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Recent advances in caries diagnosis

Digital technologies have enabled new methods for diagnosing dental caries beyond traditional visual and tactile exams. Fiber-optic transillumination uses light passed through the tooth to detect shadows from demineralized areas. Digital imaging fiber-optic transillumination captures and stores transillumination images. Intraoral cameras provide magnified views of the mouth to examine hard and soft tissues. Electrical conductance methods measure differences in conductivity between sound and demineralized tooth structure to identify caries. Recent advances have improved sensitivity and specificity for early caries detection compared to conventional techniques.

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RECENT ADVANCES IN CARIES DIAGNOSIS 22/07/2020
CONTENTS  Introduction  What is diagnosis?  Requisites of diagnostic tool  Various diagnostic aids • Conventional techniques • Recent advances  ILLUMINATION METHODS Fiber-optic transillumination (FOTI) Digital imaging FOTI (DIFOTI) CariVu  ENDOSCOPY Videoscope Intraoral television camera  ELECTRICAL CONDUCTANCE MEAUSUREMENTS CARIESCAN Caries meter Vanguard electronic detector  RADIOGRAPHY Digital imaging radiography Subtraction radiography Tuned aperture CT  LASERS Quantitative light-induced fluorescence Diagnodent MID(midwest caries ID)  MISCELLANEOUS Species specific monoclonal antibodies Infrared thermography Terahertz imaging  Conclusion  Public health significance  References
INTRODUCTION Dental caries is the localised destruction of susceptible dental hard tissues by acidic by-products from bacterial fermentation of dietary carbohydrates. (According to Shafer) It can be defined as the progressive, irreversible microbial disease of the calcified tissues of teeth characterized by demineralization of the inorganic portion and destruction of organic substance of the tooth. ( According to WHO) 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.
WHAT IS DIAGNOSIS? • The word diagnosis is derived from the 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.
• The PRIMARY OBJECTIVE of caries diagnosis is to identify those lesions that require restorative treatment, those that require non-surgical treatment, and those persons who are at high risk for developing carious lesions.
• Some decades ago, visual diagnosis (light and mirror) and probing, supplemented by bitewing radiographs were the only tools available for clinical diagnosis of caries. For epidemiologic surveys and for examination of most patients, these are still useful tools. • Recent years have seen an increase in research activity surrounding diagnostic methods, particularly in the assessment of early caries lesions. • The use of technologies as adjunct to clinical visual examination for caries diagnosis will facilitate preventive care in dentistry to lower treatment cost.
Requisites of an ideal diagnostic tool • Precise/simple • Useful for all surfaces of teeth • Identifying caries adjacent to restorations • Objectivity • Sensitivity • Specificity • Reproducibility • Validity
Sensitivity Vs Specificity • SENSITIVITY- It has been defined as the ability of a test to identify correctly all those who have the disease, that is "true-positive". • SPECIFICITY- It is defined as the ability of a test to identify correctly those who do not have the disease, that is, "true-negatives".
DIAGNOSIS OF DENTAL CARIES TRADITIONAL METHODS RECENT METHODS
TRADITIONAL METHODS
RECENT METHODS ILLUMINATION METHODS Fiber-optic transillumination (FOTI) Digital imaging FOTI (DIFOTI) CariVu ENDOSCOPY Videoscope Intraoral television camera ELECTRICAL CONDUCTANCE MEAUSUREMENTS CARIESCAN Caries meter Vanguard electronic detector RADIOGRAPHY Digital imaging radiography Subtraction radiography Tuned aperture CT LASERS Quantitative light-induced fluorescence Diagnodent MID(midwest caries ID) MISCELLANEOUS Species specific monoclonal antibodies Infrared thermography Terahertz imaging
Visual diagnosis ● Most common 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.
● 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.
Visual Tactile diagnosis •The visual-tactile method has been a mainstay of clinical dentistry for more than 100 years and is based on the use of a dental mirror, sharp probe, and a 3-in-1 syringe and clean and dry tooth surface. •The examination is primarily based on subjective interpretation of surface characteristics such as integrity, texture, translucency or opacity, location, and color. •Use of dental floss for tactile evidence of proximal caries has been shown to be effective, wherein shredding of dental floss indicates a proximal cavity.
Disadvantages of Probing with Sharp Explorer: • Traditional probing with a sharp explorer has come into question as the ultimate determinant of caries activity. • Tactile examination using a sharp probe has been criticized because of the possibility of transporting cariogenic bacteria, may cause irreversible traumatic defects in potentially remineralizable enamel and may not be able to add any information to the visual examination. • In scanning electronic microscopic study by Kuhnisch et al. in 2007 confirmed that using a sharp probe for caries detection can cause mechanical damage to the enamel.
Examples showing the benefit of cleaning and drying to detect caries (A–C) and harmful effect of probing with a sharp explorer
Internationally accepted caries detection system • DMFT/S index (Klein, Palmer, Knutson 1938, 1987,1997) • Significant caries index (Sic) (Bratthal D in 2000) • 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), etc.
