Caries Risk Assessment & Diagnostic Aids

Caries Risk Assessment
& Diagnostic Aids
Prsented By
Dr Susmita Shah
MDS Part II
1

Contents
Part I
Introduction
Risk predictors & Risk indicators
Caries Risk Assessment
Caries Activity Tests
Conclusion
Bibliography
2

Part II
Introduction
Importance of diagnosis
Criteria for diagnosis
Traditional Methods
Recent Advances
Conclusion
Bibliography
3

 INTRODUCTION
• DENTAL CARIES:- Acc to Shafers in 1993
Dental caries is an irreversible microbial disease of the calcified
tissue of the teeth, characterized by demineralization of inorganic portion and
destruction of organic substance of tooth which often leads to cavitation.
• Risk assessment is based on past caries experience, Socioeconomic
factors & biological factors.
• To identify who will most likely develop dental caries
• Provide these individuals proper preventive & treatment measures
4

 CARIES RISK PREDICTORS & INDICATORS
Per Axelson. Diagnosis and risk
predicion of dental caries.
5
Predictors
• Key Age Groups
• Risk Individuals
• Key risk teeth
• Key risk surface
Indicators
• White spots
• Caries
• Enamel lesion
• Restorations˃ 3 years

 CARIES RISK ASSESSMENT
• Can be defined as procedure to predict future dental
caries development before the clinical onset of disease.
•
• Determines caries incidence i.e number of new cavitated
or incipient lesions.
• Involves probability that there will be change in size or
activity of lesion.
Caries-risk Assessment and Management for Infants, Children, and Adolescents. REFERENCE
MANUAL V 4 0 / N O 6 1 8 / 19
6

• Risk assessment:
1. fosters the treatment of the disease process
instead of treating the outcome of the disease.
2. gives an understanding of the disease factors for a
specific patient and aids in individualizing preventive
discussions.
3. individualizes, selects, and determines frequency
of preventive and restorative treatment for a patient.
4. anticipates caries progression or stabilization
7
MANUAL V 4 0 / N O 6 1 8 / 19
MANUAL V 4 0 / N O 6 1 8 / 19

8
MANUAL V 4 0 / N O 6 1 8 / 19
Caries Risk assessment Methods
1. Caries Questionnaire in combination with
Clinical Observations
2. AAPD’s Caries-risk Assessment Form.
3. The Cariogram Model
4. Caries Assessment and Risk Evaluation (CARE)
test.
5. Caries management by risk assessment
(CAMBRA)
6. Traffic Light Matrix (TLM)

9
• Caries-risk assessment models currently involve a
combination of factors including diet, fluoride exposure, a
susceptible host, and microflora that interplay with a
variety of social, cultural, and behavioral factors.

1. Caries questionnaire in combination
with clinical observation
• Featherstone et al. evolved a consensus statement to
assess individual caries risk from a questionnaire that
addresses issues such as maternal dental history, family
dynamics, socioeconomic factors, oral hygiene measures,
fluoride exposure, and frequency of sugar exposures.
• clinical observations were made by visual, tactile, and
radiographic examination of teeth.
10
Singh E, Suneja B, Tandon B, Philip N, An Overview of Caries Risk Assessment: Rationale, Risk
Indicators, Risk Assessment Methods, and Risk-based Caries Management Protocols. Indian Journal
of Dental Sciences 2017

11
MANUAL V 4 0 / N O 6 1 8 / 19
2. AAPD’s Caries Risk
Assessment form

12
MANUAL V 4 0 / N O 6 1 8 / 19

13
MANUAL V 4 0 / N O 6 1 8 / 19

14
MANUAL V 4 0 / N O 6 1 8 / 19

15
MANUAL V 4 0 / N O 6 1 8 / 19

3. Cariogram
• Cariogram is a new way in which to illustrate the interaction
between caries related factors.
• This educational interactive program has been developed
for better understanding of the multifactorial aspects of
dental caries and to act as a guide in the attempts to
estimate the caries risk.
D. Bratthall, G Hänsel Petersson, Cariogram – a multifactorial risk assessment model for a
multifactorial disease. Community Dent Oral Epidemiol 2005; 33: 256–64

Aim
• Illustrates the interaction of caries related factors.
• Illustrates the chance to avoid caries.
• Expresses caries risk graphically.
• Recommends targeted preventive actions.

