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E-mail: [email protected]: [email protected]

Website: www.advancedental-ltd.comWebsite: www.advancedental-ltd.com

INDEXINDEXTraditional caries diagnostic modelTraditional caries diagnostic model

Caries detection dye (CDD)Caries detection dye (CDD)

False positivesFalse positives

Hypomineralized (hypocalcific) enamelHypomineralized (hypocalcific) enamel

Hidden cariesHidden caries

Variable readingsVariable readings

Current caries modelCurrent caries model

How to use the DIAGNOdentHow to use the DIAGNOdent

To exit. Press Esc.To exit. Press Esc.

Fissure sealantsFissure sealants

Interpreting the resultsInterpreting the results



Traditional Fissure Caries and Diagnostic

Model

Traditional Fissure Caries and Diagnostic

Model

Traditional Diagnostic

Model

Traditional Diagnostic

ModelLow sensitivityLow sensitivityHigh specificityHigh specificity

Low SensitivityLow Sensitivity

Conventional diagnosis can miss Conventional diagnosis can miss significant amounts of decaysignificant amounts of decay

High SpecificityHigh Specificity

Conventional diagnosis does not produce Conventional diagnosis does not produce a lot of false positive diagnosesa lot of false positive diagnoses

Traditional fissure caries modelTraditional fissure caries model

Probe does Probe does not sticknot stick

““No caries”No caries”

Enamel Enamel decalcificationdecalcification

Probe will Probe will now sticknow stick


Continuing Continuing decalcification decalcification finally leads to finally leads to cavitation of cavitation of the enamelthe enamel


Continuing Continuing acid attack acid attack

leads to dentin leads to dentin caries and caries and

further further cavitationcavitation


Penning C, van Amerongen JP, Seef RE & ten Cate JM.

Validity of probing, for fissure caries diagnosis.

Caries Res 26(6):445-9, 1993

Penning C, van Amerongen JP, Seef RE & ten Cate JM.

Validity of probing, for fissure caries diagnosis.

Caries Res 26(6):445-9, 1993

“ “ Probing found unreliableProbing found unreliable

in finding fissure caries”in finding fissure caries”

Black, G.V. Operative Dentistry. Vol. I Henry Kimpton, London. 7th Ed, p32, 1924

Black, G.V. Operative Dentistry. Vol. I Henry Kimpton, London. 7th Ed, p32, 1924

“ “ A A sharp sharp explorer should be explorer should be used with some pressure and if used with some pressure and if a very slight pull is required to a very slight pull is required to

remove it, the pit should be remove it, the pit should be marked for restoration even if marked for restoration even if there are there are no signs of decay.”no signs of decay.”

ROCK WP, KIDD EAM.Br Dent J. 164(8): 243-47, 1988.

ROCK WP, KIDD EAM.Br Dent J. 164(8): 243-47, 1988.

“… “… decay is difficult to detect in decay is difficult to detect in radiographs unless larger than radiographs unless larger than 2mm to 3mm deep into dentin, 2mm to 3mm deep into dentin,

or 1/3 the bucco-lingual or 1/3 the bucco-lingual distance.”distance.”

Not diagnosed by mirror, probe and Xray examination

Not diagnosed by mirror, probe and Xray examination

1mm deep “cavity”1mm deep “cavity”

4mm deep, total decalcification.Cavity was widened to 1/3

occlusal width to show on Xray

4mm deep, total decalcification.Cavity was widened to 1/3

occlusal width to show on Xray

4mm 1/3 occlusal width

Contact point caries is much easier to detect radiographically

Contact point caries is much easier to detect radiographically

X-R

AY

1/3rd

Digitally createdDigitally created

Chan DCN. Current methods and criteria for finding decay in North America.

J Dent Ed 57(6):422-425, 1993

Chan DCN. Current methods and criteria for finding decay in North America.

J Dent Ed 57(6):422-425, 1993

Caries is regularly found Caries is regularly found beneath a seemingly intact beneath a seemingly intact

enamel surfaceenamel surface

Frequently the diagnosis of Frequently the diagnosis of occlusal caries is less than occlusal caries is less than

straightforwardstraightforward

AL-SEHAIBANY, WHITE & RAINEYJ Clin Pediatr Dent 20(4):293-298 1996AL-SEHAIBANY, WHITE & RAINEYJ Clin Pediatr Dent 20(4):293-298 1996

The reliability of carious lesion The reliability of carious lesion diagnosis by sharp explorer compared diagnosis by sharp explorer compared

to diagnosis of carious lesion by to diagnosis of carious lesion by histological cross section was 25%.histological cross section was 25%.