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. • Caries-detecting stains differentiate mineralized from demineralized dentin in both vital and nonvital teeth. • Outer carious dentin is stainable because the irreversible breakdown of collagen crosslinking 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. (Yip et al .,1994)
Commercially available caries detector dyes • Caries check (CC), containing 1% acid red in polypropylene glycol has been recently introduced. • Caries marker (cam), • Seek (see), • Sable seek (ses), • Carbolan green, • Coomassie blue, • Lissamine blue, • Snoop, • Brilliant blue, • Basic fuschin and calcein
RADIOGRAPHIC METHODS
Radiographic methods includes: 1. Bitewing radiographs 2. IOPA radiographs 3. Digital radiography 4. Digital subtraction radiography 5. Tuned Aperture computed Tomography
Radiographic Appearance Of The Caries: • Initial enamel - small radiolucent notch. • Advanced lesions – Diffuse triangle with base to surface of the tooth-in enamel. ● Appears as triangle with base towards DEJ Advantages : ● Discloses sites inaccessible to other methods.
DISADVANTAGES ● Caries are not visible on radiographs until they penetrate more than one half the enamel thickness and enamel lesions are usually not visible until 40-60% of the lesion has become demineralized. ● Validity of detecting enamel lesions is limited on the proximal 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. (Espelid et al., 1994; Neuhaus et al.,2009)
DIGITAL RADIOGRAPHY
● Digital radiology has overtaken conventional screen-film radiography since it was introduced in the mid-1980s ● The dawn of the digital era in dental radiography came in 1987 with the first digital radiography system called radio visio graphy (RVG), launched by Dr. Francis Mouyen. ● There are two types: Direct – The direct image receptor that collects X-ray directly, for example, RVG. Indirect – For example, video camera is used for forming digital images of a radiograph.
Digital detectors • Charged couple device (CCD) • Complementary metal oxide semiconductor • Phosphor plate
Advantages of digital radiography compared with conventional radiography: •Reductions in radiation dose. •Time savings. •Digital manipulation of the image to enhance viewing. •Avoiding unnecessary or repeated radiographs. •Facilitate communication and case discussion among dental professionals. •Visual aid to be shown to the patient on the computer screen, increasing the confidence and credibility in the treatment-decision making process. •Primary disadvantages include the rigidity and thickness of the sensors, the high initial system cost and unknown sensor lifespan.
• One important advance with digital radiology was the introduction of caries detection software, Logicon Caries Detector™ Software (Kodak Dental Systems, Atlanta), for assisting in the diagnosis of interproximal caries. • Logicon software extracts image features of the digital radiographic image and correlates them with a database of known and identified caries problems. This software has the ability to locate and classify proximal caries, indicating the depth of caries penetration. • The Logicon program had an increased sensitivity, especially in lesions with caries extending into the dentin.
Digital subtraction radiography •A digital bitewing radiograph is taken and later a second radiograph of exactly the same region is produced with identical exposure time, tube current, and voltage •By subtracting gray values for each coordinate of the first radiograph from equivalent coordinate of second, a subtraction image is obtained. •If no changes have occurred, the result of subtraction is zero. •Non zero result will be obtained in case of onset or progression of demineralization. •It is not yet routinely applied in clinical caries detection due to difficulty of image registration. Advantages: •Detects onset or progression of demineralization. Disadvantages: •Difficulty of image registration
Tuned-aperture computed tomography
Tuned-aperture computed tomography • This method constructs radiographic section through teeth. The slices can be viewed for the presence of radiolucency • Series of radiographs taken in different angles. • Used for caries detection, vertical root fracture, osseous defects • Low cost , low dose than conventional CT. • Technique sensitive.
ILLUMINATION METHODS
Fiber-optic transillumination (FOTI) • FOTI was initially designed by Friedman and Marcus in 1970 • It refers to flexible, thin cylindrical fibers of high optical- quality glass or plastic • Single optical fiber that consists of glass or plastic material with an outer cladding of a material with lower refractive index. • Fiber core has a higher refractive index. • Individual fibers are grouped together to form a fiber optic bundle. • Fibers can be as small as 0.01mm for glass and 0.1 mm for plastic.
Fiber-optic transillumination (FOTI)…. • Based on the phenomenon of light scattering. • The light that is shone through the tooth scatters and observed shadows may indicate the presence of a carious lesion. The reason why shadows may indicate caries is because demineralized areas of enamel or dentine scatter light more than sound areas. Hence, caries appear as darker areas under FOTI.
ADVANTAGES • It is simple, noninvasive, painless procedure that can be used repeatedly with no risk to the patient. • The research around FOTI with a recent review finding a mean sensitivity of only 14 and a specificity of 95%.
DISADVANTAGES • The system is subjective. • Furthermore, foti can only be used for coronal tooth surfaces (occlusal, interproximal, and smooth) and not below the gingiva.