19

Advantages
• Model is affordable
• User friendly
• Easy to understand
• Tool for motivating patients
• Also serves as support for clinical decision making while
selecting preventive strategies.
Texbook of Pediatric Dentistry By Nikhil Marwah. Jaypee Brothers Publication. 3rd edition. 20

Texbook of Pediatric Dentistry By Nikhil Marwah. Jaypee Brothers Publication. 3rd edition. 21

22
TITLE AUTHORS
JOURNAL
LO
E
AIM MATERIAL AND
METHODODOLGY
CONCLUSION
Validating
the Usage
of
Cariogram
in 5- and
12-year-
old
School-
going
Children
in Paonta
Sahib,
Himachal
Pradesh,
India: A
12-month
Prospectiv
e Study
Garg A,
Madan M,
Dua, Saini
S, Mangla
R, Singhal
P, Dupper
A. Int J Clin
Pediatr
Dent. 2018
Mar-Apr;
11(2): 110–
115.
IIIb To validate
the caries
risk profiles in
5- and 12-
year-old
school-going
children and
to single out
main
contributing
factor, if any,
using
cariogram
over a period
of 1 year
A cariogram model
was used to create
caries risk profiles
on 499 children
aged 5 and 12 years
±6 months. They
were divided into 2
groups. The group I
and group II
consisted of 250 and
249 children
respectively. Re-
examination was
done after 1 year
and caries increment
was recorded. The
caries risk profiles
generated by the
cariogram software
The risk of
developing new
carious lesions
consistently
reduced from high-
risk category to
low-risk category,
reflecting the
cariogram ability in
accurately
estimating future
caries. Hence,
cariogram can be
said to be a useful
tool for caries
prediction.

4. Caries Assessment & Risk Evaluation Test
23Singh E, Suneja B, Tandon B, Philip N, An Overview of Caries Risk Assessment: Rationale, Risk

• The CARE test is probably the only CRA method that
can potentially promote caries prevention at the primary
level itself (before any carious lesions have appeared),
by identifying high caries risk children early and
instituting a preemptive aggressive preventive regimen in
them.
24

5. Caries Management by Risk Assessment
• The science of CAMBRA deals with caries
management using risk assessment protocols
for diagnosis, treatment, and prevention,
including nonsurgical means for repairing or
remineralizing tooth structure.
25

6. Traffic Light Matrix
• Commonly used CRA tool in Australia
• Color codes such as red, green, and orange
• to alert the clinician regarding the current risk status
• based on 19 criteria in 5 different categories including
saliva (6 criteria), plaque(3 criteria), diet (2 criteria),
fluoride exposure (3 criteria), and modifying factors (5
criteria).
27

• Saliva: (a) Resting: Hydration, viscosity, and pH (b) stimulated:
Quantity/rate, pH, and buffering capacity
• Plaque: PH, maturity, and bacteria – mutans count
• Diet: Number of sugar and acid exposures in-between meals/day
• Fluoride: Exposure to fluoride through water/toothpaste/ professional
treatment
• Modifying factors: Drugs that reduce salivary flow, diseases
resulting in dry mouth, fixed/removable appliances, recent active
caries, and poor compliance.
28

 CARIES ACTIVITY TEST
• Caries activity tests have been well known in dentistry for the past
few years.
• in routine clinical practice these caries activity tests require specially
prepared culture media and laboratory facilities for incubation and
expensive kits to perform.
• principle causative organism being Streptococci mutans.
Nemmarugommula N, Arun A, Mythri H. Caries Activity Tests. Research and Reviews:
Journal of Dental Sciences 2013.
30

WHY CARIES ACTIVITY TESTS ???
• To determine the need and extent of personalized
preventive measures.
• To serve as a index of the success of therapeutic
measures.
• To motivate and monitor the effectiveness of education
process.
• To identify high risk groups and individuals.

Various caries activity tests
A. Tests which measure caries activity
-Lactobacillus colony count test
-Streptococcus mutans level in saliva
-S. Mutans screening tests
Plaque-tooth pick method
Saliva/tongue blade method
S. Mutans adherence method
-Alban test
-Dewar test
-Swab test
-Salivary buffer capacity test
• B. Tests which measure caries susceptibility
-Snyder’s colorimetric test
-Enamel solubility test
-Dewar test
-Fosdick calcium
-Salivary Reductase Test

Lactobacillus Colony Count test
(Hadley 1933)
ACTION :- To estimate the number of acidogenic and acid
uric bacteria in the patients saliva by counting the
number of colonies appearing on tomato peptone agar
plates (PH-5.0) after inoculation with a sample of saliva.
EQUIPMENT : Saliva collecting bottles, Paraffin, two 9-ml
tubes of saliva, two agar plates, two bent glass rods,
Quebec counter and pipettes.

Interpretation:-
No. of lactobacilli per
ml saliva
Caries activity
0-1000 Little or No
1000-5000 Slight
5000-10,000 Moderate
>10,000 Marked

Snyder’s Test
• Introduced by Snyder in 1951.
Measures the rapidity of acid formation by salivary
microorganisms, when a sample of stimulated saliva is
inoculated into glucose agar medium with bromocresol
green as color indicator.
Equipment: Saliva collecting bottles, Paraffin a tube of
Snyder glucose agar containing bromocresol green and
adjusted to PH 4.7 to 5 pipettes and incubating facilities.