____________________________________________________________

A seemingly intact occlusal enamel surface A seemingly intact occlusal enamel surface may conceal an extensive lesion of the may conceal an extensive lesion of the

dentindentin

The traditional fissure caries diagnostic

model is very crude

LOW SENSITIVITY

The traditional fissure caries diagnostic

model is very crude

LOW SENSITIVITY

Current caries model

Current caries model

Modern fissure caries modelModern fissure caries model

Organic plugOrganic plug

Decalcified or Decalcified or hypocalcific hypocalcific

enamelenamel


Acid percolation Acid percolation through porous, through porous,

hypocalcific hypocalcific enamel can lead to enamel can lead to

failure of the failure of the organic plugorganic plug



Consequently, Consequently, dentin can be dentin can be

exposed to acid exposed to acid without cavitation without cavitation

of the enamel of the enamel leading to leading to

developmental developmental dentin cariesdentin caries

Enamel may be Enamel may be developmentally developmentally hypomineralized, hypomineralized, and consequently and consequently porous through its porous through its

full thickness full thickness ACID


OROR

by the time the by the time the tooth has tooth has

emerged from emerged from under the under the

operculum, the operculum, the fissure enamel fissure enamel can already be can already be

cariouscarious

ACID

These areas may These areas may not be not be

decalcified, and a decalcified, and a probe won’t stickprobe won’t stick


Once the organic Once the organic plug fails, plug fails,

bacteria have bacteria have access to the access to the depths of the depths of the

fissurefissure

Fissure walls are Fissure walls are in close in close

appositionapposition

DecalcificationDecalcification

A probe will be A probe will be unable to detect unable to detect

caries herecaries here


Continuing Continuing decalcification decalcification +dentin caries+dentin caries

Presentation is Presentation is inverted inverted

compared to the compared to the traditional traditional

modelmodel


Defects in the Defects in the fissure walls fissure walls can lead to can lead to

dentin caries dentin caries

with with NONO enamel enamel

decalcificationdecalcification

Can’t Can’t diagnose diagnose

this with a this with a probe or probe or Caries Caries

Detection Detection Dye (CDD)Dye (CDD)



((This area may This area may not be not be

decalcified decalcified thus a probe thus a probe won’t stick)won’t stick)

Enamel defects Enamel defects in fissure wallin fissure wall


enamel (caries in enamel (caries in this zone is this zone is

undetectable by undetectable by probe)probe)

De-mineralizing De-mineralizing dentindentin

Modern Fissure CariesAnatomy Model

(Summary of realistic ‘coke bottle ‘ shape)

Modern Fissure CariesAnatomy Model

(Summary of realistic ‘coke bottle ‘ shape)

The DIAGNOdent can diagnose this zone in the fissure

The DIAGNOdent can diagnose this zone in the fissure

Fissure CariesFissure CariesThe DIAGNOdent can “read” 2mm The DIAGNOdent can “read” 2mm

into the toothinto the toothAs long as the fissure is cleaned of As long as the fissure is cleaned of

debris, readings will detect changes in debris, readings will detect changes in the underlying enamel and dentin the underlying enamel and dentin

The use of caries detection dye (CDD) The use of caries detection dye (CDD) to stain porous, carious enamel will to stain porous, carious enamel will help identify carious tooth structure help identify carious tooth structure that needs removingthat needs removing

How Does Caries Detection Dye Work


Fusayama T. A Simple Pain –Free Adhesive Fusayama T. A Simple Pain –Free Adhesive Restorative System.1:18 1993Restorative System.1:18 1993

““The mechanism of differential staining The mechanism of differential staining does not involve selective chemical does not involve selective chemical

bonding of the dye in usual staining, bonding of the dye in usual staining, but the selective penetration of the but the selective penetration of the

solvent”solvent”



It is simply filling the voids in enamel and It is simply filling the voids in enamel and dentin that are created by acid attack, or dentin that are created by acid attack, or filling voids present in hypomineralized filling voids present in hypomineralized

enamelenamel

Fusayama T. A Simple Pain –Free Adhesive Fusayama T. A Simple Pain –Free Adhesive Restorative System.1:18 1993Restorative System.1:18 1993

Enamel prisms remain, but with some mineral loss P

Loss of interprismatic enamel creates a “micro-pore” effect S

Slow onset cariesSlow onset cariesCaries Detection DyeCaries Detection Dye

SEM Haikel et al.1983SEM Haikel et al.1983

AL-SEHAIBANY F, WHITE G & RAINEY J.T.J Clin Pediatr Dent 20(4):293-298, 1996

AL-SEHAIBANY F, WHITE G & RAINEY J.T.J Clin Pediatr Dent 20(4):293-298, 1996

CDD is a reliable diagnostic tool for occlusal CDD is a reliable diagnostic tool for occlusal carious lesions. Ratio of occlusal grooves carious lesions. Ratio of occlusal grooves

stained by dye, to underlying carious stained by dye, to underlying carious lesions, is 1:1 by histological x-section in lesions, is 1:1 by histological x-section in

extracted teethextracted teeth

75% of occlusal carious lesions missed 75% of occlusal carious lesions missed by probing were by probing were found using CDDfound using CDD

Carious fissure walls in very close apposition




Fissure appears totally sound



Fissure appears totally sound

Carious (decalcified) enamel in the depths

of the fissure

Stained with Caries Detection Dye



CDDCDD

Occlusal fissure cariesOcclusal fissure caries

Stained with CDDStained with CDDThis tooth was This tooth was

partially erupted partially erupted under an under an

operculum for operculum for 18 months. 18 months.