Digital imaging FOTI (DIFOTI) • DIFOTI system consists of two handpieces (one for occlusal surface and one for smooth surface and interproximal areas), a disposable mouthpiece, a foot pedal for selecting the image of interest and a computer system to capture and store the resulting image. • It is based on the principle that carious tooth tissue absorbs more light than surrounding healthy tissue and appears as darker area. INTRODUCED IN YEAR1998 • Developed by Schneidermann et al, Department of Oral Pathology, Radiology and Diagnostic Sciences, New Jersy Dental School, University of Medicine and Dentistry of NewJersey.
Digital imaging FOTI (DIFOTI) … ADVANTAGES • Detects initial areas of demineralization • Inspects integrity of teeth • Detects cracks, tooth fractures, and wear • No harmful radiation • Uses safe white light Images all coronal surfaces including interproximal, occlusal, smooth surfaces • Determines depth of lesion accurately • Only dental diagnostic imaging instrument approved by the Food and Drug Administration for detection of incipient and recurrent caries • Magnification of up to ×16
Digital imaging FOTI (DIFOTI) … DISADVANTAGES • Technique sensitive • High cost
CariVu- Compact, Portable Caries Detection Device ● 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. •Uses transillumination technology that makes enamel appear transparent while porous lesions trap and absorb light •Allows the clinician to see through the tooth, exposing its structure and the development of any carious lesions •CariVu images read like familiar X-ray images •Uses non-ionizing radiation which is ideal for children, pregnant women and cancer patients who are X-ray averse
ENDOSCOPE BASED DIAGNOSIS
INTRAORAL TELEVISION CAMERA (IOTV) • IOC systems consist of video display, processing unit, and intra-oral camera with a light source. • These sensors receive light which is converted to an electronic signal that is processed by IOC imaging software to produce an image on the computer monitor. • The LED lighting provides a continuous source of light to eliminate the need for a flash. Images captured by most of the IOC are stored in the in- built memory or can be stored in the computer.
• Widely ranged features for intra-oral cameras including Macro mode (magnification), curing light for composite, LED lights, picture or video record, fluorescence for detecting various stages of caries, plaque and gingival inflammation. • Through the IOTV, the dentist can educate the patient and at the same time, can also improve their own diagnostic expertise as they see magnified oral conditions which are significantly better than direct vision.
Boye et al. compared diagnostic performance for the detection of caries using photographs (taken with intra-oral camera) with an established visual examination method and histological sections as the reference standard and concluded that the photographic assessment method had higher sensitivity for caries detection than visual examination.
ELECTRIC CURRENT BASED DIAGNOSTICS
Electrochemical machining (ECM) is based on the principle that a demineralized tooth has more pores filled with water or saliva, and this is more conductive than intact tooth surface. It was first proposed by Magitot in 1878. Greater the amount of demineralization, higher is the electrical conductivity through enamel. Demineralized sites and sites with high pore volume and cavities can be detected by measuring the conductance.
VANGUARD ELECTRONIC CARIES DETECTOR: • It used a current of 25 Hz. Measured conductance was then converted to an ordinary scale of 0–9. Moisture and saliva were removed by a continuous stream of air to prevent surface conductance. CARIES METER: • It used a current of 400 Hz. Measured conductance was then converted to four colored lights. Green: No caries Yellow: Enamel caries Orange: Dentin caries Red: Pulpal involvement.
CARIESCAN • This device is based on alternating current impedance spectroscopy and involves the passing of an insensitive level of electrical current through the tooth to identify the presence and location of the decay. • It is the first dental diagnostic tool to use an impedance spectroscopy to quantify dental caries early enough to enhance preventive treatment. • It provides a qualitative value based on the disease state rather than the optical properties of the tooth.
CARIESCAN • Bader et al. carried out a systematic review comparing CarieScan with a clinical visual examination, bitewing radiograph, and DIAGNOdent reported CarieScan to have superior sensitivity and specificity both 92.5% over other methods. • The available data on clinical studies is at present minimal.
FLUORESCENCE BASED DIAGNOSTICS
Quantitative light-induced fluorescence (QLF) •QLF system consists of a hand-held intraoral micro CCD camera, interfaced with a personal computer and custom software. •The software enables to capture and analyze images of the tooth during clinical examination. •QLF uses a 50-watt xenon arc-lamp and 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. •When the tooth surface is illuminated by this high-intensity blue light, caries presence shows red fluorescence.
● 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
DIAGNODENT • A laser examination tool for the early detection of decay. • At the specific wavelength that the device operates(655 nm), clean healthy tooth structure exhibits little or no fluorescence, resulting in very low scale readings on the display. • However, carious tooth structure will exhibit fluorescence, proportionate to the degree of caries, resulting in elevated scale readings on the display.
Goel A, Chawla HS, Gauba K , Goyal A. Comparison of validity of DIAGNOdent with conventional methods for detection of occlusal caries in primary molars using the histological gold standard: An in vivo study. J Indian Soc Pedod Prevent Dent 2009;27(4):227-234 DIAGNOdent showed higher sensitivity and accuracy as compared with other conventional methods for detection of enamel caries, whereas for detection of dentinal caries, even though the sensitivity was high, accuracy of the DIAGNOdent device was similar to other conventional caries diagnostic methods. • To compare the in vivo effectiveness of diagnodent with other conventional methods (visual, tactile and bitewing radiographs) for the detection of occlusal caries in primary molars. • Eighty-four primary molars in 52 children (aged 8–12 years), which were indicated for extraction, were selected and evaluated for dental caries using diagnodent, visual and tactile examination and bitewing radiographs. • Histological examination of the sections, prepared subsequent to extraction of the teeth, served as the gold standard for comparison of the above-mentioned methods.