36
Procedure
Interpretation 24 hrs 48hrs 72 hrs
If yellow
Marked caries
susceptibility
If yellow
Definite caries
susceptibility
If yellow
Limited caries
susceptibility
If green
Continue to
incubate &
observe at 48
hrs
If green
Continue to
incubate &
observe at 72
hrs
If green
Caries inactive

Alban’s Test
• It is a simplified substitute for the Snyder test.
• Recommended, for all patients prone to caries,
especially children undergoing orthodontic treatment.

2 tubes are
taken & patient
is asked to
expectorate
directly in test
tube
Tubes are
Labeled and
Incubate at
98.6°F for upto 4
days
Agar is
Distribute 5 ml
solution per
test tube
60 gms of
Snyder test agar
placed in 1 liter
of water and
suspension is
bring to boil
Agar is
Distribute 5 ml
solution per
test tube
Procedure:-

Interpretation:
No colour change
One-third colour
change
One Half colour
change
Three Fourth
colour change
Total colour
change
+ + +
+ +
+
0
+ + +
+
pH≤4
pH=5
1.
2.
3.
4.
5.

Fosdick calcium dissolution test
Action: The test measures the milligrams of powdered
enamel dissolved in 4 hours by acid, formed when the
patients saliva is mixed with glucose and powdered
enamel.
Equipment: Powdered human enamel, saliva collection
bottles, sterile test tubes, test tube agitation equipment
and equipment for determining the calcium content of
saliva.

Procedure
• 2.5ml of stimulated saliva are collected, one part of this is analyzed for
calcium content, the rest is placed in an 8 inch sterile test tube with
about 0.1g of powdered human enamel.
• The tube is sealed and shaken for 4 hours at body temperature after
which it is again analyzed for calcium content.
• The chewing of gum to stimulate saliva produces sugar. If paraffin is
used, a concentration of about 5% glucose is added. The amount of
the enamel dissolution increases as the caries activity increases.
Interpretation
• Amount of calcium increases, as the caries activity increases.
• Amount of dissolution increases, as the caries increases.

Dewar test
• Action: Similar to Fosdick calcium dissolution test
except that the final pH after four hrs is measures,
instead of the amount Of calcium dissolved.
• Not commonly used as it has not been adequately
tested for clinical correlation.

Swab test
• developed by Grainger et al in 1965.
• It has advantage compared to other tests, as no saliva
collection is necessary.
• Valuable in evaluating caries activity in very young
patients.
• Action: It is based on the same principle as the snyder’s
test.

Procedure
Oral flora is sampled by swabbing the buccal surfaces of the teeth
with the help of cotton applicator.
Sample is subsequently incubated in the medium.
The change in the Ph following a 48 hour incubation period is read on
a pH meter.
pH ≤ 4.1 Marked Caries
Activity
pH 4.2 - 4.4 Active
pH 4.5 - 4.6 Slightly Active
pH > 4.6 Caries inactive

Salivary Reductase Test
(Susceptibility test)
Action: Measures the rate at which an indicator molecule,
diazo-resorcinol, changes from blue to red reduction by
the mixed salivary flora. The test “measures the activity of
a Single Enzyme reductase.”
Equipment: The Reductase test comes in a kit (Treatex) that
includes calibrated saliva collection tubes with the reagent
inside of the tubes, cap, plus flavored Paraffin.

Procedure:- Saliva is collected
by chewing
paraffin &
expectorated
directly in the test
tube
Sample is mixed with
dye Diazo-resorcinol
Observe the color
change after 15 minutes
Interpretation
Colour Time Score Caries Activity
Blue 15
minutes
1 Non conducive
Orchid 15
minutes
2 Slightly
conducive
Red 15
minutes
3 Moderately
conducive
Red Immediat
ely
4 Highly
conducive
Pink/
White
Immediat
ely
5 Extremely
conduciveNemmarugommula N, Arun A, Mythri H. Caries Activity Tests. Research and Reviews:

Buffer Capacity Test
Action: Buffer capacity can be quantitated using either a pH
meter or color indicator.
The test measures the number of millilitres of acid
required to lower the pH of saliva through an arbitrary pH
interval, such as from pH 7.0 to 6.0 or the amount of acid or
base necessary to bring color indicators to their end point.
Equipment: Needed equipment includes a pH meter, titration
equipment, 0.05N lactic acid, 0.05N base, Paraffin, Sterile
glass jars containing a small amount of oil.