CDD has stained CDD has stained the carious the carious

enamel.enamel.

Carious enamel and dentin stained

Carious enamel and dentin stained

Note diffusion Note diffusion of the dye into of the dye into demineralized demineralized

occlusal occlusal enamel, as enamel, as well as into well as into the fissurethe fissure

Fissure CariesFissure Caries

Demineralized, Demineralized, opaque carious opaque carious enamel in the enamel in the opening of the opening of the fissuresfissures

Stained pitsStained pits

DIAGNOdent

45

38


Stained with Stained with Caries Detection Caries Detection DyeDye

DIAGNOdent

45

38


What the What the DIAGNOdent DIAGNOdent detecteddetected

None of this was None of this was detected using a detected using a probe and X-raysprobe and X-rays

DIAGNOdent

45

38

KaVo DIAGNOdent laserKaVo DIAGNOdent laser

KaVo DIAGNOdent laserKaVo DIAGNOdent laser

655 nm diode laser655 nm diode laser

Reads 2mm into the toothReads 2mm into the tooth

Detects “fluorescence” in Detects “fluorescence” in ANYTHING ANYTHING you aim it atyou aim it at

High sensitivityHigh sensitivityLow specificityLow specificity

It responds to…It responds to…

High natural fluorescence of the toothHigh natural fluorescence of the tooth

Plaque and organic plugPlaque and organic plug

Composite and stained marginsComposite and stained margins

CalculusCalculus

Food (particularly greens)Food (particularly greens)

Hypocalcific enamel, carious enamel / dentinHypocalcific enamel, carious enamel / dentin

However, the decay However, the decay could be found with a could be found with a

diagnostic laserdiagnostic laser

A probe would not A probe would not stick in these fissuresstick in these fissures

DIAGNOdent LaserDIAGNOdent Laser

Sectioned Sectioned toothtooth

DIAGNOdent SleeveDIAGNOdent Sleeve

Denticator 600 – 800 HL 1000 High Long Sleeve

You can use a sleeve so that you don’t need You can use a sleeve so that you don’t need to autoclave the tips all the timeto autoclave the tips all the time

Simply calibrate the unit through the sleeveSimply calibrate the unit through the sleeve

Scanning the FissuresScanning the Fissures

Do not apply pressure. It is not a probe!!Do not apply pressure. It is not a probe!!

Scanning the FissuresScanning the Fissures

Rotate the tip to “read” the fissure wallsRotate the tip to “read” the fissure walls

TechniquesTechniques

Thorough sodium bicarbonate prophy Thorough sodium bicarbonate prophy before scanning. If debris is missed, before scanning. If debris is missed,

false positives can still occur.false positives can still occur.

These areas then require further These areas then require further cleaning with the PROPHYflex to cleaning with the PROPHYflex to ensure an accurate second reading.ensure an accurate second reading.

There are two main techniquesThere are two main techniques

PROPHYflex (KaVo)Sodium Bicarbonate for cleaning fissures


TechniquesTechniques

Scan the mouth and note areas with positive Scan the mouth and note areas with positive readings >15readings >15

Many will have no debris or organic plug, and the Many will have no debris or organic plug, and the reading will be reliablereading will be reliable

If there is a plug or debris with a high reading, If there is a plug or debris with a high reading, selectively clean these fissures and re-scanselectively clean these fissures and re-scan

Negative readings <10 are almost always reliableNegative readings <10 are almost always reliable

A more time-efficient techniqueA more time-efficient technique



DO NOTDO NOT use the RONDOflex use the RONDOflex (air abrasion) to clean fissures (air abrasion) to clean fissures prior to using the prior to using the DIAGNOdentDIAGNOdent

Air abrasion with Aluminum Air abrasion with Aluminum Oxide cuts tooth structureOxide cuts tooth structure

Unnecessary removal of Unnecessary removal of sound enamel is NOT sound enamel is NOT indicated for diagnostic indicated for diagnostic purposespurposes

PROPHYflex (KaVo)- to ensure trouble-free use

PROPHYflex (KaVo)- to ensure trouble-free use

Use a second powder container

After use, remove the powder container and replace it with the empty one

Operate the unit for 10 secs to flush out the internal lines and tip, then run for 10 secs with water turned off before autoclaving

Interpreting the ResultsInterpreting the Results

A sound knowledge is required ofA sound knowledge is required of Fissure anatomy and developmental defectsFissure anatomy and developmental defects The caries processThe caries process Enamel morphology in relation toEnamel morphology in relation to

Developmental hypocalcific enamelDevelopmental hypocalcific enamel Carious enamelCarious enamel

Sources of false positivesSources of false positives

When scanning carious enamel, the When scanning carious enamel, the DIAGNOdent reacts to intensity of DIAGNOdent reacts to intensity of demineralization rather than the depth demineralization rather than the depth of the lesionof the lesion