MIDWEST CARIES ID™ (MID) MID is a small, battery-operated technology that emits a soft LED light for detecting caries. A specific fiber optic signature captures the resulting reflection and refraction of the light in the tooth and is converted to electrical signals that run through a computer-based algorithm for analyzing the presence of caries.
Patel et al. reported the sensitivity and specificity for this detection device as 0.56 and 0.84, respectively. Useful in detecting the presence of demineralization, but cannot be utilized to adequately assess the depth of the demineralization Patel SA, Shepard WD, Barros JA, Streckfus CF, Quock RL. In vitro evaluation of Midwest caries ID: A novel light-emitting diode for caries detection. Oper Dent 2014;39:644-51.
RECENT ADVANCES IN CARIES DIAGNOSIS
MISCELLANEOU S
TERAHERTZ IMAGING • This method uses waves in terahertz frequency (10¹² Hz or a wavelength of 30μm). • Terahertz Pulsed Imaging (TPI) has great potential for medical applications since it is a nondestructive imaging method. • It does not cause any ionization hazard on biological samples due to low energy of THz radiation. • Low powers are used for imaging.
TERAHERTZ IMAGING… • Erbium (Er) is employed for optical excitation. • It generates pulses at a center wavelength of 1550 nm with a repetition rate of 89 MHz and a pulse duration of 230 fs. • Output of the laser is separated into a pump beam which is used to generate THz pulse • Terahertz waves are capable of diagnosis dental caries. • The images are clear but due to long wavelength of the source spatial resolution is low. • Limited studies concerning this method of imaging are promising.
INFRARED THERMOGRAPHY • The thermal energy emitted by sound tooth structure is compared with that emitted by carious tooth structure. • The method uses indium thermal sensors, which can detect temperature changes in the order of 0.025°C. With a constant flow of air over the surface of the tooth, the change in temperature of the lesion is compared with that of the sound tooth structure. • The source-to-sensor distance is 20 cm, and the time taken to capture the data for a lesion is up to 2 min.
INFRARED THERMOGRAPHY.. • The technique has not been used intra-orally. This technique was considered efficient for in vitro studies. • Problems will exist in relation to variations in the temperature of the mouth with respiration or fluid evaporation from other oral surfaces.
SPECIES SPECIFIC MONOCLONAL ANTIBODIES • This was given by Shi et al. in 1998, identified specific monoclonal antibodies that recognize the surface of cariogenic bacteria. • Highly species-specific monoclonal IgG antibodies against S. mutans that quantitatively detect S. mutans in <1 min and is sensitive enough to detect a single bacterial cell. • MAb-based salivary S. mutans tests exhibit significantly higher specificity and sensitivity than the commonly used selective culture method and thus provides useful information and tools for analyzing the role of S. mutans in human dental caries. • Advantages include that it can be used at chairside by dentist, quick results, and the overall risk assessment can be made in operatory itself.
CONCLUSION • Unfortunately there is no single diagnostic method on the horizon that can reliably detect pre-cavitated carious lesions with all advantages and can be called as ideal. • The prospects look favorable that, with continued research, laser fluorescence, quantitative light induced fluorescence, electrical conductivity measurements, direct digital radiography, and digital fiberoptic transillumination, will provide the high degree of sensitivity and specificity needed to detect early dental caries.
PUBLIC HEALTH SIGNIFICANCE • Visual-tactile method(with appropriate Index) plays a key role in Public Health Programs. Dental caries index helpful in detection of oral diseases on large scale in field survey. • It provides data to support recommendations for public health interventions to improve the health status of population. • If the non-cavitated lesions had been omitted, a very important message about the disease prevalence and severity in this population would have been missing.
REFERENCES • Hall A, Girkin JM. A review of potential new diagnostic modalities for carious lesions. J Dent Res 2004;83:C89-94 • Mohanraj M, Prabhu VR, Senthil R. Diagnostic methods for early detection of dental caries-A review. Int J of Ped Rehab. 2016;10(1):29-35. • Anusavice KJ. Present and future approaches for the control of caries. J of Dent Ed.2005;69(3):538–54. • Wang J, Sakuma S, Yoshihara A, Kobayashi S, Miyazaki H. An evaluation and comparison of visual inspection. Electrical caries monitor and caries detector dye methods in detecting early occlusal caries in vitro study. J of Dent Health.2000;50(2):223–30.
Diagnosing an illness is an art. If the diagnosis is wrong, most probably so is the treatment.

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Recent advances in caries diagnosis

  • 1.
  • 2.