Procedure:-
• 10ml of stimulated saliva is collected under oil at least 1hr
after eating: 5ml of this are measured into a beaker.
• The pH of the saliva is adjusted to 7.0 by addition of lactic
acid or base.
• The level of lactic acid in the graduated cylinder is
recorded ,lactic acid is then added to the sample until a
pH of 6.0 is reached.

Interpretation
• There is an inverse relationship between buffering
capacity of saliva and caries activity
Acid buffering
capacity
Caries
Activity

Cariostat test
A sterile cotton swab - run across the buccal surfaces of all
maxillary teeth present.
The cotton swab is then placed into the ampule supplied by
the manufacturer (2 ml of the culture medium).
Incubated for 48 hr at 37°C.

• The test medium’s color change was compared with four
reference tubes provided.
• Scored :
Dark blue (pH 7) = 0;
Green (pH 5.5) = 1;
Yellow-green (pH 4.5) = 2;
Bright yellow (pH 4) = 3.

Dentocult SM Strip mutans
• Mutans streptococci play an important role in the initiation
and progression of dental caries and they are considered
the primary cause of bacteriological caries.
• This bacterium thrives in the plaque that forms on the
surface of teeth.
• The earlier the colonisation of teeth occurs, the higher
the prevalence of dental caries.

Interpretation:
• Mutans streptococci adhere to the rough area of the strip
in proportion to their density in saliva. After incubation they
are visible as light to dark blue, raised colonies on the
rough area of the test strip.

ORATEST
• based on the rate of oxygen depletion by micro organisms.
• Under aerobic conditions the bacterial enzyme, aerobic dehydrogenase
transfers electrons or protons to oxygen.
• Once oxygen gets utilized by the aerobic organisms and an anaerobic
environment is attained, methylene blue [redox indicator] acts as an
electron acceptor and gets reduced to leucomethylene blue.
• The metabolic activity of the aerobic microorganism is reflected by the
reduction of methylene blue to leucomethylene blue.
• The test is based on rinsing the mouth with sterile milk which dislodges
the micro-organisms and also produces a substrate for their further
metabolism. The formation of leucomthylene blue can be easily
observed because of the white color of milk.
•

Conclusion
• Clinical variables especially past caries experience,
bacterial levels, sociodemographic variables are most
significant predictors of future dental caries
development.
• Caries risk assessment is goal of practitioners to
establish more efficient dental care delivery system.
55

Bibliography
• Caries-risk Assessment and Management for Infants, Children, and Adolescents.
REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19.
• Pediatric Dentistry Infacy through Adolescence by Casamasimo p, Field H. 5th edition.
• Per Axelson. Diagnosis and risk predicion of dental caries.
• Texbook of Pediatric Dentistry By Nikhil Marwah. Jaypee Brothers Publication. 3rd edition.
• S. Uma Maheswari, Jacob Raja1, Arvind Kumar, R. Gnana Seelan. Caries management by
risk assessment: A review on current strategies for caries prevention and management.
Journal of Pharmacy and Bioallied Sciences August 2015 Vol 7 Supplement 2.
• Nemmarugommula N, Arun A, Mythri H. Caries Activity Tests. Research and Reviews:
• Soben Peter; Essential of Preventive And Community Dentistry;3rd & 4th ed.
• D. Bratthall, G Hänsel Petersson, JR Stjernswärd. Cariogram, Internet Version 2.01. April 2,
2004.
• Nagaraj and Vishnani: Cariogram .A caries risk prediction software. International Journal of
Scientific Study .January 2014.Vol 1.Issue 4.
• Bratthall D, Hänsel Petersson G. Cariogram a multifactorial risk assessment model for a
multifactorial disease. Community Dent Oral Epidemiol. 2005 Aug;33(4):256-64.
56

57
Part II
Introduction
Importance of diagnosis
Criteria for diagnosis
Traditional Methods
Recent Advances
Conclusion
Bibliography

INTRODUCTION
• Diagnosis is derived from Greek word ‘dia’ means- by
and ‘gnosis’ means knowledge.
• Dental caries is the most common disease in the world.
• Diagnosis 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.
Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi (2012). Traditional and Novel Caries
Detection Methods, Contemporary Approach to Dental Caries, Dr. Ming-Yu Li (Ed.), ISBN: 978-953-51-
58

• Objectives of caries diagnosis are to identify those
lesions that require surgical treatment, those that require
nonsurgical (restorative) treatment, and those persons
who are at high risk for developing carious lesions.
59
Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi (2012). Traditional and Novel
Caries Detection Methods, Contemporary Approach to Dental Caries, Dr. Ming-Yu Li (Ed.), ISBN: 978-
953-51-0305-9, InTech.

 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.
60
Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi (2012). Traditional and Novel
953-51-0305-9, InTech.

 CRITERIA FOR DIAGNOSIS
• 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 assessment
• According to PITTS(1997)the ideal method 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
61Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi (2012). Traditional and Novel
953-51-0305-9, InTech.

