Caries Caries diagnosisdiagnosis

Etiology of dental Etiology of dental cariescaries

four factors are necessaryfour factors are necessary

to produce dental cariesto produce dental caries

Dental plaque Dental plaque A suitableA suitable

carbohydrate carbohydrate

(mainly sugar)(mainly sugar) Tooth surfaceTooth surface Time Time

How does it happenHow does it happen ????

Plaque bacteria fermentationPlaque bacteria fermentation

(sugars, sucrose & glucose(sugars, sucrose & glucose(( of carbohydrates of carbohydrates

Produce acidProduce acid

plaque pH within 1-3 minutesplaque pH within 1-3 minutes

& Plaque remains acidic for some & Plaque remains acidic for some

time taking time taking (30-60 min)(30-60 min) to neutralize to neutralize

Repeated falls in pHRepeated falls in pH

(in time) (in time) may result may result

in demineralization of in demineralization of susceptible tooth susceptible tooth

surface surface

Initiation of carious Initiation of carious processprocess

Things to be Things to be consideredconsidered

Dental caries should be Dental caries should be diagnosed and managed as a diagnosed and managed as a

dynamic diseasedynamic disease of enamel and of enamel and dentin with alternating dentin with alternating demineralization and demineralization and

remineralizationremineralization

less than 5.5 pH of oral fluidsless than 5.5 pH of oral fluids loss of Ca & ph loss of Ca & ph

fromfrom

E crystals on E crystals on thethe

surface and surface and sub-sub-

surface layers surface layers

large microporous large microporous areas developareas develop

"white "white spots"spots"

caries spreads more rapidly in caries spreads more rapidly in dentin than in enameldentin than in enamel

Continue loss ofContinue loss of tooth structuretooth structure

cavitationcavitation

In the In the pastpast

““Drill and fillDrill and fill”” approach approach

Symptomatic & failed to Symptomatic & failed to deal with etiological deal with etiological

factorsfactors

## Subsurface Subsurface demineralization precedes demineralization precedes cavitation of tooth surfacecavitation of tooth surface

Intact non restored Intact non restored teeth are superior to teeth are superior to

restored teethrestored teeth

************

What is the difference between What is the difference between lesion detection and diagnosislesion detection and diagnosis?? ??

Detecting mineral loss resulting fromDetecting mineral loss resulting from

carious process is only the first stepcarious process is only the first stepInformation is importantInformation is important

arrestedarrested

activeactive

Diagnosis adds the dimension of Diagnosis adds the dimension of lesionlesion

activity to detectionactivity to detection

Is the lesionIs the lesionor

objectives ofobjectives of caries diagnosis caries diagnosis

Identify lesions that require Identify lesions that require surgical treatment surgical treatment (restorative (restorative treatment).treatment).

Lesions that require Lesions that require nonsurgical nonsurgical treatment.treatment.

Those personsThose persons who are at who are at high high riskrisk for developing carious for developing carious lesions.lesions.

Is the patient at Is the patient at high high

risk for cariesrisk for caries?? ??

Diagnosis should not only Diagnosis should not only bebe

to search for cavitation but to to search for cavitation but to predict caries progression predict caries progression

Early diagnosisEarly diagnosis

Knowing which patients are at Knowing which patients are at high riskhigh risk for developing caries for developing caries

Implementation of Implementation of specific specific preventive strategiespreventive strategies

that may prevent cariesthat may prevent caries

Early diagnosisEarly diagnosis

If patient atIf patient at low risk for carieslow risk for caries

Preventive measures may be Preventive measures may be limited to oral hygiene limited to oral hygiene

ButButEarly diagnosisEarly diagnosis

How to diagnose How to diagnose a carious lesions ??a carious lesions ??

