had been shortened
to “pixels”.

36.  The numbers describing each pixel are stored in
an image file in the computer.
 Digital images can be modified after they have
been produced.
 Thus, the user can apply mathematical operations
to modify the pixel values, improving the image
quality and modifying other characteristics, such
as zoom, contrast, density and brightness of an
image.

37. Digital
subtraction
radiography

38.  B.G Zeldes Des Plantes 1920
 Introduced into dentistry in 1980
 Based on the principle:
 Two digital radiographic images obtained under
different time intervals, with the same projection
geometry, are spatially and densitometrically aligned
using specific software.

39. Two images are registered
and intensities of
corresponding pixels are
subtracted of the gray scale
values
A uniform different image is
produced, resulting in a new image
representing the differences
between the two, called the
subtraction image.

40. follow-up examination, all the
anatomical structures that do
no change between
radiographs are shown as
neutral gray background
regions that had mineral loss or
gain are shown as a darker or
brighter area, respectively.

41. TRANSILLUMINATION

42. FOTI
DIFOTI
CariVu

43. FOTI
 Fiber optics Introduced in 1970’s.
 It refers to flexible, thin cylindrical fibers of
high-optical-quality glass or plastic.
 Theory:
 Single optical fiber that consists of glass or
plastic material with an outer cladding of a
material with lower refractive index.

44.  Fiber core has a higher refractive index.
 Individual fibers are grouped together to form
a fiber optic bundle.
 Fibers can be as smal as 0.01mm for glass
and 0.1 mm for plastic.

46.  It is based on the changes in the
scattering and absorption phenomenon
of light photons that increases the
contrast between sound and enamel
caries.

47.  The illumination is delivered via fiber-optics from a
light source to a tooth surface.
 The light propagates from the fiber illuminator
across tooth tissue to non-illuminated surfaces.
 The resulting images of light distribution are then
used for diagnosis.

48. DIFOTI
 INTORDUCED IN YEAR 1998
 Employs digital image processing for quantitative
diagnosis and prognosis in dentistry.

49.  It uses fiber-optic transillumination of safe visible
light to image the tooth.
 In this system, light delivered by a fiber-optic is
collected on the other side of the tooth by a mirror
system and recorded with a CCD imaging camera,
instantaneously.
 The acquired information is sent to a computer for
analysis with dedicated algorithms

50.  Digital images produce can be viewed by the
dentist and patient in real time or stored for later
assessment.
 It can also be used to detect other changes in
coronal tooth anatomy, such as tooth fractures and
fluorosis.

51. CariVu
 DEXIS CariVu™ is a compact, portable caries
detection device that uses transillumination
technology to support the identification of occlusal,
interproximal and recurrent carious lesions and
cracks.

52. CariVu

53. FLUORESCENC
E

54.  QLF
 Diagnodent
 Diagnodent Pen
 Vistaproof

55. MECHANISM OF
FLUORESCENCE
 Benedict (1928) was first to describe enamel
fluorescence.
 Fluorescence results from a change in the
characteristics of light caused by an alteration in
the wavelength of the incident light rays following
reflection from the surface of a material

56.  The intensity of the emitted fluorescence can be
measured by using a filter system.
 Through these filter system only fluorescent rays
pass and inherent fluorescence of a material is
often referred to as auto-fluorescence.
 The exact identity of the material responsible for
the fluorescence in enamel remains to be
established.

57.  NATURE OF FLUORESCENCE ON ENAMEL
SURFACE
 Near-ultraviolet light- blue
 Incident light in the blue and green- yellow and
orange fluorescence.
 Incident light in the red or near-infrared region-
red fluorescence

58.  Booij & ten Bosch (1982)
 Dityrosine are the chromophores responsible for
blue fluorescence.
 Scharf (1971)
 Yellow fluorescence is attributable to cross-
linked chains of structural proteins.

59.  Konig et al., (1998; 1999)
 Red fluorescence may be attributed to the
presence of various protoporphyrins that are
considered to be products of bacterial
decomposition and other oral bacterial
metabolites.

60. PRINCIPAL OF LASER
FLUORESCENCE
 Laser devices are based on the principle that a
monochromatic light source (655 nm wavelength)
passes unhindered through a mature enamel crystal
with little or no alteration.