• 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.
62

 TRADITIONAL METHODS
• Meticulous clinical examination
• Tactile examination
• Radiographic examination
• Tooth separation
• Dental floss
63Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi (2012). Traditional and Novel Caries

Meticulous clinical examination
• Careful examination of the teeth under clean and dry
conditions using good illumination may reveal visual
signs of caries like
1. Brownish discoloration of pit and fissure
2. Opacity beneath pit and fissures or marginal ridges
3. Frank cavitation of the tooth surface
64Jeffery B. Price. A Review of Dental Caries Detection Technologies. PennWell
Publications. June 2013.

• 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.

RADIOGRAPHIC EXAMINATION
• Conventional, intraoral periapical and bitewing
radiographs are employed for diagnosis of dental
caries.
Bitewing radiographs have more diagnostic value because
• Interproximal caries
• Recurrent caries below proximal restoration
• Both maxilla and mandible in one film
Diniz M, Rodrigues A, Lussi A. Traditional and Novel Caries Detecion Methods. Chapter · March
2012
66

Advantages
• Discloses
inaccessible sites
• Depth of lesion
• Noninvasive
• Record purpose
Disadvantages
• Accuracy-
Angulation, exposure
timing, processing.
• 2 Dimensional
• Does not reveal
earliest stage of
caries
• Differentiate- caries,
fracture/ cervical
burnout
• Observer bias
67Diniz M, Rodrigues A, Lussi A. Traditional and Novel Caries Detecion Methods. Chapter · March
2012

TOOTH SEPARATION
• Temporary elective tooth separation to detect the
approximal smooth surface caries.
• orthodontic elastic separator can be applied for 2-3 days
around the contact areas of approximal surfaces.
2012

69
TITLE AUTHOR
S
JOURNA
L
LO
E
AIM MATERIAL AND
METHODODOLGY
CONCLUS
ION
The
influence of
interdental
spacing on
the
detection of
proximal
caries
lesions in
primary
teeth.
Novaes T
F,
Matos,Ce
libert p,
Braga M,
Mendes
F.
Brazilian
Oral
Research
. Aug
2012
IIa to investigate
the influence
of interdental
spacing on
the
performance
of proximal
caries
detection
methods in
primary
molars.
The proximal spaces
between the posterior
primary teeth (n = 344) of
76 children (4–12 years old)
were evaluated before and
after temporary separation.
Stainless steel strips with
different standardized
thicknesses were used to
measure the presence of
biological spacing and the
spacing obtained after
temporary separation with
orthodontic rubber rings.
First, the presence of
proximal caries lesions was
assessed by visual
inspection, bitewing
radiographs and a pen-type
biological
interdental
spacing
does not
influence
the
performanc
e of
proximal
caries
detection
methods in
primary
molars,
and
temporary
tooth
separation
provides
TITLE AUTHOR
S
JOURNA
L
LO
E
AIM MATERIAL AND
METHODODOLGY
CONCLUS
ION
The
influence of
interdental
spacing on
the
detection of
proximal
caries
lesions in
primary
teeth.
Novaes T
F,
Matos,Ce
libert p,
Braga M,
Mendes
F.
Brazilian
Oral
Research
. Aug
2012
IIa to investigate
the influence
of interdental
spacing on
the
performance
of proximal
caries
detection
methods in
primary
molars.
The proximal spaces
between the posterior
primary teeth (n = 344) of
76 children (4–12 years old)
were evaluated before and
after temporary separation.
Stainless steel strips with
different standardized
thicknesses were used to
measure the presence of
biological spacing and the
spacing obtained after
temporary separation with
orthodontic rubber rings.
First, the presence of
proximal caries lesions was
assessed by visual
inspection, bitewing
radiographs and a pen-type
biological
interdental
spacing
does not
influence
the
performanc
e of
proximal
caries
detection
methods in
primary
molars,
and
temporary
tooth
separation
provides

DENTAL FLOSS
• Dental floss is sawed through the contact areas between
the teeth.
• If it frays or shreds then it is a sign of proximal caries.

 RECENT ADVANCES
1. Xeroradiography
2. Digital Subtraction radiography
3. Fiber optic transillumination
4. Digital fiberoptic transillumination
5. Diagnodent
6. Electrical caries monitor (ECM)
7. Quantitative laser fluorescence
8. Ultrasonic imaging
9. Cone beam computated tomography (CBCT)
10. Radiovisuography (RVG)
11. Optical coherence tomography
12. Caries detector dyes
71

• Invented & first used by engineer Dr. Robert
C. McMaster in 1950.
• Highly electrostatic imaging technique
• 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.
72
1. XERORADIOGRAPHY
2012

• 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.
2012

• Advantages
– Edge enhancement
– Less radiation exp.
– No wet processing
– No accidental film
exposure
– No special room
required
– Less time req.
• Disadvantages
– Expensive
– Discomfort
because of electric
charge
74
• Advantages
– Edge enhancement
– Less radiation exp.
– No wet processing
– No accidental film
exposure
– No special room
required
– Less time req.