An understanding of the way caries An understanding of the way caries develops in enamel allows for a better develops in enamel allows for a better interpretation of the information interpretation of the information provided by the DIAGNOdentprovided by the DIAGNOdent


Slow onset caries leads to loss of Slow onset caries leads to loss of interprismatic enamel that becomes micro-interprismatic enamel that becomes micro-porous through to the dentinporous through to the dentin

This allows acid to dissolve mineral content This allows acid to dissolve mineral content from the dentin without any macroscopic from the dentin without any macroscopic cavitation of the overlying enamel cavitation of the overlying enamel

This is the most common type of damage This is the most common type of damage that occurs in the walls of fissuresthat occurs in the walls of fissures


Early Carious EnamelEarly Carious Enamel

SEMSThylstrup and Fejerskov 1981

Enamel is micro-porous Enamel is micro-porous but macroscopically but macroscopically

soundsound

Carious EnamelCarious Enamel

Rapid onset Intraprismatic enamel is lost. Chalky and prone

to cavitation.

Slow onset Interprismatic enamel is lost. Enamel is porous

without cavitation.

SEMSSEMSHaikel et al.1983Haikel et al.1983

Enamel prisms remain, but with some mineral loss P

Loss of interprismatic enamel creates a “micropore” effect S

Slow Onset Carious EnamelSlow Onset Carious EnamelAcid infiltrationAcid infiltration

SEMS Haikel et al.1983SEMS Haikel et al.1983

Smooth surface dentin cariesSmooth surface dentin caries

Cusp implosion due to non-cavitated

lingual decalcification in a

15yr. old

Cusp implosion due to non-cavitated

lingual decalcification in a

15yr. old

Microporous enamelMicroporous enamel

Smooth surface dentin cariesSmooth surface dentin caries

Acid infiltration through porous, but

macroscopically sound lingual enamel

lead to demineralization of

the underlying dentin

Acid infiltration through porous, but

macroscopically sound lingual enamel

lead to demineralization of

the underlying dentin

Rapid onset cariesRapid onset caries

13 yr old patient. Rapid onset contact point caries.

Rapid mineral loss of intraprismatic enamel and associated cavitation


Caries Detection Dye accurately stains demineralized carious enamel


Enamel cavitation has

occurred before any

mineral loss in the dentin

Rapid onset caries


Compare this to…

Slow onset cariesSlow onset caries

… slow onset, non-cavitated contact point caries

This is also the usual presentation of caries in the depths of a fissure complex


The DIAGNOdent reacts equally to The DIAGNOdent reacts equally to either form of enamel damage and either form of enamel damage and cannot differentiate between slow cannot differentiate between slow onset and rapid onset cariesonset and rapid onset caries

Treatment decisions are related to an Treatment decisions are related to an understanding of the caries process and understanding of the caries process and the recognition of the type of enamel the recognition of the type of enamel damage presentdamage present

Interpreting the Results DIAGNOdent readings of smooth surface caries


Enamel cavitation beginning



2020

36364848

9999

6565


The readings are related to the degree and The readings are related to the degree and intensity of demineralization, rather than intensity of demineralization, rather than the depth of the lesionthe depth of the lesion

As the enamel becomes more porous, from As the enamel becomes more porous, from right to left, the reading increasesright to left, the reading increases

Dentin damage is more intense under the Dentin damage is more intense under the more porous enamel, and is worst where more porous enamel, and is worst where cavitation of the enamel has commenced cavitation of the enamel has commenced

Interpreting the ResultsInterpreting the ResultsDentin caries was Dentin caries was

at its deepest at its deepest where the where the

DIAGNOdent DIAGNOdent readings were the readings were the

highesthighest


Therefore, there is a correlation between Therefore, there is a correlation between the dentin caries and the DIAGNOdent the dentin caries and the DIAGNOdent reading, but this is related to the reading, but this is related to the intensity of the damage to the overlying intensity of the damage to the overlying enamel, rather than the DIAGNOdent enamel, rather than the DIAGNOdent giving a numerical reading that is giving a numerical reading that is indicative of depth of the lesionindicative of depth of the lesion

Relating DIAGNOdent readings of smooth surface caries to fissure caries

Relating DIAGNOdent readings of smooth surface caries to fissure caries

By understanding that the By understanding that the DIAGNOdent indicates intensity of DIAGNOdent indicates intensity of demineralization rather than depth, demineralization rather than depth, fissure caries presents the potential to fissure caries presents the potential to generate misleading responsesgenerate misleading responses