    CONTENTS  Introduction  Whatis diagnosis?  Requisites of diagnostic tool  Various diagnostic aids • Conventional techniques • Recent advances  ILLUMINATION METHODS Fiber-optic transillumination (FOTI) Digital imaging FOTI (DIFOTI) CariVu  ENDOSCOPY Videoscope Intraoral television camera  ELECTRICAL CONDUCTANCE MEAUSUREMENTS CARIESCAN Caries meter Vanguard electronic detector  RADIOGRAPHY Digital imaging radiography Subtraction radiography Tuned aperture CT  LASERS Quantitative light-induced fluorescence Diagnodent MID(midwest caries ID)  MISCELLANEOUS Species specific monoclonal antibodies Infrared thermography Terahertz imaging  Conclusion  Public health significance  References
  • 3.
    INTRODUCTION Dental caries isthe localised destruction of susceptible dental hard tissues by acidic by-products from bacterial fermentation of dietary carbohydrates. (According to Shafer) It can be defined as the progressive, irreversible microbial disease of the calcified tissues of teeth characterized by demineralization of the inorganic portion and destruction of organic substance of the tooth. ( According to WHO) 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? •The word diagnosis is derived from the 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.
  • 5.
    • The PRIMARYOBJECTIVE of caries diagnosis is to identify those lesions that require restorative treatment, those that require non-surgical treatment, and those persons who are at high risk for developing carious lesions.
  • 6.
    • Some decadesago, visual diagnosis (light and mirror) and probing, supplemented by bitewing radiographs were the only tools available for clinical diagnosis of caries. For epidemiologic surveys and for examination of most patients, these are still useful tools. • Recent years have seen an increase in research activity surrounding diagnostic methods, particularly in the assessment of early caries lesions. • The use of technologies as adjunct to clinical visual examination for caries diagnosis will facilitate preventive care in dentistry to lower treatment cost.
  • 7.
    Requisites of anideal diagnostic tool • Precise/simple • Useful for all surfaces of teeth • Identifying caries adjacent to restorations • Objectivity • Sensitivity • Specificity • Reproducibility • Validity
  • 8.
    Sensitivity Vs Specificity •SENSITIVITY- It has been defined as the ability of a test to identify correctly all those who have the disease, that is "true-positive". • SPECIFICITY- It is defined as the ability of a test to identify correctly those who do not have the disease, that is, "true-negatives".
  • 9.
    DIAGNOSIS OF DENTALCARIES TRADITIONAL METHODS RECENT METHODS
  • 10.
  • 11.
    RECENT METHODS ILLUMINATION METHODS Fiber-optictransillumination (FOTI) Digital imaging FOTI (DIFOTI) CariVu ENDOSCOPY Videoscope Intraoral television camera ELECTRICAL CONDUCTANCE MEAUSUREMENTS CARIESCAN Caries meter Vanguard electronic detector RADIOGRAPHY Digital imaging radiography Subtraction radiography Tuned aperture CT LASERS Quantitative light-induced fluorescence Diagnodent MID(midwest caries ID) MISCELLANEOUS Species specific monoclonal antibodies Infrared thermography Terahertz imaging
  • 12.
    Visual diagnosis ● Mostcommon 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 shouldbe 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.
  • 14.
    Visual Tactile diagnosis •Thevisual-tactile method has been a mainstay of clinical dentistry for more than 100 years and is based on the use of a dental mirror, sharp probe, and a 3-in-1 syringe and clean and dry tooth surface. •The examination is primarily based on subjective interpretation of surface characteristics such as integrity, texture, translucency or opacity, location, and color. •Use of dental floss for tactile evidence of proximal caries has been shown to be effective, wherein shredding of dental floss indicates a proximal cavity.
  • 15.
    Disadvantages of Probingwith Sharp Explorer: • Traditional probing with a sharp explorer has come into question as the ultimate determinant of caries activity. • Tactile examination using a sharp probe has been criticized because of the possibility of transporting cariogenic bacteria, may cause irreversible traumatic defects in potentially remineralizable enamel and may not be able to add any information to the visual examination. • In scanning electronic microscopic study by Kuhnisch et al. in 2007 confirmed that using a sharp probe for caries detection can cause mechanical damage to the enamel.
  • 16.
    Examples showing thebenefit of cleaning and drying to detect caries (A–C) and harmful effect of probing with a sharp explorer
  • 17.
    Internationally accepted cariesdetection system • DMFT/S index (Klein, Palmer, Knutson 1938, 1987,1997) • Significant caries index (Sic) (Bratthal D in 2000) • 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), etc.
  • 18.
    Detection with chemicaldyes Fusayama introduced a technique in 1972 that used a basic fuchsin red stain to aid in differentiating layers of carious dentin. • Caries-detecting stains differentiate mineralized from demineralized dentin in both vital and nonvital teeth. • Outer carious dentin is stainable because the irreversible breakdown of collagen crosslinking 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. (Yip et al .,1994)
  • 19.
    Commercially available cariesdetector dyes • Caries check (CC), containing 1% acid red in polypropylene glycol has been recently introduced. • Caries marker (cam), • Seek (see), • Sable seek (ses), • Carbolan green, • Coomassie blue, • Lissamine blue, • Snoop, • Brilliant blue, • Basic fuschin and calcein
  • 20.
