NEW TECHNOLOGIES IN CARIES
DIAGNOSIS
The Canary System in
Pediatric Practice
Dr. Ian McConnachie AAPD Annual Session May 24-27, 2012
New Technologies in Caries Diagnosis
• Diagnodent by Kavo • Caries ID by Dentsply • Spectra by Air Techniques • CarieScan by CarieScan Ltd • The Canary System by Quantum Dental
Technologies
A Micro Review of Cariology
Measuring and Recording Decay - The Current Reality
The Shift in Dealing with Decay
Newer Technologies Detecting Decay
The Canary System
Use of the Canary in Pediatric Dentistry – The 9 Month Story
Canary-Ready for Prime Time?
Outline of the presentation
• No Commercial Interest or Reimbursement from Quantum Dental Technologies
• Member of Unpaid Dentist Advisory Panel to Quantum Dental Technologies
Disclosures
Physical Changes and interactions with the Biofilm
A micro review of cariology
Caries Progression
Early Carious Lesion in Enamel
ENAMEL SALIVA PLAQUE PLAQUE
Pathogenesis of Dental Caries (biological balances)
SUGARS
Polysaccharides
Bacterial Enzymes
Salivary buffers
Plaque buffers
Calcium Salts
Calcium Salts
ACID
mouth inside of tooth
Demineralization Re-mineralization
ENAMEL
• Visual Exam
• Mirror and Explorer
• Dental Radiographs
• Transillumination
• Dmfs/dmft
Measuring and recording decay – the current reality
Methods for Caries Detection
Conventional methods
• Visual examination: + non-destructive + safe - poor resolution - unable to detect incipient demineralization - unable to detect subsurface caries
• X-rays: + non-destructive + can detect subsurface caries - limited safety - unable to detect incipient demineralization - low resolution
Public Perception
In other words – NO BIG DEAL
Our Reality
A VERY BIG DEAL
Lower body weight
Psychological impact
TOOTH DECAY is PREVENTABLE
• Don’t treat underlying disease
• Don’t address plaque biofilm issues
• Don’t change risk level
We need to from a surgical approach to a RISK management & preventive
approach.
Caries is a transmissible bacterial infection and a multifactorial disease that reflects
change in one or more significant factors in the total oral environment. (NIH Consensus Conference 2001)
D i a g n o s i s i n v o l v e s r e c o g n i t i o n o f t h e s e c h a n g e s rather than simply no t i ng cav i t i es
• Growing awareness of social determinants
• Newer recording of caries levels-ICDAS
• Risk-based care
• A myriad of new products
• New diagnostic devices
The shift in dealing with decay
Copyright ©2007 American Academy of Pediatrics
Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520
FIGURE 1 Child, family, and community influences on oral health outcomes of children
“ It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be” Isaac Asimov
UNDERLYING DARK
SHADOW +/-
SURFACE INTEGRITY
LOSS
Score 4
Score 5
DISTINCT CAVITY
WITH VISIBLE
DENTINE
EXTENSIVE DISTINCT CAVITY
WITH VISIBLE
DENTINE
Score 6
OPACITY Distinct Visible Change
without air-
drying: WHITE, BROWN
Score 2
Score 0
LOCALISED ENAMEL
BREAKDOWN
SURFACE INTEGRITY
LOSS
Score 3
OPACITY First Visible
Change
only after airdrying: WHITE, BROWN
Score 1
SOUND ICDAS-II detection criteria, 2005
Enamel Caries Dentin Caries
UNDERLYING DARK
SHADOW +/-
SURFACE INTEGRITY
LOSS
Score 4
Score 5
DISTINCT CAVITY
WITH VISIBLE
DENTINE
EXTENSIVE DISTINCT CAVITY
WITH VISIBLE
DENTINE
Score 6
OPACITY Distinct Visible Change
without air-
drying: WHITE, BROWN
Score 2
Score 0
LOCALISED ENAMEL
BREAKDOWN
SURFACE INTEGRITY
LOSS
Score 3
OPACITY First Visible
Change
only after airdrying: WHITE, BROWN
Score 1
SOUND ICDAS-II detection criteria, 2005
ICDAS II (International Caries Detection & Assessment System) scores Enamel Caries Dentin Caries
Product Decisions?