Carious or hypocalcific Carious or hypocalcific enamelenamel

Severe, but superficial Severe, but superficial demineralization in this zone demineralization in this zone will give a high reading, even will give a high reading, even though there is not significant though there is not significant caries present in the depths of caries present in the depths of

the fissurethe fissure

DIAGNOdent readingsDIAGNOdent readings

Fissure walls in this zone Fissure walls in this zone are soundare sound

Caries developing in the Caries developing in the depths of the fissure will give depths of the fissure will give

a lower reading than the a lower reading than the previous case, even though previous case, even though the enamel damage may be the enamel damage may be

more severe, because the laser more severe, because the laser is now scanning through a is now scanning through a

layer of sound enamellayer of sound enamel



Caries in this site will also give a lower reading,

compared to a similar lesion on a smooth surface, due to

the filtering effect of the overlying sound enamel

As the lesion progresses, the As the lesion progresses, the demineralization in the demineralization in the

enamel fissure walls enamel fissure walls becomes more severe becomes more severe

This gives a higher reading, This gives a higher reading, but this is still not totally but this is still not totally

predictive of the depth of the predictive of the depth of the dentin cariesdentin caries



Dentin caries developing Dentin caries developing under enamel defects in the under enamel defects in the

depths of the fissure will depths of the fissure will give lower readings because give lower readings because

of the thickness of the of the thickness of the overlying sound enameloverlying sound enamel

This is a form of “hidden This is a form of “hidden caries”caries”

If a reading is obtained that If a reading is obtained that causes concern, yet there is causes concern, yet there is

no visible evidence to no visible evidence to support the reading, support the reading, minimally invasive minimally invasive

techniques are essential techniques are essential when investigating the when investigating the

fissurefissure

Step down techniqueStep down technique

Carefully open the fissure Carefully open the fissure entrance with Air-abrasionentrance with Air-abrasion


Re scan the fissure. If the Re scan the fissure. If the reading drops, the enamel reading drops, the enamel damage was present in the damage was present in the

fissure opening. If the fissure opening. If the reading remains constant, or reading remains constant, or

increases, there is caries increases, there is caries deeper in the fissure deeper in the fissure

complex.complex.


Sudden increase in reading while rotating

the tip in a fissure


the tip in a fissureIf there is fissure caries If there is fissure caries

developing in one wall of a developing in one wall of a fissure, the initial angulation fissure, the initial angulation of the beam may completely of the beam may completely

miss the lesion. As an miss the lesion. As an example, the reading at this example, the reading at this point the reading may only point the reading may only

be 5-10be 5-10

As the beam approaches the As the beam approaches the carious wall, the reading carious wall, the reading

will begin to increasewill begin to increase





Once the beam is directed at Once the beam is directed at the lesion, there will be a the lesion, there will be a

rapid increase in the rapid increase in the reading. The reading could reading. The reading could now be 30-40, yet there is now be 30-40, yet there is no external evidence of a no external evidence of a

lesion.lesion.





Many of these lesions are Many of these lesions are very localized and subtle very localized and subtle and if the fissure is not and if the fissure is not entered with minimally entered with minimally invasive techniques like invasive techniques like

Air-abrasion, they will not Air-abrasion, they will not be observed and the reading be observed and the reading from the DIAGNOdent is from the DIAGNOdent is consequently discredited.consequently discredited.








the tip in a fissureReadings that oscillate with Readings that oscillate with simple rotation of the tip are simple rotation of the tip are generally very reliable. If generally very reliable. If

there was something present there was something present in the fissure entrance to in the fissure entrance to cause a false positive, the cause a false positive, the

reading would remain reading would remain constantly high, rather than constantly high, rather than oscillate with the rotation of oscillate with the rotation of

the tipthe tip

False PositivesFalse Positives Organic plugOrganic plug CompositesComposites Stained composite marginsStained composite margins CalculusCalculus Impacted food in the fissuresImpacted food in the fissures Some prophy pastesSome prophy pastes Remineralized cariRemineralized carious enamelous enamel Naturally fluorescent enamelNaturally fluorescent enamel

False PositivesFalse PositivesSome prophy pastesSome prophy pastes

If you are not using sodium bicarbonate If you are not using sodium bicarbonate prophylaxis (PROPHYflex), check if your prophy prophylaxis (PROPHYflex), check if your prophy paste causes a high reading by placing the paste causes a high reading by placing the DIAGNOdent tip into the prophy paste you are DIAGNOdent tip into the prophy paste you are usingusing

Impacted paste in the fissures will give a high Impacted paste in the fissures will give a high reading, particularly with green coloured pastesreading, particularly with green coloured pastes

False PositivesFalse PositivesSome polishing pastesSome polishing pastes

If you are not using sodium bicarbonate If you are not using sodium bicarbonate prophylaxis (PROPHYflex), check if your prophylaxis (PROPHYflex), check if your prophypaste casues a high reading by placing the prophypaste casues a high reading by placing the DIAGNOdent tip into the prophypaste you are DIAGNOdent tip into the prophypaste you are usingusing

Impacted paste in the fissures will give a high Impacted paste in the fissures will give a high reading, particularly with green coloured pastesreading, particularly with green coloured pastes

False PositivesFalse Positives Naturally fluorescent enamelNaturally fluorescent enamel

Calibrate by placing the tip on a Calibrate by placing the tip on a smooth surface and hold the ring smooth surface and hold the ring switch for two beeps to auto-calibrate switch for two beeps to auto-calibrate for the fluorescencefor the fluorescence

Initial DIAGNOdent readings

34345858

2020

Latest model is one beepLatest model is one beep

False PositivesFalse Positives After deducting the natural After deducting the natural

fluorescence reading of 10, the display fluorescence reading of 10, the display indicated the followingindicated the following

Natural fluorescence reading 10

24244848

1010

34345858

2020

False PositivesFalse Positives What was in there?What was in there?