  • 21.
    Radiographic methods includes: 1.Bitewing radiographs 2. IOPA radiographs 3. Digital radiography 4. Digital subtraction radiography 5. Tuned Aperture computed Tomography
  • 22.
    Radiographic Appearance OfThe Caries: • Initial enamel - small radiolucent notch. • Advanced lesions – Diffuse triangle with base to surface of the tooth-in enamel. ● Appears as triangle with base towards DEJ Advantages : ● Discloses sites inaccessible to other methods.
  • 23.
    DISADVANTAGES ● Caries arenot visible on radiographs until they penetrate more than one half the enamel thickness and enamel lesions are usually not visible until 40-60% of the lesion has become demineralized. ● Validity of detecting enamel lesions is limited on the proximal 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. (Espelid et al., 1994; Neuhaus et al.,2009)
  • 24.
  • 25.
    ● Digital radiologyhas overtaken conventional screen-film radiography since it was introduced in the mid-1980s ● The dawn of the digital era in dental radiography came in 1987 with the first digital radiography system called radio visio graphy (RVG), launched by Dr. Francis Mouyen. ● There are two types: Direct – The direct image receptor that collects X-ray directly, for example, RVG. Indirect – For example, video camera is used for forming digital images of a radiograph.
  • 26.
    Digital detectors • Chargedcouple device (CCD) • Complementary metal oxide semiconductor • Phosphor plate
  • 27.
    Advantages of digitalradiography compared with conventional radiography: •Reductions in radiation dose. •Time savings. •Digital manipulation of the image to enhance viewing. •Avoiding unnecessary or repeated radiographs. •Facilitate communication and case discussion among dental professionals. •Visual aid to be shown to the patient on the computer screen, increasing the confidence and credibility in the treatment-decision making process. •Primary disadvantages include the rigidity and thickness of the sensors, the high initial system cost and unknown sensor lifespan.
  • 28.
    • One importantadvance with digital radiology was the introduction of caries detection software, Logicon Caries Detector™ Software (Kodak Dental Systems, Atlanta), for assisting in the diagnosis of interproximal caries. • Logicon software extracts image features of the digital radiographic image and correlates them with a database of known and identified caries problems. This software has the ability to locate and classify proximal caries, indicating the depth of caries penetration. • The Logicon program had an increased sensitivity, especially in lesions with caries extending into the dentin.
  • 29.
    Digital subtraction radiography •Adigital bitewing radiograph is taken and later a second radiograph of exactly the same region is produced with identical exposure time, tube current, and voltage •By subtracting gray values for each coordinate of the first radiograph from equivalent coordinate of second, a subtraction image is obtained. •If no changes have occurred, the result of subtraction is zero. •Non zero result will be obtained in case of onset or progression of demineralization. •It is not yet routinely applied in clinical caries detection due to difficulty of image registration. Advantages: •Detects onset or progression of demineralization. Disadvantages: •Difficulty of image registration
  • 30.
  • 31.
    Tuned-aperture computed tomography •This method constructs radiographic section through teeth. The slices can be viewed for the presence of radiolucency • Series of radiographs taken in different angles. • Used for caries detection, vertical root fracture, osseous defects • Low cost , low dose than conventional CT. • Technique sensitive.
  • 32.
  • 33.
    Fiber-optic transillumination (FOTI) •FOTI was initially designed by Friedman and Marcus in 1970 • It refers to flexible, thin cylindrical fibers of high optical- quality glass or plastic • Single optical fiber that consists of glass or plastic material with an outer cladding of a material with lower refractive index. • Fiber core has a higher refractive index. • Individual fibers are grouped together to form a fiber optic bundle. • Fibers can be as small as 0.01mm for glass and 0.1 mm for plastic.
  • 34.
    Fiber-optic transillumination (FOTI)…. •Based on the phenomenon of light scattering. • The light that is shone through the tooth scatters and observed shadows may indicate the presence of a carious lesion. The reason why shadows may indicate caries is because demineralized areas of enamel or dentine scatter light more than sound areas. Hence, caries appear as darker areas under FOTI.
  • 36.
    ADVANTAGES • It issimple, noninvasive, painless procedure that can be used repeatedly with no risk to the patient. • The research around FOTI with a recent review finding a mean sensitivity of only 14 and a specificity of 95%.
  • 37.
    DISADVANTAGES • The systemis subjective. • Furthermore, foti can only be used for coronal tooth surfaces (occlusal, interproximal, and smooth) and not below the gingiva.
  • 38.
    Digital imaging FOTI(DIFOTI) • DIFOTI system consists of two handpieces (one for occlusal surface and one for smooth surface and interproximal areas), a disposable mouthpiece, a foot pedal for selecting the image of interest and a computer system to capture and store the resulting image. • It is based on the principle that carious tooth tissue absorbs more light than surrounding healthy tissue and appears as darker area. INTRODUCED IN YEAR1998 • Developed by Schneidermann et al, Department of Oral Pathology, Radiology and Diagnostic Sciences, New Jersy Dental School, University of Medicine and Dentistry of NewJersey.