Fluoride CPP-ACP (Recaldent) NovaMin ProArgin Xylitol products Antibacterial rinses Salivary products Neutralizing agents Silver Diamine Fluoride Povidone Iodine CHX varnish (Prevora) Sealants ICON
• RISK Demand? • Age and Ability? • Buffering? • Fluoride Uptake? • Contact time needed? • Desensitization? • Antibacterial Activity? • Salivary Stimulant? • Compliance?
Newer technologies detecting decay
1. isis the ability to control the disease process in order
2. to contain, arrest, or remineralize lesions in order
3. to avoid or delay the burdens and costs associated with a spiral of restoration and re-restoration
4. s the ability to control the disease process in order
5. to contain, arrest, or remineralize lesions in order
6. to avoid or delay the burdens and costs associated with a spiral of restoration and re-restoration
• If the lesion is left to extend until a filling is needed, the clinical opportunity for effective prevention is lost
The Value of early detection:
1. Is the ability to control the disease process in order 2. To contain, arrest or remineralize lesions, in order 3.
The Value of Early Detection
1. Is the ability to control the disease process in order 2. To contain, arrest or remineralize lesions, in order 3. To avoid or delay the burdens or costs associated with a spiral of restoration and re-restoration If a lesion is left to extend until a filling is needed, the clinical opportunity for effective prevention is lost
Page 25
Methods for Caries Detection Fluorescence-based methods
• DIAGNODent (Kavo Danaher): detects fluorescence light emitted by porphyrins present in carious tissue following absorption of laser light + non-invasive - low resolution - risk of false diagnosis (porphyrins are present in stained healthy enamel, and not in the primary bacteria that cause tooth decay) - unable to quantify the level of demineralization •Caries ID (MidWest Dentsply) •Detection similar to DIAGNODent –Looks at fluorescence and reflection +Not repeatable –Low resolution
Methods for Caries Detection Fluorescence-based methods
• Quantitative Light-Induced Fluorescence (QLF):
+ non-invasive + quantifies mineral gain & loss + repeatable measurements - low resolution - expensive - unable to quantify lesion depth - unable to detect interproximal lesions
Spectra QLF based Technology •May be issues with accuracy and sensitivity of the technology •Software may not be as accurate •Camera may not capture pixels as accurately •Need more clinical information including comparison to original QLF
Methods for Caries Detection
Methods of Caries Detection DIFOTI (Digital Fibreoptic
Transillumination) + non-invasive - Low resolution - Tooth decay scatters & absorbs
more light than healthy tissue. + DIFOTI is 2x, more sensitive than bite-
wing radiography for detection of decay * (Caries Research, 1997)
Methods of Caries Detection Caries Scan (Electrical Impedance
Measurement) Tooth decay delays or changes the conduction
of an electric current. - Only detects surface defects +Repeatable +Non-invasive - May be able to monitor and quantify mineral
loss - Can not detect caries at restoration margins - Low resolution
The Characteristics of an Ideal Caries Detection System
Primary - High sensitivity & specificity for caries detection - Detects & monitors de & re-mineralization - Detects smooth surface, root surface, occlusal surface & interproximal lesions - Detects caries around restoration margins - Non-invasive & safe - Repeatable measurements
The key is to understand what the device is measuring.
The Characteristics of an Ideal Caries Detection System
Secondary - Imaging and or image capture - System for recording & storing measurements - Patient Education and Motivation - In-vitro and in-vivo data & publications - Minimal or no preparation of the tooth surface prior to taking a reading - Ability to detect and monitor erosion lesions
The key is to understand what the device is measuring.
Sensitivity and Specificity
Sensitivity • The proportion of true positives correctly identified
by the test Specificity • The proportion of true negatives correctly identified
by the test Because these are proportions, can calculate confidence intervals Closer the C.I. is to 1.0 the better
The Canary System
by Quantum Dental Technologies
Canary interactive software and printed patient reports
The Canary Console
Science Behind The Canary System
•Pulses of laser light hit the tooth surface.
•Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).
•PTR can provide a depth profile by varying the frequency of the laser beam.
Temperature increase < 1oC not harmful
•Detected signals reflect the tooth’s condition.
•Detects 50 micron lesion up to 5 mm below the surface.