2. DIGITAL SUBTRACTION RADIOGRAPHY
• Introduced by Richard Webber
• Digitization- taking a picture of the radiograph using
high quality camera.
• This is fed to a computer imaging device called digitizer
.
75

• 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.
2012

77
• Disadvantages
– Expensive
• Advantage
– Superior to
conventional
radiography
– Approximal caries
visualized better
2012

78
TITLE AUTHOR
S
JOURNA
L
LO
E
AIM MATERIAL AND
METHODODOLGY
CONCLUSIO
N
To assess
the one-
year
outcome of
glass-
ionomer
cement
(GIC)
restorations
with partial
carious
dentin
removal in
primary
molars
using digital
subtraction
radiographs
Phongha
nyudha A,
Ruangdit
b C,
Pornpras
ertsuk-S,
Oral
Health &
Preventiv
e
Dentistry.
2017
Ia To assess the
one-year
outcome of
glass-
ionomer
cement (GIC)
restorations
with partial
carious
dentin
removal in
primary
molars using
digital
subtraction
radiographs.
Children ages 6-8 years
were recruited. Forty-
nine primary molars with
deep carious lesions
were studied. The
carious dentin was
removed at the
dentoenamel junction
(DEJ) and restored with
GIC. Digital radiographs
were taken immediately
after restoration, and at 6
and 12 months after
restoration.
Using digital
subtraction
radiographs,
GIC
restorations
with partial
carious dentin
removal in
primary
molars
showed a high
potential for
dentin
remineralisatio
n after 1 year.
.

3. 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.
Diş Hekimliğinde Güncel Çürük Tanı Yöntemleri. Recent Methods for Diagnosis of Dental
Caries in Dentistry. Meandros Med Dent J 2018;19:1-8
79

80
• Disadvantages
– Observer bias
– No permanent
record of findings
– Accessibility to
place probe
• Advantage
– Noninvasive
– No radiation
hazards
– Acceptance of
patient
– Useful in patients
with crowding
2012

4. DIGITAL FIBEROPTIC TRANSILLUMINATION
• This is a digitized and computed version of the FOTI.
• DIFOTI can also be used to detect fractures, cracks, and
secondary caries around restorations.
• DIFOTI uses white light to trans illuminate each tooth
and to instantly create high-resolution digital images of
the tooth.
81
Bennett T. Amaechia. Emerging technologies for diagnosis of dental caries: The road so far. J. Appl. Phys. Jun 2009

• It is based on the principle that carious tooth tissue scatters and
absorbs more light than surrounding healthy tissue.
• The light is then directed through the mouthpiece to a miniature
electronic charge coupled device CCD camera in the handpiece.
• The camera digitally images the light emerging from either the
smooth surface opposite the illuminated surface or the occlusal
surface.
• These images are displayed on a computer monitor in real time and
stored on the hard drive for easy retrieval for comparative review of
images over time.
2012

5. Diagnodent
• laser auto fluorescence technology
• instead of using blue light it uses red light of wavelength 655nm.
• 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.
• 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 dentinoenamel junction and
underlying dentine
83Diş Hekimliğinde Güncel Çürük Tanı Yöntemleri. Recent Methods for Diagnosis of Dental

• Diagnodent unit comprises a pen like device 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
2012

85
• Scores above 25 are considered to suggest a high probability
of caries
Bennett T. Amaechia. Emerging technologies for diagnosis of dental caries: The road so far. J. Appl. Phys. Jun
2009

86
TITLE AUTHOR
S
JOURNA
L
LO
E
AIM MATERIAL AND
METHODODOLGY
CONCLUSION
Evaluation
of Accuracy
of
DIAGNOde
nt in
Diagnosis
of Primary
and
Secondary
Caries in
Compariso
n to
Convention
al Methods
Nokhbatol
foghahaie
H et.al.
Journal of
Lasers in
Medical
Sciences
Volume 4
Number 4
Autumn
2013
Ia comparative
review of the
efficiency of
DIAGNOdent
in
comparison
to visual
methods and
radiographic
methods in
the
diagnostic of
teeth occlusal
surfaces
Search of PubMed,
Google Scholar
electronic resources
was performed in
order
to find clinical trials in
English in the period
between 1998 and
2013. Full texts of
only
35 articles were
available.
Conclusion:
Considering the
Considering the
sensitivity and
specificity
reported in the
different studies,
it
seems that
DIAGNOdent is
an appropriate
modality for
caries detection
as a
complementary
method beside
other methods
and its use alone
to obtain
treatment plan is
not enough.