61.  The 655 nm light has the ability to excite bacterial
photoporphyrins, resulting in fluorescence.
 With decalcification in the enamel, increasing
amount of the light is scattered, and the changes
in fluorescence can be quantified to describe the
presence and severity of the caries.

62. Quantitative light-induced
fluorescence (QLF)
 QLF measures :
 The degree of
fluorescence,
 Change of demineralised
enamel compared with
surrounding sound
enamel, and
 Relates it directly to the
amount of mineral lost by
demineralisation

63.  QLF system consists of a hand-held intraoral
colour micro video CCD camera, interfaced with
a personal computer and custom software.
 The software enables to capture and analyze
images of the tooth during clinical examination.

64.  QLF uses a 50-watt xenon arc-lamp and an optical
filter in order to produce a blue light with a 290- to
450-nm wavelength, which is carried to the tooth
through a light guide fitted with a dental mirror.
 The fluorescence images are filtered by a yellow
high-pass filter (λ ≥ 540 nm) and then captured by
a colour CCD camera.

65.  When the tooth surface is illuminated by this
high-intensity blue light, auto-fluorescence of the
enamel is obtained by the intraoral camera,
since all excitation light reflected or diffused is
filtered.
 The exact nature of the fluorescing
chromophores is still unidentified.

66.  Red fluorescence which
has been detected in QLF
images has been
supposed to be associated
with caries risk.
 Red fluorescence is found
in more advanced lesions
(dentinal lesions),
progressive white spots
and in aged plaque as well
as in calculus

67.  Heinrich et al., 2005
 compare the outcome of quantitative
laser/lightinduced fluorescence (QLF) and
visual inspection (VI) for the detection of initial
caries lesions on all maxillary and mandibular
smooth surfaces in caries-risk adolescents.
 The subjects were 34 students, age 15 yr.
 A total of 879 buccal and 882 lingual were
examine

68.  Fluorescence images of each smooth surface
were captured with QLF, displayed, store, and
analyse the images.
 Fluorescence loss and area of the lesion, and
fluorescence loss integrated over the lesion area,
were determined.
 4.9% were detected by VI alone and 7.9% by
QLF alone

69.  It was concluded that
 (i) QLF seems to be a sensitive method that is
suitable for the detection of visually u ndetected
initial caries lesions; and
 (ii) that the clinical use of QLF is limited by
several confounding factors in caries risk
adolescents.

70. DIAGNOdent 2095
 DIAGNOdent was
intorduced by KaVo,
Biberach, Germany in
1998.
 Cost-72025 rs
 It emits a red light (λ=
655 nm), which is
absorbed by bacterial
by-products such as
porphyrins.

71.  This light is partially reemitted as near-infrared
fluorescence.
 The device captures this fluorescence and
translates it on a numerical scale from 0 to 99:
the higher the number, the deeper the caries
lesions.
 Designed for the detection of caries lesions in
occlusal and smooth surfaces and is not
designed for proximal caries detection,

72. Diagram illustrating
working of a DIAGNOdent

73. With the classification of the obtained numbers
from the device, the degree of decay is determined
and a treatment plan adopted based on the decay
depth.

74. DIAGNOdent PEN
 The device works on the
principles of DIAGNOdent,
but the design is different.
 The device weights 140g
and only one battery (1,5V)
is needed.
 Cost-261912 rs

75.  The tip is rotatable around the axis of its length,
enabling the operator to assess mesial and distal
surfaces from both sides (buccal and lingual).
 The tip designed for proximal surfaces is made of
sapphire fiber with a prismatic shape, and the light
is directed laterally to the longitudinal axis of the
tip.

76.  Another cylindrical tip is
recommended for
occlusal surfaces, and
the direction of its light is
perpendicular to the axis
of the length of the tip.

77.  The DIAGNOdent pen is-
 less bulky,
 more flexible and
 cordless mobile instrument with differently
shaped tips for different surfaces as compared
to DIAGNOdent.

78. VISTA PROOF
[FLUORESCENCE CAMERA,
(FC)
 VistaProof (FC; Vista Proof,
D€urr Dental, Bietigheim-
Bissingen, Germany) is a
fluorescence-based camera
and software system.


