Recent Advances In Caries Diagnosis

Introduction :
Over a period of time dentistry has undergone a phase of transition Changes have also been observed in the prevalence of caries, distribution patterns and rate of progression. So according to these changes the diagnostic methods have also been changed to more sophisticated and accurate methods Visual and tactile process have been supplemented by other techniques

Diagnosis is essential to intelligent treatment

Diagnostic procedure must be systematic and organized for specific purpose In Greek Dia means thoroughly Gignoska means to know WHAT IS DIAGNOSIS ? it is the art or act of identifying a disease Diagnosis : is a determination and judgment of variation from normal ..As utilization of scientific knowledge for identifying a disease process and to differentiate it from other disease

WHY IS DIAGNOSIS IMPORTANT ? It forms the basis for a treatment decision To advise and inform the patient At a population level it advices health service planners APPROPRIATE LEVELS OF DIAGNOSIS: Carious lesions can be diagnosed at any level of carious process D1- enamel lesion, no cavity D2- enamel lesion, cavity D3- dentin lesion, cavity D4- dentin lesion, cavity to the pulp

Dental caries is a dynamic disease, quite hard to encase by a simple defination It quite like parallels to the task of defining the wind Caries : dry rot (latin) it is fundamentally a microbiological disease which affects the calcified tissues of the teeth, beginning first with localized dissolution of the inorganic structures by acids of bacterial origin leading to disintegration of organic matrix (Earnest Newburn)

 localized post eruptive, pathological process of external origin involving softening of the hard tissue and proceeding to the formation of a cavity (WHO) microbial disease of the calcified tissues of the teeth characterized by demineralization of the inorganic portion and destruction of organic substance of the teeth (shafer) is an infectious microbiological disease of teeth that results in localized dissolution and destruction of calcified tissues (sturdevant)

History :

Etiology of dc worms as the causative agent 1819 - L.S.Parmly caries began on the enamel surface and speculated that a chemical agent was involved. 1867- Leber and Rotenstein reported microorganisms and activity of acid producing bacteria

1871,1879 Clarke 1873 Tomes

bacteria was essential for caries

1878 Magitot 1881 - Underwood and Milles caries was due to bacteria, affecting organic and inorganic elements 1882 - W.D.Miller Acidogenic theory 1899 G.V Black described dental plaque as gelatinous plaque 1911 - Baumgarner acids produced by bacteria were capable of destroying the inorganic portion 1915 Gies and Klinger found high no. of microorg. In persons with caries

1924 Clarke isolated streptococcus mutants from carious lesions 1927 Jay and Voorhees found the presence of L.acidopilus was potent for development of caries 1934 Mellanby a comparable effect on diet was demonstrated 1944,1946 - Gottleib and Diamond Applebaum caries is essentially a proteolytic process 1951 - Manley and Hardwick pointed out that acidogenic and proteolytic theories need not be separate 1952 Finn stated that lower 1st molar was most frequently affected

Classifications :
a. Pit and fissure caries b. Smooth surface caries c. Forward / backward caries

d. Incipient caries e. Rampant caries f. Arrested caries g. Recurrent caries h. Nursing bottle caries i. Senile caries j. Hidden caries

determine the disease Diagnosis

risk assessment
Objectives of diagnosis : To identify lesions do not require restoration restorations high risk patients

Conventional
1. Visual and tactile examination mouth mirror & probe tooth separation 2. Radiographic method IOPA bite wing 3. Xeroradiography 4. Dyes

Advanced Methods
1.Dental digital radiography 2.Subtraction radiography 3.Tuned aperture comp. tomography 4.Digital image enhancement 5.Fiber optic transillumination 6.Digital fiber optic transillumination 7.Quantitative light induced fluorescence

8.Laser fluorescence 9.Electrical conductance measurement 10.Electric current impedance measurement 11.Ultrasonic imaging 12.Endoscope 13.Videoscope

Visual and tactile examination:

Conventional method for detection Visual examination is aided by compressed air Tactile examination mirror and probe Sharp probe blunt periodontal probe