  • 39.
    Digital imaging FOTI(DIFOTI) … ADVANTAGES • Detects initial areas of demineralization • Inspects integrity of teeth • Detects cracks, tooth fractures, and wear • No harmful radiation • Uses safe white light Images all coronal surfaces including interproximal, occlusal, smooth surfaces • Determines depth of lesion accurately • Only dental diagnostic imaging instrument approved by the Food and Drug Administration for detection of incipient and recurrent caries • Magnification of up to ×16
  • 40.
    Digital imaging FOTI(DIFOTI) … DISADVANTAGES • Technique sensitive • High cost
  • 41.
    CariVu- Compact, PortableCaries Detection Device ● 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. •Uses transillumination technology that makes enamel appear transparent while porous lesions trap and absorb light •Allows the clinician to see through the tooth, exposing its structure and the development of any carious lesions •CariVu images read like familiar X-ray images •Uses non-ionizing radiation which is ideal for children, pregnant women and cancer patients who are X-ray averse
  • 43.
  • 44.
    INTRAORAL TELEVISION CAMERA (IOTV) • IOCsystems consist of video display, processing unit, and intra-oral camera with a light source. • These sensors receive light which is converted to an electronic signal that is processed by IOC imaging software to produce an image on the computer monitor. • The LED lighting provides a continuous source of light to eliminate the need for a flash. Images captured by most of the IOC are stored in the in- built memory or can be stored in the computer.
  • 45.
    • Widely rangedfeatures for intra-oral cameras including Macro mode (magnification), curing light for composite, LED lights, picture or video record, fluorescence for detecting various stages of caries, plaque and gingival inflammation. • Through the IOTV, the dentist can educate the patient and at the same time, can also improve their own diagnostic expertise as they see magnified oral conditions which are significantly better than direct vision.
  • 46.
    Boye et al.compared diagnostic performance for the detection of caries using photographs (taken with intra-oral camera) with an established visual examination method and histological sections as the reference standard and concluded that the photographic assessment method had higher sensitivity for caries detection than visual examination.
  • 47.
  • 48.
    Electrochemical machining (ECM)is based on the principle that a demineralized tooth has more pores filled with water or saliva, and this is more conductive than intact tooth surface. It was first proposed by Magitot in 1878. Greater the amount of demineralization, higher is the electrical conductivity through enamel. Demineralized sites and sites with high pore volume and cavities can be detected by measuring the conductance.
  • 50.
    VANGUARD ELECTRONIC CARIESDETECTOR: • It used a current of 25 Hz. Measured conductance was then converted to an ordinary scale of 0–9. Moisture and saliva were removed by a continuous stream of air to prevent surface conductance. CARIES METER: • It used a current of 400 Hz. Measured conductance was then converted to four colored lights. Green: No caries Yellow: Enamel caries Orange: Dentin caries Red: Pulpal involvement.
  • 51.
    CARIESCAN • This deviceis based on alternating current impedance spectroscopy and involves the passing of an insensitive level of electrical current through the tooth to identify the presence and location of the decay. • It is the first dental diagnostic tool to use an impedance spectroscopy to quantify dental caries early enough to enhance preventive treatment. • It provides a qualitative value based on the disease state rather than the optical properties of the tooth.
  • 52.
    CARIESCAN • Bader etal. carried out a systematic review comparing CarieScan with a clinical visual examination, bitewing radiograph, and DIAGNOdent reported CarieScan to have superior sensitivity and specificity both 92.5% over other methods. • The available data on clinical studies is at present minimal.
  • 53.
  • 54.
    Quantitative light-induced fluorescence(QLF) •QLF system consists of a hand-held intraoral micro CCD camera, interfaced with a personal computer and custom software. •The software enables to capture and analyze images of the tooth during clinical examination. •QLF uses a 50-watt xenon arc-lamp and 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. •When the tooth surface is illuminated by this high-intensity blue light, caries presence shows red fluorescence.
  • 55.
    ● Red fluorescencewhich 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
  • 56.
    DIAGNODENT • A laserexamination tool for the early detection of decay. • At the specific wavelength that the device operates(655 nm), clean healthy tooth structure exhibits little or no fluorescence, resulting in very low scale readings on the display. • However, carious tooth structure will exhibit fluorescence, proportionate to the degree of caries, resulting in elevated scale readings on the display.
  • 58.
    Goel A, ChawlaHS, Gauba K , Goyal A. Comparison of validity of DIAGNOdent with conventional methods for detection of occlusal caries in primary molars using the histological gold standard: An in vivo study. J Indian Soc Pedod Prevent Dent 2009;27(4):227-234 DIAGNOdent showed higher sensitivity and accuracy as compared with other conventional methods for detection of enamel caries, whereas for detection of dentinal caries, even though the sensitivity was high, accuracy of the DIAGNOdent device was similar to other conventional caries diagnostic methods. • To compare the in vivo effectiveness of diagnodent with other conventional methods (visual, tactile and bitewing radiographs) for the detection of occlusal caries in primary molars. • Eighty-four primary molars in 52 children (aged 8–12 years), which were indicated for extraction, were selected and evaluated for dental caries using diagnodent, visual and tactile examination and bitewing radiographs. • Histological examination of the sections, prepared subsequent to extraction of the teeth, served as the gold standard for comparison of the above-mentioned methods.