79.  It is ideal for the integrated diagnosis, prophylaxis
and therapy concept of modern surgeries.
 It emits blue light at 405 nm and captures images
of occlusal surfaces

80. Principle of FC
 The FC device works at a different wavelength than
the LFpen device and is based on different principles.
 Special light-intensity LEDs project high-energy violet
light onto the tooth surface (405 nm wavelength).
 Light of this wavelength stimulates porphyrins (special
metabolites of cariogenic bacteria) to emit red light.

81.  Sound enamel sends out green light.
 These light signals are recorded by the highly
developed optics and analysed by software.
 On the monitor the fluorescent image of the porphyrins
appear in a bright red colour tone, and are thereby
easily detected.
 The denser the colonisation, the more intensive the
red fluorescent signal

82. Light-intense blue LEDs with a wavelength of
405 nm stimulate the porphyrins of cariogenic
bacteria to emit red light. Sound enamel emits
green light

83. Optical and numerical analysis of the
caries activity

84. LED technology (Midwest Caries
I.D.)
 The handheld device emits a soft
light emitting diode (LED)
between 635 nm and 880 nm.
 It analyzes the reflectance and
refraction of the emitted light from
the tooth surface, which is
captured by fiber optics and is
converted to electrical signals for
analysis

85.  The microprocessor of the device
contains a computer-based
algorithm.
 It identifies the different optical
signature (changes in optical
translucency and opacity)
between healthy and
demineralized tooth.

86.  Demineralization leads to a change in the LED
from green to red with a simultaneous audible
signal, which is directly related to the severity of
caries lesions.

87. SOPROLIFE
SOPROLIFE is a more recently released
device using a light induced fluorescence
evaluator for diagnostic and treatment.
Cost – 150,000

88. 0 Fissure appears
as shiny green,
enamel appears
sound
1 Tiny, thin red
shimmer in the pit
and fissure
systems viewed.
No red dots
appeared

90. The Canary System
 Named after the “canary in a coal mine.
 Canary Number scale of 0 to 100

91. SCORE INTERPRETATION
0 to 20 (green) Health tooth structure
21 to 69 (yellow) loss of crystallization of the
tooth structure
70 to 100 (red) significant loss of crystal
structure within the tooth
21 to 40 tends to respond well
to remineralization therapy
>45 often requires a
conservative restoration

92.  Detects caries under sealants and around
the margins of restorations.
 Detects caries on all tooth surfaces, as small as
50 microns up to 5 mm below the surface.
 Not affected by stain or calculus.
 Does not require isolation or dry field.

93. Electronic caries monitor (ECM)
 The ECM device employs a single, fixed-frequency
alternating current which attempts to measure the
‘bulk resistance’ of tooth tissue.
 This can be undertaken at either a site or surface
level.

94.  When measuring the electrical properties of a
particular site on a tooth, the ECM probe is directly
applied to the site, typically a fissure, and the site
measured.
 Tooth demineralization due to caries process
causes increased porosity of tooth structure. This
porosity contains fluid containing ions.

95.  This leads increased electrical conductivity,
conversely, leads to decreased electrical
resistance or impedance.
 There are also a number of physical factors that
will affect ECM results. These include-
• the temperature of the tooth
• the thickness of the tissue
• the hydration of the material (i.e. one should
not dry the teeth prior to use)
• the surface area.

96.  A major advantage of the ECM is to present
objective readings, which have the potential for
monitoring lesion progression, arrest, or
remineralization.
 when used to detect occlusal caries in vivo and
ex vivo the sensitivity and the specificity of this
machine have been reported to be very high,
0.75 and 0.77, respectively.
 Indicating that it is a valid indicator for detecting
the presence or absence of lesion porosity.

97.  A strong relationship between both lesion depth
and mineral content in enamel has been shown
with ECM readings.

98. CONCLUSION
 Early diagnosis of initial enamel lesions is very
important in order to be able to create at an
optimum time, an appropriate treatment allowing
the re-mineralization of these lesions.
 Many methods are available to the clinician;
however, it is imperative that methods with suitable
levels of sensitivity and specificity are used in
conjunction to obtain a valid diagnosis which will
inform the correct and appropriate treatment for
the patient.