(Assessment tools)(Assessment tools) Patient historyPatient history Clinical examinationClinical examination Nutritional analysis Nutritional analysis Salivary analysisSalivary analysis Radiographic assessment Radiographic assessment

Patient historyPatient history

Age, gender, fluoride exposure, Age, gender, fluoride exposure, smoking habits, medications, smoking habits, medications, dietary habits, economic and dietary habits, economic and educational status, and general educational status, and general health health

can assist in diagnosis of can assist in diagnosis of caries caries

&&

identification of high-identification of high-riskrisk

patientspatients

e.ge.g..

smoking, alcoholsmoking, alcohol consumption, use of consumption, use of medication , & sucrose intakemedication , & sucrose intake

risk for caries risk for caries developmentdevelopment

Children and elderly adultsChildren and elderly adults Lower economic statusLower economic status Lower education Lower education fluoride exposurefluoride exposure Poor general healthPoor general health

caries caries riskrisk

A past history of caries A past history of caries experience is the best experience is the best

predictor of future caries predictor of future caries activityactivity

Clinical examination Clinical examination ((visual & tactile)visual & tactile)

Salivary functioningSalivary functioning

(adequate or inadequate)(adequate or inadequate) Plaque accumulationPlaque accumulation Inflammation of soft tissueInflammation of soft tissue Poor oral hygienePoor oral hygiene Cavitated lesionsCavitated lesions Existing restorationsExisting restorations

Risk to caries Risk to caries developmentdevelopment

The more factors present The more factors present

The greater the The greater the riskrisk

Assessing individual tooth Assessing individual tooth surfaces for cavitationsurfaces for cavitation Noncavitated lesions Noncavitated lesions (preventive (preventive

treatment indicated)treatment indicated)

important

If cavitation occurred If cavitation occurred (restorative treatment (restorative treatment indicated)indicated)

Visual assessmentVisual assessment of of discoloration.discoloration.

translucency or opacitytranslucency or opacity

How to assessHow to assess? ?

Proper cleaning & drying of teeth together with adequate illumination

Tactile assessmentTactile assessment

Determining the roughness or Determining the roughness or

softness of the tooth surfacesoftness of the tooth surface

Probing of the suspected lesionProbing of the suspected lesion

Penetration and resistance to Penetration and resistance to removal of explorer tip removal of explorer tip (a (a ““catchcatch””) )

evidence ofevidence of

demineralizationdemineralization

??

It may not be necessarly decayIt may not be necessarly decay It could be the local anatomicIt could be the local anatomic

features of the toothfeatures of the tooth Sharpness of the explorerSharpness of the explorer Force of application Force of application

ButButButBut

There is no There is no needneed to apply too to apply too much pressure much pressure on an on an explorerexplorer

There is no There is no needneed to apply too to apply too much pressure much pressure on an on an explorerexplorer

noncavitated incipientnoncavitated incipient lesions lesions could cause cavitation could cause cavitation

The use of sharp dental

explorer

alsoalso entrance of bacteria entrance of bacteria

lesion lesion susceptibilitysusceptibility

Nutritional analysisNutritional analysisFrequent exposure to sucrose e.g. Frequent exposure to sucrose e.g.

candycandy

(cariogenic MS organisms)(cariogenic MS organisms)

plaque developmentplaque development

caries activitycaries activity

ButBut not all patients with high not all patients with high sugar intake will develop caries.sugar intake will develop caries.

HoweverHowever, its unusual to find a , its unusual to find a patient with multiple carious patient with multiple carious lesions who does not have a high lesions who does not have a high sugar intake. sugar intake.

Salivary analysisSalivary analysis

Secretion rate Secretion rate Buffering capacityBuffering capacity Number of both mutans Number of both mutans

streptococci (MS) and streptococci (MS) and lactobacillilactobacilli

Helps to identify high patientsHelps to identify high patients

Salivary rate (salivary flow)Salivary rate (salivary flow):: High level of salivary flow High level of salivary flow

cariostatic effect cariostatic effect

Xerostomia or dry mouth Xerostomia or dry mouth

favorable favorable environmentenvironment

for caries for caries developmentdevelopment

Buffering and remineralization

Antidepressants, tranquilizers & diureticsRadiation therapy

With reduced salivary flowWith reduced salivary flow

Less Less ““washingwashing”” action allowing action allowing acidacid

& plaque to accumulate& plaque to accumulate

Buffering capacity:Buffering capacity:

Saliva is a buffer solutionSaliva is a buffer solution Helps to neutralize acid produced Helps to neutralize acid produced

by bacteriaby bacteria

saliva contains calcium and saliva contains calcium and phosphorous phosphorous

remineralizationremineralization

Mutans streptococci & Mutans streptococci & lactobacilli:lactobacilli:

High S.mutans countHigh S.mutans count

high risk high risk

Low S.mutans countLow S.mutans count

low risklow risk

Thick plaque on tooth surfaceThick plaque on tooth surface

enhance carious enhance carious processprocess

How? How? By shielding the bacteria from the By shielding the bacteria from the

buffering effects of saliva at tooth-buffering effects of saliva at tooth-plaque interface plaque interface

By preventing remineralization By preventing remineralization

At chairsideAt chairside

several Kits are available several Kits are available (e.g. Patient (e.g. Patient

Check-up Kit from GC)Check-up Kit from GC) that can be that can be

used to test for: used to test for: • Salivary flow rateSalivary flow rate• Buffering capacity &Buffering capacity &• Mutans streptococci & lactobacilliMutans streptococci & lactobacilli

Salivary flowSalivary flow

Patient chews Patient chews paraffin waxparaffin wax to to stimulatestimulate

saliva, then pt spits into a saliva, then pt spits into a measuringmeasuring

Cylinder (mL /min)Cylinder (mL /min)

Buffering capacityLitmus paper dipped in the pt’s saliva& color compared with manufacturer’s Chart to read the pt’s buffering capacity

To estimate the number ofTo estimate the number of S.mutans & lactobacilli S.mutans & lactobacilli

The number of S.mutans & The number of S.mutans & lactobacillilactobacilli

can be estimated in reference to can be estimated in reference to the the

manufacturermanufacturer’’s charts chartS.mutans lactobacilli

radiographic assessmentradiographic assessment

Radiographs shows carious Radiographs shows carious lesions that are not visible lesions that are not visible clinicallyclinically butbut they tend to they tend to under estimate the under estimate the histologic extent of the histologic extent of the carious lesioncarious lesion

Detection of Detection of occlusal caries in occlusal caries in dentindentin although enamel caries although enamel caries cannot be seen cannot be seen “hidden” caries

Diagnosis of Diagnosis of proximal cariesproximal caries in both in both E & DE & D

Bite-wing Bite-wing radiographsradiographs

What kind of x-ray?

Conventional radiography

Proximal lesions develops slowlyProximal lesions develops slowly

it may take more than a year it may take more than a year before it becomes evident on before it becomes evident on

radiograph radiograph

““white chalkywhite chalky”” appearance appearance

RadiographicallyRadiographically

A small A small radiolucent notchradiolucent notch is is evident below the contact area in evident below the contact area in enamelenamel

Advanced proximal caries

Very advanced

Approximately 60 % of teeth Approximately 60 % of teeth with radiographic proximal with radiographic proximal lesions in the outer half of lesions in the outer half of

dentin dentin

are likely to beare likely to be

Noncavitated Noncavitated And should be And should be remineralized and not restoredremineralized and not restored

Caries in dentin

with sound enamel “hidden” or

“occult’’ caries

bite-wing radiographs cannotbite-wing radiographs cannot be used solely for complete be used solely for complete caries diagnosis without caries diagnosis without additional clinical additional clinical

examinationexaminationand historyand historyWhy??

Overlaps & false-positive diagnosis

•Positioning mistakes of the cone

•Curvature of the dental arch

Prior caries activityPrior caries activity Frequent sucrose intakeFrequent sucrose intake Minimal exposure to fluorideMinimal exposure to fluoride Young or old ageYoung or old age Decrease in salivary functioningDecrease in salivary functioning High number of cariogenic High number of cariogenic

bacteriabacteria Presence of existing carious lesion Presence of existing carious lesion

patient ispatient is at high risk to cariesat high risk to caries

If a patient presents with many If a patient presents with many cavitated lesions & were skillfully cavitated lesions & were skillfully

restoredrestored Is the patient still at risk of caries??Is the patient still at risk of caries??

The answer is The answer is yesyesBiological environment that causedBiological environment that caused

caries was not changedcaries was not changed

A A change in diet change in diet or or oral oral hygiene habitshygiene habits in in

combination with optimal combination with optimal fluoridationfluoridation may may stop the stop the

progressionprogression of a lesion of a lesion and possibly allow its and possibly allow its

remineralization. remineralization.