24244848

1010

No caries in the mesial fissures

What about this fissure?What about this fissure?

Heavily stained fissureHeavily stained fissure

Is it carious or not?Is it carious or not?

Images courtesy R EhrlichImages courtesy R Ehrlich

What about this fissure?What about this fissure?

The fissure was stained, but The fissure was stained, but there was no active caries there was no active caries

presentpresent(Dormant caries)(Dormant caries)


Laser DiagnosisLaser Diagnosis

Diagnodent 6

Cautious, minimally invasive techniques are essential when there is

doubt


Smooth surfaceSmooth surface

DIAGNOdent 99

Caries potential is related to the site Low risk

Found in newly erupted teethFound in newly erupted teeth

Higher level of poresHigher level of pores

Highly substituted enamelHighly substituted enamel

NO Treatment!!

FissuresFissures

High risk

DIAGNOdent 99

Caries potential is related to Caries potential is related to the sitethe site

Plaque retention (acid) will Plaque retention (acid) will mean caries WILL develop mean caries WILL develop under this hypocalcific under this hypocalcific enamelenamel

FissuresFissures

High risk

This is an extreme This is an extreme example. Most often, the example. Most often, the presentation of presentation of developmental hypocalcific developmental hypocalcific enamel is much more subtleenamel is much more subtle

The caries establishes in The caries establishes in the dentin via the porous, the dentin via the porous, developmentally defective developmentally defective enamelenamel

High risk

Defects existed that led Defects existed that led directly to the dentindirectly to the dentin

ConclusionConclusionDevelopmental hypocalcific Developmental hypocalcific enamel is of significance if it enamel is of significance if it

is detected in the pit and is detected in the pit and fissure systemfissure system

High risk

Defects existed that led Defects existed that led directly to the dentindirectly to the dentin

The DIAGNOdent will alert The DIAGNOdent will alert youyou

Use CDD to confirm it Use CDD to confirm it CDD will stain porous CDD will stain porous

hypocalcific enamel that is hypocalcific enamel that is becoming cariousbecoming carious

Hypocalcific enamel and carious fissure enamel


The fluorotic or hypocalcific

enamel on the cusps has

remineralized. It is hard and shiny.

15 yr old. High caries risk

DIAGNOdent 45

DIAGNOdent 65

HOWEVER

In the fissure, the enamel has been

continually exposed to plaque acid. It has the dull chalky appearance associated with active

caries.15 yr old. High caries risk



Fissure caries alongside

developmentally defective enamel

A SITE SPECIFIC PROBLEM




The porous, actively carious fissure enamel

absorbs CDDThe remineralized

hypocalcific enamel does not

A SITE SPECIFIC PROBLEM







Do not treat

Treat

Arrested caries/remineralizationArrested caries/remineralization

35 yr oldEruption phase, smooth surface caries has

remineralized. It is hard and shiny and does not absorb CDD.

DIAGNOdent 55

Arrested caries/remineralization concepts

Arrested caries/remineralization concepts

35 yr oldEruption phase, smooth surface caries has

remineralized. It is hard and shiny and does not absorb CDD.

Diagnodent 55

NO Treatment!!


An understanding of the fissure caries An understanding of the fissure caries process is essential to be able to process is essential to be able to interpret the information provided by interpret the information provided by the DIAGNOdent. the DIAGNOdent.


((This area may This area may not be not be

decalcified decalcified thus a probe thus a probe won’t stick)won’t stick)

Enamel defects Enamel defects in fissure wallin fissure wall


enamel (caries in enamel (caries in this zone is this zone is

undetectable by undetectable by probe)probe)

De-mineralizing De-mineralizing dentindentin

Hidden Caries or Hypo-calcificationHidden Caries or Hypo-calcification

Hidden Fissure CariesHidden Fissure CariesThe DIAGNOdent can detect these The DIAGNOdent can detect these

lesions up to 2mm into the toothlesions up to 2mm into the tooth

Low readings may occur if the caries is Low readings may occur if the caries is developing at the bottom of an developing at the bottom of an otherwise sound fissureotherwise sound fissure

Readings in the following tooth Readings in the following tooth increased as the fissure was opened upincreased as the fissure was opened up

Hidden Fissure CariesHidden Fissure Caries

Step down Step down techniquetechnique

No visible No visible demineralizationdemineralization

DIAGNOdent

40

Hidden Fissure CariesHidden Fissure Caries DIAGNOdent

Fissure minimally investigated with

Air-abrasion and re-stained with Caries Detection

Dye48

Hidden Fissure CariesHidden Fissure Caries DIAGNOdent Reading has

increased. The caries

developing in the depths of the fissure

has not been reached.The enamel in the

fissure entrance was non carious.