Criteria for visual examination: score criteria

No or slight translucency after prolonged air drying Opacity or discoloration hardly visible on the wet surface, but distinctly visible after air drying Opacity or discoloration distinctly visible with out air drying Localized enamel breakdown in opaque or discolored enamel or grayish discoloration from dentin Cavitation in opaque or discolored enamel exposing the dentin

0
1 2 3 4

Following changes should be carefully observed:

Changes in color and translucency White spot lesion that appears chalky white Break in the enamel surface Grayish white discoloration adjacent to marginal ridge Shadowing on proximal surface Black discoloration (arrested caries)

Interpretation:
Occlusal caries : If discolored area is noncavitated and soft pit and fissure caries discontinuity in which the explorer easily enters a cavity Smooth surface caries : visual enamel opacity under sound marginal ridge noncavitated carious lesion Enamel break down cavitated carious lesion Recurrent caries : A restoration with discolored margin or a small marginal ditch early recurrent caries A large defect advanced recurrent caries

Visual method with elective tooth separation:

RADIOGRAPHY: Radiography has been gold standard to detect the dental caries. Primarily for the detection of lesions on proximal surfaces of teeth that are not clinically visible Occlusal caries may also be detected once it has progressed into dentin.

PRINCIPLE: Radiographic diagnosis of caries the mineral content of enamel and dentin decreases, decrease in the attenuation of X-ray beam as it passes through the teeth area appears radiolucent on the radiograph

Radiographic index by Grondahl et al and modified by Moller & Polusen-based on depth of lesion. 0 No Radiographic changes in Enamel 1 Radiographic change in Enamel 2 Radiolucency extending to DEJ 3 Radiolucency penetrating halfway to dentin 4 Radiolucency close to pulp

Radiographic scores used to classify the depth of approximal carious lesions: R0 no radiolucency R1- radiolucency confined to the outer half of the enamel R2 radiolucency in the inner half of the enamel including lesions extending up to but not beyond the DEJ R3 radiolucency with obvious spread in the outer half of the dentin R4 radiolucency with obvious spread in the inner half of the dentin (> half way through the pulp)

Conventional radiography: Many techniques available, two types of techniques are popular and commonly practiced IOPA Bitewing Bite wing radiography: Used to detect proximal caries Important to detect incipient lesions at contact points. Cervical margins of restoration Alveolar crest height Lamina dura Size of pulp chambers

Conditions resembling caries: A number of radiolucencies that involve crown and roots are seen in X-ray may be confused with caries. Restorative Materials Abrasion Attrition Cervical burn out so findings should be correlated

Interproximal caries viewed on radiograph can be classified, according to the depth of penetration as:
1. Incipient Interproximal Caries: Lesion extends less than halfway through the thickness of enamel. Seen in enamel only. 2. Moderate Interproximal Caries: Extends greater than halfway through the thickness of enamel, but does not involve DEJ. Seen in enamel only. 3. Severe Interproximal Caries: Lesion extends through Enamel, dentin and greater than half the distance towards pulp. Clinically appears as cavitation in the tooth

Occlusal caries:
1. Incipent Occlusal Caries:

Cannot be seen in radiograph and must be detected clinically. 2. Moderate Occlusal Caries: Extends into dentin and is seen as very thin radiolucent line. 3. Severe Occlusal Caries: Extends into dentin and seen as large radiolucency. It is apparent clinically and appears as cavitation Advantages.. limitations

Xeroradiography : This technique simulates the photocopying machine. It is a technique in which aluminum plate is coated with Selenium particles Uniform electrostatic charge and stored in conditioner. When X-rays are passed on to the film, it causes selective discharge of particles. This forms the latent images and is converted to a positive image

Advantage :
Edge enhancement is possible. (diff. areas of diff densities

Disadvantage :
Electric charge over film cause discomfort to patient since it is in humid environment (Oral Cavity) which acts as medium for flow of current. Process of development has to be completed with in 15 minutes.

DYES:
Dye are used to visualize a substance from its routine background or if several objects have similar appearance colouring by dye is to discriminate between them for identification. The observation of dye may be:

Qualitative to observe the colour or differentiate coloured objects from non- coloured ones. Quantitative - Intensity of colour is to be determined In caries diagnosis qualitative examination ie visual appearance of dye is sufficient.