6. ELECTRICAL CARIES MONITOR
• 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 machine displayed a frowning face that indicated
extensive demineralization or smiling face indicated a
sound site
87Diş Hekimliğinde Güncel Çürük Tanı Yöntemleri. Recent Methods for Diagnosis of Dental

88
• The main disadvantage of this ECM is difficult
measuring procedure.
• Enamel cracks and hypo mineralized areas can give
false positive readings

•Mital P, Mehta N, Saini A, Raisingani D, Sharma M. RECENT ADVANCES IN DETECTION AND
DIAGNOSIS OF DENTAL CARIES. Journal of Evolution of Medical and Dental Sciences/Volume
89
• BENNEDICT-first person to observe the fluorescence in human
teeth
• He noted a differential fluorescence between sound and carious
enamel.
• 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.
7. QUANTITATIVE LASER FLOURESENCE

• When the teeth are illuminated with high intensity blue
light, the resultant auto-fluorescence of enamel is
detected by an intraoral camera which produces a
fluorescent image.
• The emitted fluorescence has a direct relationship with
the mineral content of the enamel.
• Thus, the intensity of the tooth image at a demineralised
area is darker than the sound area.
90•Mital P, Mehta N, Saini A, Raisingani D, Sharma M. RECENT ADVANCES IN DETECTION AND

• 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
• This can also be used to image plaque and calculus, and
therefore be useful in identifying active caries.

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 are
obtained.
 The enhanced contrast between sound and demineralized enamel
enables the clinician to identify areas of concern.

Bennett T. Amaechia. Emerging technologies for diagnosis of dental caries: The road so far. J. Appl. Phys. Jun 2009
5/23/2020 92•Mital P, Mehta N, Saini A, Raisingani D, Sharma M. RECENT ADVANCES IN DETECTION AND

5/23/2020 93•Mital P, Mehta N, Saini A, Raisingani D, Sharma M. RECENT ADVANCES IN DETECTION AND

94
• Disadvantages
– Does not differentiate
between caries &
developmental defects
– Expensive
– Secondary caries with
metal filings can not
be detected
• Advantage
– Early detection of
caries possible- ↑
contrast
– Depth of lesion can
be estimated
– No harm to
patient/operator-
visible light

8. ULTRASONIC IMAGING
• Ultrasonic imaging can be used to detect early caries on the smooth
surfaces.
• Here an ultrasonic probe is used to send and receive sound waves from the
surfaces of the tooth.
• Normal enamel produces -no echoes
Initial white spot lesions - weak surface echoes
cavitated areas -echoes of high amplitude.
• This method may be more sensitive than visual, tactile or radiographic
method for detecting early lesions.

 Ultrasonic system is composed of a transducer (probe) & an ultrasonic
precision thickness gauge.
 The contact transducer is of the right angle type with a 1.5mm tip
contact diameter, 11MHz nominal center frequency with a removable
plexiglass delay tip.
 The delay line tip of the contact transducer is at a right angle so that it
could be inserted or used in restricted height areas.
 These high frequency focused delay line transducers are compatible
with any ultrasonic instrument capable of displaying a return echo at
depths as minute as 0.010inches.
 The useful range is from 0.010 to 0.25 inches approximately.
96
3/Issue 01/ January 06, 2014

9. CONE BEAM COMPUTATED
TOMOGRAPHY (CBCT)
• CBCT also called as dental volumetric tomography, cone-
beam volumetric tomography, dental CT, and cone beam
imaging.
• Initially developed for angiography in 1982 and subsequently
applied to maxillofacial imaging.
• The principal feature of CBCT is that multiple planar
projections are acquired by rational scan to produce a
volumetric dataset from which inter-relational images can be
generated.

• Cone-beam scanners use a 2D digital array providing an area detector
rather than a linear detector as CT does. This is combined with a 3D X-
ray beam with circular collimation so that the resultant beam is in the
shape of a cone, hence the name “cone beam.”
• As CBCT requires only a single scan for capturing the necessary data
the time required for CBCT scanning is substantially less (< 30 sec).
• This technology has limitations related to the cone beam projection
geometry, detector sensitivity, and contrast resolution that produce
images that lack the clarity and utility of conventional CT images.
5/23/2020 98

10. RADIOVISUOGRAPHY(RVG)
• The very first system that was introduced in digital radiography in
dentistry was radiovisiography by Trophy in France in 1987.
• Digital radiography is a method of reproducing a radiographic image
using a technology sensor of solid-state, which are broken into
electronic pieces, and presented and stored as an image using a
computer.