  • 59.
    MIDWEST CARIES ID™(MID) MID is a small, battery-operated technology that emits a soft LED light for detecting caries. A specific fiber optic signature captures the resulting reflection and refraction of the light in the tooth and is converted to electrical signals that run through a computer-based algorithm for analyzing the presence of caries.
  • 60.
    Patel et al.reported the sensitivity and specificity for this detection device as 0.56 and 0.84, respectively. Useful in detecting the presence of demineralization, but cannot be utilized to adequately assess the depth of the demineralization Patel SA, Shepard WD, Barros JA, Streckfus CF, Quock RL. In vitro evaluation of Midwest caries ID: A novel light-emitting diode for caries detection. Oper Dent 2014;39:644-51.
  • 61.
  • 62.
  • 63.
    TERAHERTZ IMAGING • Thismethod uses waves in terahertz frequency (10¹² Hz or a wavelength of 30μm). • Terahertz Pulsed Imaging (TPI) has great potential for medical applications since it is a nondestructive imaging method. • It does not cause any ionization hazard on biological samples due to low energy of THz radiation. • Low powers are used for imaging.
  • 64.
    TERAHERTZ IMAGING… • Erbium(Er) is employed for optical excitation. • It generates pulses at a center wavelength of 1550 nm with a repetition rate of 89 MHz and a pulse duration of 230 fs. • Output of the laser is separated into a pump beam which is used to generate THz pulse • Terahertz waves are capable of diagnosis dental caries. • The images are clear but due to long wavelength of the source spatial resolution is low. • Limited studies concerning this method of imaging are promising.
  • 65.
    INFRARED THERMOGRAPHY • Thethermal energy emitted by sound tooth structure is compared with that emitted by carious tooth structure. • The method uses indium thermal sensors, which can detect temperature changes in the order of 0.025°C. With a constant flow of air over the surface of the tooth, the change in temperature of the lesion is compared with that of the sound tooth structure. • The source-to-sensor distance is 20 cm, and the time taken to capture the data for a lesion is up to 2 min.
  • 66.
    INFRARED THERMOGRAPHY.. • Thetechnique has not been used intra-orally. This technique was considered efficient for in vitro studies. • Problems will exist in relation to variations in the temperature of the mouth with respiration or fluid evaporation from other oral surfaces.
  • 68.
    SPECIES SPECIFIC MONOCLONALANTIBODIES • This was given by Shi et al. in 1998, identified specific monoclonal antibodies that recognize the surface of cariogenic bacteria. • Highly species-specific monoclonal IgG antibodies against S. mutans that quantitatively detect S. mutans in <1 min and is sensitive enough to detect a single bacterial cell. • MAb-based salivary S. mutans tests exhibit significantly higher specificity and sensitivity than the commonly used selective culture method and thus provides useful information and tools for analyzing the role of S. mutans in human dental caries. • Advantages include that it can be used at chairside by dentist, quick results, and the overall risk assessment can be made in operatory itself.
  • 69.
    CONCLUSION • Unfortunately thereis no single diagnostic method on the horizon that can reliably detect pre-cavitated carious lesions with all advantages and can be called as ideal. • The prospects look favorable that, with continued research, laser fluorescence, quantitative light induced fluorescence, electrical conductivity measurements, direct digital radiography, and digital fiberoptic transillumination, will provide the high degree of sensitivity and specificity needed to detect early dental caries.
  • 70.
    PUBLIC HEALTH SIGNIFICANCE •Visual-tactile method(with appropriate Index) plays a key role in Public Health Programs. Dental caries index helpful in detection of oral diseases on large scale in field survey. • It provides data to support recommendations for public health interventions to improve the health status of population. • If the non-cavitated lesions had been omitted, a very important message about the disease prevalence and severity in this population would have been missing.
  • 71.
    REFERENCES • Hall A,Girkin JM. A review of potential new diagnostic modalities for carious lesions. J Dent Res 2004;83:C89-94 • Mohanraj M, Prabhu VR, Senthil R. Diagnostic methods for early detection of dental caries-A review. Int J of Ped Rehab. 2016;10(1):29-35. • Anusavice KJ. Present and future approaches for the control of caries. J of Dent Ed.2005;69(3):538–54. • Wang J, Sakuma S, Yoshihara A, Kobayashi S, Miyazaki H. An evaluation and comparison of visual inspection. Electrical caries monitor and caries detector dye methods in detecting early occlusal caries in vitro study. J of Dent Health.2000;50(2):223–30.
  • 72.
    Diagnosing an illnessis an art. If the diagnosis is wrong, most probably so is the treatment.

Editor's Notes

  • #70 Unfortunately no one device has all the advantages and can be called as ideal.