Reqirements of dyes. Dyes for detection of caries in enamel Procion Calcein Fluorescent dye studied invitro but invivo Brilliant blue enhance diagnostic quality of during transillumination Dyes for detection of caries in dentin: 2 layers of carious dentin outer carious dentin inner carious dentin (Infected, unremineralizable) (uninfected remineral.)

Caries detector: Composition: 0.5% Basic Fuchsin + Propylene Glycol. technique using basic fuchsin which aids in differentiating 2 layers of carious dentin was introduced. Dye was considered as carcinogenic Replaced by Acid Red 52 ( Acid Rhodamine B) which functions almost same as fuchsin when dissolved in 1% solution of propylene glycol. Disadvantage: Level of infection in stained and unstained dentin at the DEJ were measured not all dye stainable dentin was infected

Microbiological analysis of dye stained and nonstained sites- recovery of few levels of infection. Lack of specificity of caries detector dyes was confirmed by- Yip et al in 1994 A study concluded that when freshly extracted caries free teeth took up the stain bcoz of high portions of organic matrix surrounds circumpulpal dentin It was established that dyes do not stain bacteria only but instead stain the organic matrix of less demineralized dentin

Based on the various physical principles used:

Utilizing computers: digital imaging
direct indirect (PSP) CCD CMOS-APS Receptors charged coupled device complementary metal oxide semiconductor active pixel sensor photostimulatable phosphor plate system X-rays digital image enhancement digital subtraction radiography tuned aperture computed tomography Visible light optical caries monitor quantitative fiber optic transillumination quantitative light induced fluorescence

Laser light laser fluorescence measurement (diagnodent) Electrical current electrical conductance measurement electrical impedance measurement Ultrasound ultrasonic caries detector

Direct digital imaging:

A digital image is an image formed and represented by spatially distributed set of discrete sensor and pixels.
Components x-ray source electronic sensor digital interface card computer with an analog to digital converter screen monitor, software, printer

2 sensors.

The CCD is a solid-state detector composed of an array of X-ray or light sensitive pixels on a pure silicon chip. Charge-coupling is a process whereby the number of electrons deposited in each pixel are transferred from one well to the next in a sequential manner to a read-out amplifier for image display on the monitor Sensors are rigid and thicker than radiographic film Smaller sensitive area for image capture.

Complementary metal oxide semiconductor active pixel sensor (CMOS-APS): Latest development in direct digital sensor technology. CMOS sensors appear identical to CCD detectors but they use an active pixel technology The APS technology reduces system power required to process the image. APS system eliminates need for charge transfer improve the reliability lifespan of the sensor. CMOS sensors have several advantages : Design integration, Low power requirements, Manufacturability, Low cost.

ADVANTAGES AND DISADVANTAGES: Advantages: Exposure reduction, Elimination of processing chemicals, Instant or real time image production and display, Image enhancement, Patient education utility, and Convenient storage. Disadvantages: Rigidity and thickness of the sensor, Decreased resolution, Higher initial system cost, Unknown sensor lifespan Charge transfer. Diff to sterilize .

Diagnostic Utility of Digital Imaging A number of studies have investigated the efficacy of digital imaging vs. film-based imaging in a variety of diagnostic tasks: caries, periodontal disease, and periapical lesion detection. 1998, Wenzel - evidence on the diagnostic efficacy of digital imaging systems for caries detection digital imaging systems appear to be as accurate as film for caries diagnosis in general. 1998, Tyndall et al.- investigated the accuracy of proximal caries detection comparing CCD-based digital images with Ektaspeed Plus films. Paurazas et al and Wallace et al conducted studies in detection of periapical lesions

Indirect digital imaging: Image is captured in an analog

or continuous format and then converted into a digital format Consequently, many edges are lost or distorted in an analog to digital conversion. As imaging systems became more sophisticated, other techniques for capturing the digital image from an analog original were developed.