• There are two advanced technologies that create digital images
without an analog precursor;
1. Direct digital images.
2. Semi direct digital images.
• Direct digital images are acquired using a solid-state sensor.
• The solid-state sensors are based on charge coupled device (CCD)
and complementary metal oxide semiconductor (CMOS) and
CMOS-active pixel sensor (CMOS-APS) based chips.
• Semidirect digital images are obtained using a phosphor plate
system.

11. 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 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

12. CARIES DETECTOR DYES
• Useful to aid the dentist in differentiation of infected dentin.
• They are non-specific protein dyes that stain the organic
matrix of less mineralized dentin, including normal circum
pulpal dentin and sound dentin in the area of the dentino-
enamel junction.
• Observation of colored dye signifies presence of caries.
 Various dyes like Procion, calcein, brilliant blue, propylene
glycol have been used to detect enamel caries.

Commercial products:
1. SNOOP (Pulpdent) (propylene glycol)(Rs.2100)
2. Seek/Sable Seek(Ultradent)(Rs.653)
3 Caries Detector(Kuraray)(Rs.2149)
4. Caries Finder/Caries Finder G(Danville Materials)
5. Cari-D-Tect (Gresco)

13. TERAHERTZ PULSATING IMAGNING
 Uses waves with Terahertz frequency(1012 Hz ) for an
image to be obtained by terahertz irradiation.
 Object is placed in the path of the beam.
 It is possible to record terahertz images using CCD
detector.
 Dental Applications – limited.

CO2 LASER
• Radiation of wavelength - 10.6 µm is used.
• Philosophy underlying application of carbon dioxide lasers is based on
assumption that subsurface layer of early carious lesions has more organic
content when compared with adjacent sound enamel.
• Photo-vaporization by a CO2 laser of this organic material in the incipient
carious lesions will leave a carbonized residue, which appears dark black.
• At low power levels & short duration times, inorganic substance of sound
enamel with minimum water content will be much less affected by laser
beam.

Conclusion
• It is clear from the above discussion that the differences
in caries presentations and behavior in different
anatomical sites make it unlikely that any one diagnostic
modality will have adequate sensitivity and specificity of
detection of carious lesions for all sites.
• A combination of diagnostic tools will help us diagnose
lesions earlier and detect failing restorations sooner, all
to avoid more costly, destructive dental procedures and
truly take dentistry into the preventive rather than the
reactive mode.
110

• Raper HR. Practical clinical preventive dentistry based upon periodic
roentgen ray examinations. J Am Dent Assoc 1925; 112(9):1084–100.
• Theodore M.R., Harald O.H, Edward J. S Sturdevant’s Art and Science of
operative dentistry 5th Edition Elsevier publication, Chapter
• Cariology: The lesions, etiology, prevention and control; pg 65 - 134 3. Holt
RD. Advances in dental public health. Primary Dental Care 2001; 8(3):99–
102.
• Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi
Traditional and Novel Caries Detection Methods: uploaded 3rd April 2012 by
Jonas Almeida Rodrigues
• Ekstrand, K.R.; Ricketts, D.N. & Kidd, E.A. Reproducibility and accuracy of
three methods for assessment of demineralization depth on the occlusal
surface: an in vitro examination. Caries Research. 1997; Vol.31, No.3, pp.
224-231, ISSN 0008-6568
• Nyvad, B.; Machiulskiene, V. & Baelum, V. Reliability of a new caries
diagnostic system differentiating between active and inactive caries lesions.
Caries Research. 1999;Vol.33, No.4, (July-August), pp. 252–260, ISSN
0002-8177
111
Bibliography

• Bader, J.D.; Shugars, D.A. & Bonito, A.J. Systematic reviews of selected dental caries
diagnosis and management methods. Journal of Dental Education. 2001;Vol.65,
No.10, (October), pp. 960-968, ISSN 0022-0337
• Pitts, N. “ICDAS” -- an international system for caries detection and assessment being
developed to facilitate caries epidemiology, research and appropriated clinical
management. Community Dental Health. 2004;Vol.21, No.3, (September), pp. 193-
198, ISSN 0256-539X
• Michele Baffi Diniz, Jonas de Almeida Rodrigues and Adrian Lussi (2012). Traditional
and Novel Caries Detection Methods, Contemporary Approach to Dental Caries, Dr.
Ming-Yu Li (Ed.), ISBN: 978-953-51-0305-9, InTech.
• Diş Hekimliğinde Güncel Çürük Tanı Yöntemleri. Recent Methods for Diagnosis of
Dental Caries in Dentistry. Meandros Med Dent J 2018;19:1-8
• Mital P, Mehta N, Saini A, Raisingani D, Sharma M. RECENT ADVANCES IN
DETECTION AND DIAGNOSIS OF DENTAL CARIES. Journal of Evolution of Medical
and Dental Sciences/Volume 3/Issue 01/ January 06, 2014
112

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