48


Fissure opened and re-stained

with CDD

Significant lateral spread of dentin

caries was encountered

Stained with Caries Detection Dye. NO CDD stain.

DIAGNOdent 24


Conservatively investigated and rechecked with the DIAGNOdentConservatively investigated and

rechecked with the DIAGNOdent

The DIAGNOdent tip is now 1mm closer to the dentin, and is reading the caries better

DIAGNOdent 38

and itand it

ConclusionConclusion

If the fissure is clean and If the fissure is clean and unstained, and CDD is not unstained, and CDD is not staining carious enamel then….staining carious enamel then….

the DIAGNOdent is probably the DIAGNOdent is probably reading deeper, “hidden” cariesreading deeper, “hidden” caries

ConclusionConclusion

To use the DIAGNOdent in this step-To use the DIAGNOdent in this step-down technique requires the use of a down technique requires the use of a minimally invasive technologyminimally invasive technology

-the best of which is Air-abrasion, -the best of which is Air-abrasion, due to its ability to selectively dissect due to its ability to selectively dissect out damaged tooth structureout damaged tooth structure

Non-probeable stained fissureNon-probeable stained fissure

DIAGNOdent 20

Photo courtesy A BrostekPhoto courtesy A Brostek

NO Caries!NO Caries!

Cautious investigation with Air Abrasion

meant a fissure sealant could be placed without undue “cutting” of the

tooth.

What if a high speed fissure bur had been

used instead?Photo courtesy A BrostekPhoto courtesy A Brostek

The result was a fissure sealantThe result was a fissure sealant

Photo courtesy A BrostekPhoto courtesy A Brostek

Stained Pits and FissuresStained Pits and Fissures

Non-probeable pits and fissures (32yr old)

6

21

WHAT HAPPENED HERE!!!

WHAT HAPPENED HERE!!!

The early enamel caries has remineralized. Hence the

low reading of 6.However, there was a

defect at the bottom of the fissure that allowed dentin caries to progress. It was

more than 2mm inside the tooth and the DIAGNOdent

could not “see” it.

6

21

Stained enamel does not always give positive DIAGNOdent readings

Stained enamel does not always give positive DIAGNOdent readings

The mesial pit had enamel fissure caries and dentin

caries not on X-rays.

From the history of the distal pit, it was only going to be

time before the mesial grew.

The dilemma of stained fissures.

Cautious, minimally invasive techniques like the step-down

technique are required at marginal DIAGNOdent readings

Under 30 because…

..you might be scanning very shallow, intensely demineralized

enamel, or it might be deep caries developing under 2mm of

sound enamel

Laser fluorescence basically responds to the intensity of the

damage to the enamel rather than the depth of damage. There is a basic

correlation to intensity of demineralization and depth, but it is not consistent in the caries process.

Most reliably confirms the

absence of disease

It is NOT a traffic light for when to treat a tooth!

Accurate caries diagnosis requires….


Consistent use of magnification with illuminationAn understanding of the caries process and the variability of fissure anatomy

Elimination of debris

Laser caries diagnosis

CDD to guide caries removal

Quality radiography

....the consistent use of ALL the modern diagnostic

modalities because caries can have varied presentations in

a mouth



Caries initiation factorsCaries initiation factors

2 factors are considered important 2 factors are considered important for plaque accumulation and caries for plaque accumulation and caries initiation on occlusal surfacesinitiation on occlusal surfaces

-The stage of eruption / functional statusThe stage of eruption / functional status

-Tooth specific anatomyTooth specific anatomy

Caries initiation factorsCaries initiation factorsStudies have shown that due to the chemical immaturity of the newly erupted enamel

-almost all molar occlusal caries is initiated in the long eruption period (12-18 months)

-premolars are the opposite, with a short eruption period and consequent low incidence of occlusal caries

Caries initiation factorsCaries initiation factorsPer Axelsson DDS PhD. Diagnosis and Risk Prediction of Dental Caries, Vol 2; Ch 5: Development and diagnosis of

carious lesions: p182. Quint Pub, 2000.

Cavalho et al (1989) showed that most occlusal lesions in molars are initiated

during eruption…

(12-18 months)

Caries initiation factorsCaries initiation factorsKotsanis N, Darling A. Influence of post-eruptive age of enamel on it's susceptibility to artificial caries.Caries Res. 25:241-250 1991.

…in addition, susceptibility to caries is strongly correlated to the post-eruptive age of the

enamel

The enamel is most susceptible to dental caries during and just after eruption, until secondary

maturation is completed, after some years exposure to the oral environment

Slow eruption phaseSlow eruption phaseThis is

when most fissure caries

becomes established

Slow eruption phaseSlow eruption phaseCombine this

with some developmental

fissure morphology

defects

Instant caries

Caries initiation factorsCaries initiation factorsMorphology and slow eruption phaseMorphology and slow eruption phase

Enamel defectsWhat if the defects are in the depths of a fissure?