““RiskRisk”” is the probability that some is the probability that some harmful event will occurharmful event will occur

““Caries riskCaries risk””

Is probability that an individual will Is probability that an individual will develop carious lesion during a develop carious lesion during a

specified period specified period

CariogramCariogram ItIt’’s a s a computer programcomputer program that serves as that serves as

a new risk assessment modela new risk assessment model It It assesses and graphically illusratesassesses and graphically illusrates

the caries risk for a patientthe caries risk for a patient It is expressed as the It is expressed as the ““chance to avoid chance to avoid

new cariesnew caries”” in the coming year in the coming year It can demonstrate It can demonstrate how and to what how and to what

extentextent the various caries-causing the various caries-causing factors may affect this factors may affect this ““chancechance””

The original purpose of the The original purpose of the program was educational but it program was educational but it

helps the dentist in making helps the dentist in making correct decisions.correct decisions.

Illustrate the chance to avoid Illustrate the chance to avoid cariescaries

Illustrate the interaction of caries-Illustrate the interaction of caries-related factors related factors

Express caries risk graphicallyExpress caries risk graphically Recommend preventive actionRecommend preventive action Motivate patient in clinical settingMotivate patient in clinical setting Provide an educational programProvide an educational program

The aims of the cariogram are to:The aims of the cariogram are to:

How does it worksHow does it works????

1-1- Patient examined & data Patient examined & data collectedcollected

Factors of direct relevance to cariesFactors of direct relevance to caries

(Bacteria, diet )(Bacteria, diet ) Indirect factors (susceptibility-Indirect factors (susceptibility-

related factors) related factors)

2- 2- factors are given a score from factors are given a score from 0-30-3 or or (0-2 for some factors)(0-2 for some factors) & &

entered into computer programentered into computer program

Score Score ““00”” is the most favorable values is the most favorable values &&

maximum score maximum score ““33”” (or (or ““22””)) indicates indicates high ,unfavorable risk valuehigh ,unfavorable risk value

1.1. Red Red ““bacteriabacteria””

2.2. Dark blue Dark blue ““dietdiet””

3.3. Light blue Light blue ““susceptibilitysusceptibility””

4.4. Yellow Yellow ““circumstancescircumstances””

The four sectors are mapped The four sectors are mapped outout

and what is left is theand what is left is the

5.5. Green Green ““chance to avoid carieschance to avoid caries””

The The pie-circle diagrampie-circle diagram is divided into 5 is divided into 5

sectorssectors

High risk High risk

low chance low chance

small green small green sectorsector

““Chance to avoid cariesChance to avoid caries”” & & caries risk are inversely relatedcaries risk are inversely related

Low risk Low risk

high chance high chance

large green large green sectorsector

Risk assessment needs Risk assessment needs

both clinical skill and both clinical skill and experienceexperience

Patient should realize that caries

risk status can change and that the dentist can detect

this change

Advanced diagnostic toolsAdvanced diagnostic tools11--Intraoral cameraIntraoral camera

22--Digital radiographDigital radiograph

33--Laser based deviseLaser based devise

44--Fibroptic trans-illuminationFibroptic trans-illumination

55--Electric caries monitorElectric caries monitor

66--dye penetrationdye penetration

11--Intra oral cameraIntra oral camera--Camera placed inside oral cavity to Camera placed inside oral cavity to

displaydisplayIntra oral images on a computerIntra oral images on a computer

--Has improved visual access to dental Has improved visual access to dental cavitycavity

--Improved lighteningImproved lightening--Improved magnificationImproved magnification

--Demonstrate the pt needs for treatmentDemonstrate the pt needs for treatment

22--Digital radiographyDigital radiography--Image recorded with non film Image recorded with non film

receptorreceptor

--The film replaced by flat electronic The film replaced by flat electronic pad or sensorpad or sensor

--Images sent to computer displayed Images sent to computer displayed on monitor screenon monitor screen

AdvantagesAdvantages11--Lower exposure of radiation for the ptLower exposure of radiation for the pt

22--Absence of dark roomAbsence of dark room

33--Convenience of image enhancement, Convenience of image enhancement, magnification and color codingmagnification and color coding

44--Diagnosis of initial caries lesion adequatelyDiagnosis of initial caries lesion adequately

DisadvantagesDisadvantages11--Under estimate the size of the Under estimate the size of the

lesionlesion

22--High false positive results in High false positive results in occlusal caries detectionocclusal caries detection

Radiographic Radiographic classification for classification for proximal cariesproximal caries