What it is - Screenshot
Odontogram
Menu Options
Canary Number
Camera Image
Caries Mapping
Canary Number
Camera Image with
Grid
38
Canary Scale
Canary Patient Report
• Customized patient report on dental practice letterhead
• Clear simple indication of problem areas
• Patient can track their progress
• Engages patient in their oral health care
Internet Connectivity
• The Canary System equipped with wireless connect to
the ‘Canary Cloud’. • Benefits for internet connectivity include:
– Back-up and storage of data – Seamless software updates – Data and risk analysis for report generation – Online access of patient reports via Canary Web Portal – Access to data even when the system is being serviced or
upgraded – Enables dentists to access all patient data among all dental
operatories – HIPPA and PIPEDA Compliant
Value Proposition
Value to the Dentist
• Attract new patients: with state of the art technology and a minimally invasive approach
• More patient visits: more frequent visits for patients enrolled in remineralization programs
• Reduce costs: scans can be performed by lower cost staff (hygienists, assistants)
• Affordable: flexible leasing options provide immediate profitability
Value to Patients & Insurers
• Reduce costly & painful restorations
Healthy Tooth
Early Enamel Decay
Advanced Enamel Decay
Demineralization
The Life Cycle of Tooth Decay
Remineralization
Remineralization Therapies The Canary System Scan X-Ray, Drill Fill & BIll
• Between teeth (interproximal areas)
• Around the edges of fillings
• Enamel and root surfaces
Canary detects small lesions from 50 microns in depth and up to 5 mm below the tooth surface.
• Biting Surfaces (occlusal pits and fissures)
Caries Detection on ALL Surfaces
Sensitivity and Specificity
Sensitivity • Overall measurement in vitro 97% Specificity • Overall measurement In vitro 82%
*Bench study Dr. B Amaechi UTSA
Integrating into Dental Practice
• Scanning done by lower cost staff (dental assistant)
• Applying remineralizing therapies
• Return for repeat monitoring of suspect lesions
• Good practice management tool
Our questions at the start
• How easy to measure
• How reproducible
• How accurate
• Canary Scale 21-70
• Specificity and Sensitivity
The canary in pediatric practice – the 9 month story
The canary in pediatric practice – the 9 month story
Issues at Outset
• How easy to learn
• How reproducible the numbers
• Canary Scale 21-70
• Sensitivity and specificity
Houston, We Had a Problem
Range of Measurements Verified by Treatment
Surface Canary # ICDAS #
Facial
Occlusal
Interproximal
Pit and Fissure Caries
Pit and Fissure Caries
Pit and Fissure Caries
Pit and Fissure Caries
Detecting Caries under a sealant
Detecting Caries under a sealant
Detecting Caries under a sealant
Lab study on extracted teeth comparing Canary and Diagnodent Sensitivity • Canary 0.83 • Diagnodent 0.64 Specificity • Canary 0.79 • Diagnodent 0.46
• ORCA Abstract from QDT 2012
Detection Around ICON
Detection Around ICON
Anomalous Lesion
Anomalous Lesion
The Canary – ready for prime time?
The Characteristics of an Ideal Caries Detection System
Primary - High sensitivity & specificity for caries detection - Detects & monitors de & re-mineralization - Detects smooth surface, root surface, occlusal surface & interproximal lesions - Detects caries around restoration margins - Non-invasive & safe - Repeatable measurements
The key is to understand what the device is measuring.
The Characteristics of an Ideal Caries Detection System
Secondary - Imaging and or image capture - System for recording & storing measurements - Patient Education and Motivation - In-vitro and in-vivo data & publications - Minimal or no preparation of the tooth surface prior to taking a reading - Ability to detect and monitor erosion lesions
The key is to understand what the device is measuring.
MAYBE – BUT DEFINITELY THE BEST YET
Is This the Motherlode In Caries Diagnosis?
Integration into Clinical Practice
Office Integration Recall or Specific Exam •Identify White Spots •ICDAS or Measure •Risk Assessment •Apply Remineralization Therapy •Oral Hygiene Instruction •Provide Home-based Therapy
Reassess 3 Months •Assess lesion •ICDAS or Measure •Apply Remineralization therapy •Dispense Home-based therapy
Reassess 6 Months •Assess Lesion •ICDAS or Measure •Apply Remineralization Therapy •Dispense Home-Based Therapy
Summary
• Healing Dental Caries – the medical model for management of dental caries
• Dental Caries is reversible • Watch & Wait is really supervised neglect • Remineralization Therapy does work but you need
the following elements: – Ability to detect, monitor and record lesions – Office Therapy – Home Therapy – Patient Engagement
• An Additional Group of Services provided by Hygienists or Dental Assistants
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