Deep fissures retain plaque and food

DIAGNOdent

48 36

Caries initiation factorsCaries initiation factorsMorphology and slow eruption phaseMorphology and slow eruption phase

Sealing these teeth without diagnosis would lead to failure of the sealant

DIAGNOdent

48 36

Fissure SealantsFissure Sealants

Most often, sealants have been placed Most often, sealants have been placed without a detailed caries diagnosiswithout a detailed caries diagnosis

Consequently, inadvertent attempts are Consequently, inadvertent attempts are made to resin bond to hypocalcific made to resin bond to hypocalcific enamel or carious enamelenamel or carious enamel

This leads to debonding and staining at This leads to debonding and staining at the margins which the DIAGNOdent the margins which the DIAGNOdent will react towill react to

Fissure SealantsFissure SealantsOpaque sealants cannot be scanned Opaque sealants cannot be scanned

throughthroughTransparent sealants may allow Transparent sealants may allow

leakage and caries to be detectedleakage and caries to be detectedTest the resin response by scanning an Test the resin response by scanning an

obviously sound area of resinobviously sound area of resin If there is no response from the resin, it If there is no response from the resin, it

is safe to “scan” through the resinis safe to “scan” through the resin

12 Yr Old Fissure Sealant12 Yr Old Fissure Sealant

DIAGNOdent 65

Sealant removed, stained with CDD and opened

Sealant removed, stained with CDD and opened

Suspect clear fissure sealant in a 14yr oldSuspect clear fissure sealant in a 14yr old

DIAGNOdent 55

Fissure sealant removed and stained with CDD

Fissure sealant removed and stained with CDD

Was not on the X-rays!Was not on the X-rays!

Sealant placed on undiagnosed caries


Caries Detection Dye can be used to check for leakage. Here it

is penetrating through the porous,

carious enamel underneath the

partially retained sealant



Microleakage indicated by CDD Microleakage indicated by CDD diffusing under the sealantdiffusing under the sealant

5 year old opaque sealant stained with Caries Detection Dye

5 year old opaque sealant stained with Caries Detection Dye

A very seriously failed fissure sealant!!

A very seriously failed fissure sealant!!

ReliabilityReliability The DIAGNOdent is not reliable in The DIAGNOdent is not reliable in

detecting leaking sealants, however, it will detecting leaking sealants, however, it will give you some assistance when assessing give you some assistance when assessing the seal on clear sealants.the seal on clear sealants.

Be careful that you are not reading a high Be careful that you are not reading a high fluorescence resin or organic plug not fluorescence resin or organic plug not removed from the fissures prior to removed from the fissures prior to palcement of the original sealant.palcement of the original sealant.

Diagnose prior to any treatmentDiagnose prior to any treatment All fissures should be scanned with the All fissures should be scanned with the

DIAGNOdent before placing fissure sealantsDIAGNOdent before placing fissure sealants This will alert you to the presence of damaged This will alert you to the presence of damaged

enamel that could prevent successful resin enamel that could prevent successful resin bonding, which can lead to failure of the bonding, which can lead to failure of the sealantsealant

Removal of diagnosed carious or hypocalcific Removal of diagnosed carious or hypocalcific enamel with Air-abrasion will improve the enamel with Air-abrasion will improve the success rate of sealantssuccess rate of sealants

KaVoKaVo DIAGNOdentKaVoKaVo DIAGNOdent

DO YOU DO YOU NEEDNEED A A DIAGNOdent ?DIAGNOdent ?

Micro-Dentistry requires a Micro-Dentistry requires a conscious effort to adopt conscious effort to adopt

diagnostic, re-mineralization, diagnostic, re-mineralization, preparation and restorative preparation and restorative techniques that allow for techniques that allow for

conservation of sound tooth conservation of sound tooth structurestructure

Air-abrasion is the Air-abrasion is the preparation technique of preparation technique of

choice once a decision has choice once a decision has been made to instigate been made to instigate

invasive treatment. It allows invasive treatment. It allows the selective removal of the selective removal of

defective tooth structure. defective tooth structure.

KaVo RONDOflexKaVo RONDOflex

A simple Air-abrasion unit that A simple Air-abrasion unit that connects directly to a multiflex connects directly to a multiflex

couplingcoupling



For more information on Microdentistry techniques For more information on Microdentistry techniques go to the website link below.go to the website link below.

There are further CDRoms available coveringThere are further CDRoms available covering

Patient Microdentistry EducationPatient Microdentistry Education

Micro restorative techniquesMicro restorative techniques

Glass Ionomer-Composite Co-cure techniqueGlass Ionomer-Composite Co-cure technique

Postal: G W Milicich,Postal: G W Milicich,

72 Braid Rd, Hamilton 2001, New Zealand72 Braid Rd, Hamilton 2001, New Zealand

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