00--Sound surfaceSound surface11--lesion in outer half of enamellesion in outer half of enamel22--lesion in inner half of enamellesion in inner half of enamel

33--lesion in outer half of dentinlesion in outer half of dentin44--lesion in inner half of dentinlesion in inner half of dentin

Value of classificationValue of classificationTo dictate the line of treatmentTo dictate the line of treatment

Score 1,2 and possibly 3 treated Score 1,2 and possibly 3 treated with mineralizationwith mineralization

Other scores treated by cavity and Other scores treated by cavity and restorationrestoration

Laser-based device Laser-based device [DIAGNODENT][DIAGNODENT]

--Laser light passed via optical fiber to the Laser light passed via optical fiber to the area of decayarea of decay

--the decayed area fluorescencethe decayed area fluorescence

--The fluorescence passes back to the probeThe fluorescence passes back to the probe

--The decay displayed and indicated both The decay displayed and indicated both visually and audiblyvisually and audibly

AdvantagesAdvantages11--No sharp probe of the teethNo sharp probe of the teeth

22--lesse exposure to radiationlesse exposure to radiation33--Great for children and anxious patientGreat for children and anxious patient

44--Catching decay in early stages so Catching decay in early stages so minimalminimalTreatment is necessaryTreatment is necessary

55--Visual and acoustic measurementVisual and acoustic measurement66--Results are documentedResults are documented

33--Fibroptic Fibroptic transillumination[FOTI]transillumination[FOTI]

--Works under principle that caries has Works under principle that caries has lowerlowerIndex of light transmissionIndex of light transmission

--area of caries appears as darkened area of caries appears as darkened shadowshadow

--Initially designed for detection of Initially designed for detection of proximal cariesproximal caries

Consists ofConsists of::--halogen lamphalogen lamp

--Rheostat to produce light of Rheostat to produce light of variable intensityvariable intensity

--And two attachmentsAnd two attachments--Mouth mirrorMouth mirror

--Fibroptic probe 0.5mm diameterFibroptic probe 0.5mm diameter

Produce narrow beam of light for Produce narrow beam of light for transilluminationtransillumination

Displayed in computer screen for Displayed in computer screen for diagnosisdiagnosis

AdvantagesAdvantages11--No hazards of radiationNo hazards of radiation

22--Simple and comfortableSimple and comfortable

33--Lesion can not diagnose by Lesion can not diagnose by radiation diagnosed by this radiation diagnosed by this methodmethod

44--Not time consumingNot time consuming

DisadvantagesDisadvantages11--Permanent records are difficult to Permanent records are difficult to

maintainmaintain

22--Subjected to observer variationSubjected to observer variation

33--Difficult to place probe in certain Difficult to place probe in certain areasareas

44--Electrical caries monitor [ECM]Electrical caries monitor [ECM]--Based on difference of electrical Based on difference of electrical

conductivityconductivity

Between sound and carious dental tissuesBetween sound and carious dental tissues

--Works effectively for detection of occlusal Works effectively for detection of occlusal cariescaries

--Resistance should be recorded in absence Resistance should be recorded in absence of salivaof saliva

--High measurements indicates well High measurements indicates well mineralizationmineralization

--Low measurements indicates Low measurements indicates demineralized tissuesdemineralized tissues

--Has potential to monitor lesion Has potential to monitor lesion progressionprogression

7-Dye Penetration Method7-Dye Penetration Method

coloring by a dye may coloring by a dye may differentiate between several differentiate between several objects which have a similar objects which have a similar appearance appearance

Dye penetration

observation of the coloring can be: observation of the coloring can be:

qualitativequalitative or or quantitativequantitative

Intensity of colorPresence or absence

In caries diagnosisIn caries diagnosisqualitative examination is qualitative examination is

sufficientsufficient observation of colored dye observation of colored dye signifies presence of cariessignifies presence of caries

Dyes should fulfill the Dyes should fulfill the following criteria :following criteria :

1)1) Dyes should be absolutely safe for Dyes should be absolutely safe for intra oral use intra oral use3)3) Dyes should be easily removed and Dyes should be easily removed and not lead to permanent staining not lead to permanent staining

