DR HSU ZENN YEW
DIAGNOSIS OF DENTAL CARIES
SELF REFLECTION
What is dental caries? How does caries occur? – pathology and development of caries How does caries progress? What are the aetiology / modifying factors of caries?
Diet, flouride, saliva…
Have you seen a carious lesion before? Have you excavated a carious lesion before?
SELF REFLECTION Don’t know.. Not sure.. Never thought about it.. Err.. Haven’t studied yet..
IT’S TIME TO STUDY!
CARIES DIAGNOSIS
INFORMATION GATHERING
EXAMINATION TECHNIQUES & EQUIPMENT
INFORMATION GATHERING- HISTORY TAKING
Chief complaint: Symptoms
of caries:
Feel
a hole Black/ brown discolouration Pain: to sweet stimulation/ hot or cold • •
Caries even in dentine may not painful per se. Pain from pulpitis usually occurs late in the development of caries lesions
INFORMATION GATHERING- HISTORY TAKING
Medical history:
Medically compromised Handicapped Xerostomia Using medication that reduces salivary flow Sugar – containing medication
INFORMATION GATHERING- HISTORY TAKING
Dental history:
Flouride use Plaque control Dental attendance Knowledge and awareness
Social history:
Dietary habits Socio-economic status RISK ASSESSMENT
EXAMINATION TECHNIQUES & EQUIPMENTS
VISUAL
Good lighting Clean and dry teeth Sharp eyes with vision aided by magnification Oral prophylaxis – plaque removal
VISUAL
Discontinuity
Colour: white spot lesion Yellowish opaque Brown/ black / gray discolouration
Contour Shadow Loss of lustre
UniViSS (2008)
TACTILE - EXPLORER
Contour Surface texture Consistency :soft , leathery “catch”
Transfer cariogenic microorganisms from one surface to another non infected Loesche et al 1979
TACTILE - EXPLORER
The use of sharp explorer is not adequate for diagnostic of occlusal caries: - occlusal caries develop through the lateral progression (Lussi 1991)
High pressure probing can cause irreversible damages in the enamel potentially able to remineralize ( Ekstrand et al 1987)
NEVER JAB A WHITE SPOT LESION WITH A SHARP PROBE!
VISUAL-TACTILE
.
VISUAL-TACTILE
Active or arrested?
THE ICE BERG Lesion into pulp Clinically detectable lesion in dentine
Clinically detectable cavities limited to enamel Considered caries free
Clinically detectable enamel lesions with “intact� surfaces Lesion detectable only with traditional diagnostic aids (bitewings) Subclinical initial lesions in a dynamic state of progression
RADIOGRAPHIC ASSESSMENT
Bitewing radiographs Periapical radiographs Diagnose enamel and dentine caries Dark triangular radiolucency from outer enamel towards dentine
RADIOGRAPHS
Non invasive method Possible to examine inaccesible regions Approximal surface- cervical to contact area, vision obscured by adjacent teeth Caries extension Documentation: use film holder and beam aiming devices for reproducible radiographs Help to evaluate caries activity and efficacy of therapeutic methods Thylstrup & Fejerskov 1995
RADIOGRAPHIC
Insensitive: once lesion is visiblein enamel – caries already involve dentine Not possible to know whether lesion is cavitated Confused with cervical burn-out perfectly normal appearance at the gap between dense enamel over the crown of the tooth and the crest of alveolar Medical contraindication Overlapping tooth/images
TOOTH SEPARATION
Ortho elastic bands Brass wire Wood wedge Elastic rubbler blocks
MECHANICAL DEBRIDEMENT/ FISSUROTOMY
CARIES DETECTOR DYES
Stain organic material and less mineralized structure Limitations: May stain completely sound pits and fissures. Stains plaque, pellicle and other protein. Sites of early demineralisation Does not stain bacteria: difficult to differentiate between infected and affected dentine
ADVANCES IN CARIES DIAGNOSIS TOOLS
LIGHT INTERACTION WITH TOOTH (a)
(b)
(c)
(d)
(e)
reflection, wave rebounds; scattering, the incident wave enters the tooth and changes direction. transmission, the wave is illuminated through the tooth absorption with heat production; absorption with fluorescence.
SCATTERING ďƒ’
ďƒ’
Caries (demineralisation process) -> loss of mineral content -> area of demineralised tooth substance is filled mainly by bacteria and water -> Increased in porosity. Increased scattering of incident light due to this structural change appears to the human eye as a so-called white spot.
Bader et al 2006
DIGITAL FIBEROPTIC TRANSILLUMINATION
Sound tooth structure absorbs very minimum amount of light and allows light to pass through it Affected/ Carious tooth as it absorbs maximum amount of light and thus it appears dark.
ABSORPTION WITH FLUORESCENCE
•
•
Absorption -> energy lost is mostly converted into heat or into another wave which has less energy and hence longer wavelengths e.g. fluorescence Laser/ light is used to illuminate the tooth and the tooth emits yellow light due to auto florescence Induced fluorescence of enamel is lower in areas of reduced mineral content – carious tooth structure • •
Light induced fluorescence Laser induced fluorescence
QUANTITATIVE LIGHT INDUCED FLOURESCESNCE
LASER-INDUCED FLUORESCENCE
DIAGNOdent (KaVo, Biberach, Germany) Red laser light (λ= 655 nm) -> light absorbed into the porous structure and reemitted as invisible fluorescence (fluorescence is believed to originate from protoporphyrin IX and related metabolic products of oral bacteria) -> emitted light is channelled through the hand piece to the detector and digitally displayed on a screen (0–99). A higher number indicates greater fluorescence and a more extensive subsurface lesion.
OTHERS
Karlsson L. Caries Detection Methods Based on Changes in Optical Properties between Healthy and Carious Tissue. International Journal of Dentistry (2010)
ELECTRICAL CONDUCTANCE MEASUREMENT
All the teeth are covered with conducting media and measured the electrical conductance. Affected part was supposed to show high electrical conductivity. Limitation: Differences that come when A.C. Or D.C. current is used.
“Validity” : the outcome as measured by the method is compared with a reference standard, a ‘‘true’’ situation
“Reliability”: the consistency of a set of measurements performed with the method
“ Sensitivity”: probability that the test says a person has the disease when in fact they do have the disease. (true positive)
“ Specificity”: probability that the test says a person does not have the disease when in fact they are disease free (true negative)
False positive: the test reports a positive result for a person who is disease free
False negative: the test reports a negative result for a person who actually has the disease
ASSIGNMENT What do you need to know about caries diagnosis? ďƒ’ List all caries diagnostic tools in the table below. Briefly describe each of the tools, their advantages and limitations. ďƒ’
Diagnostic tools Descriptions
Advantages
Limitations