Intraoral videocameras (IOVC): The image is grabbed as a frame of a video image. One of the shortcomings of this technique is that a gray scale image is captured in a color image format. Many of these images appear blue

Photostimulable phosphor plate: (PSP)

Was 1st introduced by Fuji corp. in 1981(tokyo,japan) Image is captured on a phosphor plate as analog information and is converted into a digital format when the plate is processed. Contents: polyester base coated with a crystalline halide emulsion that converts X-radiation into stored energy. The crystalline emulsion is made up of a europium-activated barium fluorohalide compound

Advantage: Image receptor is cordless Image receptor is same size as that of conventional film flexibility

Image Enhancement: Density and contrast can both be altered. Ability to alter density salvage an image that is either too dark or too light. Density can be manipulated by simply adding (or subtracting) the same value to each pixel. Image contrast altering the gradient of the gray levels in the image. Pseudocolor enhancement is attractive,( the diagnostic utility of this feature has not been demonst.) If a digital system could identify carious lesions as red, this enhancement would be of great value. Several software packages are in the development.

Digital subtraction radiography :

A technique that allows us to determine quantitative changes in radiographs.

A radiographic image is generated before a particular treatment is performed. At some time after the treatment, another image is generated.

The two images are digitized and compared on a pixel-by-pixel basis.

The resultant image shows only the changes that have occurred and subtracts those components of the image that are unchanged.

Tuned aperture computed tomography: (TACT)

This method constructs radiographic slices, crosssection through teeth Slices can be viewed for radiolucencies Slices can be brought together in a 3 dimensional computer model called pseudohologram TACT slices and pseudohologram small primary and secondary carious lesions Occlusal and approximal caries not significantly better than film radiography and digital radiography

Diagnostic methods based on visible light: Principle :

In a sound tooth scattering absorption In dentin both scattering and absorption occur along the light path Whitish appearance of teeth absorption is lower than scattering In white spot lesion scattering is stronger than in sound enamel Penetrating photons change direction in carious enamel and are back scattered before reaching the dentin. So the lesion observed in reflection appears whiter than surrounding parts.

Optical caries monitor:

Consist of light source Measuring and reference units Detection part Light through a fiber bundle tip of the hand piece tooth reflected light is collected Scattering coefficient values are determined. Used for quantification of caries lesions on smooth surfaces

Fiber optic transillumination: (FOTI)

Initially designed for the detection of proximal caries (Friedman and Marcus in 1970).

Contents:
By optic consists of a halogen lamp, rheostat- to produce light of variable intensity. The 150watt lamp generates a maximum light intensity of 4000 1X at the end of 2mm diameter cable.

Two attachment are used: A plane mouth mirror mounted on a steel cuff. Fiber optic probe. Fiber optic probe is 0.5 to 2 mm diameter ( so as to place in embrasure region) Principle: Demineralized areas appear as darkened shadows Light is absorbed more and lower index of light transmission due to disruption of crystalline structure of enamel and dentin

Advantage: No harzards of radiations Simple and comfortable for patients Lesions which cannot be diagnosed radiographically can be diagnosed by this method. Not a time consuming procedure Disadvantage: Limited only for detecting caries in enamel. (Radiance change caused by carious lesion is mainly determined by enamel part of lesion. This precludes the methods from detecting the extent of lesion into dentin or detecting some carious lesion where enamel destruction is minimal but dentin invasion is extensive.) Difficult to locate the probe in certain areas. Permanent records are difficult to maintain.

Digital fiber optic transillumination (DFOTI)

New methodology, developed to reduce the short comings of FOTI by combining FOTI and digital camera. Procedure: Illumination is delivered on tooth surface by fibreoptics which acts as light source. The resultant changes in light distribution are captured by camera and sent to computer for analysis. Advantage: Use of digital camera allows instantaneous image. Used to compare clinical between several images of the same tooth over time.

DFOTI

RADIOGRAPH

Quantitative light induced fluorescence: Principle:

Demineralization of dental hard tissues, enamel and dentin loss of its autofluorescence Fluorescence radiance of caries lesion is lower than sound enamel. Fluorescence in enamel organic components, proteinic chromophores and apetite Dentin inorganic and organic components Demineralized areas appear as darkened areas Several effects may contribute to this effect.