DDyes for carious dentinyes for carious dentinCarious dentin is divided into two Carious dentin is divided into two layers:layers: Outer decalcified layer (infected)Outer decalcified layer (infected) soft and cannot be soft and cannot be remineralizedremineralized Inner decalcified layerInner decalcified layer (affected)(affected) hard and can be remineralized hard and can be remineralized

0.5% Basic Fuchsin in 0.5% Basic Fuchsin in propylene glycolpropylene glycol

Denatured collagen Denatured collagen is stainedis stained

while the inner while the inner zone remains unstained zone remains unstained

Basic Fuchsin dye was considered Basic Fuchsin dye was considered to be to be carcinogeniccarcinogenic

replaced byreplaced byAcid Red and Methylene BlueAcid Red and Methylene Blue

Methylene blue is alsoMethylene blue is alsoslightly toxic slightly toxic

soso

Acid red is preferredAcid red is preferred

Management of cariesManagement of cariesBy two measuresBy two measures-:-:

a-Preventive:-a-Preventive:-To prevent occurans To prevent occurans of cariesof caries

B-control & treatment:-B-control & treatment:-To stop To stop progress of active lesion and progress of active lesion and restore itrestore it

Caries preventionCaries prevention11--By the patientBy the patient

a-Low intake of carbohydratesa-Low intake of carbohydrates

B-Removal of plaque by brushing & flossingB-Removal of plaque by brushing & flossing

C-Use fluoridated tooth pastC-Use fluoridated tooth past

d-Maintenance of good healthd-Maintenance of good health

e-Stimulation of circulation of gengival e-Stimulation of circulation of gengival tissuestissues

22--By the dentistBy the dentist-:-:a-Periodic cleaning of teetha-Periodic cleaning of teeth

B-application of fluorideB-application of fluoride

C-Fissure sealant in pits & fissuresC-Fissure sealant in pits & fissures

D-Educating & motivating the D-Educating & motivating the patientpatient

E-repairing early lesionsE-repairing early lesions

Treatment of early cariesTreatment of early cariesa-fluoride exposurea-fluoride exposure-:-:

Action of fluorideAction of fluoride--Precipitated into tooth structurePrecipitated into tooth structure

--remineralizationremineralization--Inhibit enzyme productionInhibit enzyme production

--Decrease surface energy of enamel Decrease surface energy of enamel leads to decrease retention of micro leads to decrease retention of micro organismsorganisms

B-Anti microbial agent:-B-Anti microbial agent:-((chemoprophylaxischemoprophylaxis))

- -fluoridefluoride--chlorhexidine:-is chlorhexidine:-is

antiseptic ,bactericidal, fungicidalantiseptic ,bactericidal, fungicidal--Triclosan:- is broad spectrum anti Triclosan:- is broad spectrum anti

microbial agentmicrobial agent - -antibioticsantibiotics

C-Oral hygieneC-Oral hygiene-:-:

Removal of the plaque byRemoval of the plaque by-:-:--Dental flossingDental flossing

--dental brushingdental brushing

--rinsingrinsing

D-Xylitol gumsD-Xylitol gums--Reduces streptoccocus mutans by Reduces streptoccocus mutans by

Altering their metabolic pathwaysAltering their metabolic pathways

--Enhance demineralizationEnhance demineralization

--Arrest dental cariesArrest dental caries

Used as chewing gum for 5-30 Used as chewing gum for 5-30 minutesminutes

E-shewing sugar free gumE-shewing sugar free gum--Reduces acidogenicity of plaque Reduces acidogenicity of plaque

by stimulation of salivary flowby stimulation of salivary flow

--Buffering of the phBuffering of the ph

‘‘Iodine penetration method’Iodine penetration method’ measuring enamel porosity of the measuring enamel porosity of the incipient carious lesions incipient carious lesions how??how??* * potassium iodide applied on a well-potassium iodide applied on a well- defined area of enamel defined area of enamel* excess removed* excess removed* iodine remaining in micropores is * iodine remaining in micropores is estimated estimated indicates permeability of indicates permeability of enamel enamel

complicated procedurecomplicated procedure

In spite of the modern In spite of the modern diagnostic aids caries diagnostic aids caries detection remain an detection remain an

inexact scienceinexact science

Early detection of Early detection of Digital radiographyDigital radiography Quantitative light-induced Quantitative light-induced

fluorescencefluorescence Electrical conductivityElectrical conductivity UltrasonographyUltrasonography