Method :
Enhances early detection of carious lesions Uses intrinsic fluorescence of the teeth with in the yellow green spectrum of visible light Tooth is illuminated with blue green light emitted from the hand piece tooth gets fluoresceimage is captured with a microvideo charged coupled device camera Tooth is seen on the computer as fluorescent green; dark areas indicate mineral loss

DIAGNOdent :
Was introduced in 1998 Commercial development of laser fluorescence Chairside battery powered quantitative diode laser fluorescence device

Light of wave length 655nm(red laser light) Tip is paced against the tooth structure and laser light will penetrate. Fluorescent light is measured and its intensity is an indication of size and depth of the lesion Ranging from 0 to 99 Interpretation : 5 25 initial lesion in enamel 25 35 initial lesion in dentin >35 advanced lesion

Electrical conductance measurment (ECM):

This idea was given by Magitot in 1987.

Principle:
Sound tooth enamel is good electrical insulator due to high inorganic content. In caries demineralization results in increased porosity. H2O and ions from saliva fills these pores and forms conductive pathways for electric current. The electric conductivity is directly proportional to the amount demineralization occurred.

Method:
site specific
This technique has 2 modes surface specific Increase in conductivity is due to development of demineralized areas with in the enamel which are filled with saliva Examples : vanguard electronic caries detector electronic caries meter

Electrical impedance measurements:

Impedance is the measure of the degree to which an electric circuit resist electric current flow when a voltage is impressed across two electrodes Expressed in ohms. Every material has a different elec.impedance determined by its composition. Carious tissues have much lower electric impedance

Diagnostics based on ultrasound measurements: Principle:

Sound wave with frq. 1.6 to 10 MHz To find carious lesions on smooth surfaces and very useful in detecting recurrent caries Demineralization ultrasound pulse echo techq. Initial white spot lesions no or weak echo Cavitated lesions echo with high amplituted

Endoscope : Tooth is illuminated in blue light of wavelength ranging 400- 500nm. Difference is seen in the fluorescence. When tooth is viewed through a specific broadband gelatine filter, white spot appears darker than enamel. A white light source can be connected White Light Endoscopy Advantage : Allows visualization of small carious lesions in enamel which are difficult to detect through eye or X- ray.

Videoscope:
A camera integrated to Endoscope is called as Videoscope. A miniature colour video camera is mounted to metal mirror holder. It is designed in such a way that image of the surface of enamel can be viewed directly over T.V.Screen. Advantage : Provides a magnified image. Disadvantage : Requires meticulous drying and isolation of teeth. Time consuming costly.

SOME OF THE TECHNIQUES WHICH NEED FURTHER INVESTIGATIONS

Multi photon imaging: 2 infrared photons r absorbed simultaneously Ultra short pulse (100fs) of 850nm laser light r generated at 200MHz Scanning the focused beam from the focal plane fluorescence can be recorded Sound tooth structure fluoresces strongly but carious tooth to lesser extent Caries dark form within a brightly fluorescing tooth Currently used only on extracted tooth, yet to be introduced

Infrared thermography: Described by Kaneko et al in 1999 Thermal radiation travels as a wave Changes can be measured in thermal energy fluid is lost from a lesion The thermal energy emitted by sound tooth structure and carious tooth can be compared Uses indium/antimony thermal sensors detect temperature range of 0.025c With constant flow of air change in temp of the lesion is compared with sound tooth Has been used in vitro but needs to be studied more..

Infrared fluorescence: Wave length between 700 and 15000 nm Barrier filters r used to observed any resulting fluorescence Studies have suggested technique is able to discriminate between sound and carious tooth This technique is seldom used. Needs further investigations

Optical coherence tomography : (OCT) Uses light, for dental imaging wave length of 840 to 1310nm Imaging depth 0.6 to 2mm OCT is based on interference of light The intensity of interference is a function of the scattering caused by changes in the tooth structure Clinical relevance would be development of a prototype hand piece for intra oral OCT This could have implications for non invasive diagnosis of secondary caries.

Conclusion:
Advanced methods for caries diagnosis can be used as adjuncts to the conventional visual and tactile examination. Most of the advanced methods are not easily available, are time consuming and needs lot of skill to practice. A combination of these newer techniques with the conventional methods would help us to give more reliable and accurate results

THANK YOU