Caries diagnosis

Etiology of dental caries four factors are necessary to produce dental caries Dental plaque A suitable carbohydrate (mainly sugar) Tooth surface Time

How does it happen ?? Plaque bacteria fermentation Produce acid (sugars, sucrose & glucose( of carbohydrates Produce acid plaque pH within 1-3 minutes & Plaque remains acidic for some time taking (30-60 min) to neutralize

in demineralization of susceptible tooth surface Repeated falls in pH (in time) may result in demineralization of susceptible tooth surface Initiation of carious process

Things to be considered Dental caries should be diagnosed and managed as a dynamic disease of enamel and dentin with alternating demineralization and remineralization

large microporous areas develop less than 5.5 pH of oral fluids loss of Ca & ph from E crystals on the surface and sub- surface layers large microporous areas develop "white spots"

caries spreads more rapidly in dentin than in enamel

Continue loss of tooth structure cavitation

In the past “Drill and fill” approach Symptomatic & failed to deal with etiological factors

# Subsurface demineralization precedes cavitation of tooth surface

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

What is the difference between lesion detection and diagnosis ?? Detecting mineral loss resulting from carious process is only the first step Information is important arrested active Diagnosis adds the dimension of lesion activity to detection Is the lesion or

objectives of caries diagnosis Identify lesions that require surgical treatment (restorative treatment). Lesions that require nonsurgical treatment. Those persons who are at high risk for developing carious lesions.

Is the patient at high risk for caries ?? Early diagnosis Diagnosis should not only be to search for cavitation but to predict caries progression Is the patient at high risk for caries ??

Knowing which patients are at high risk for developing caries Early diagnosis Knowing which patients are at high risk for developing caries Implementation of specific preventive strategies that may prevent caries

But If patient at low risk for caries Early diagnosis But If patient at low risk for caries Preventive measures may be limited to oral hygiene

How to diagnose a carious lesions ?? (Assessment tools) Patient history Clinical examination Nutritional analysis Salivary analysis Radiographic assessment

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

can assist in diagnosis of caries identification of high-risk & identification of high-risk patients

e.g. risk for caries development smoking, alcohol consumption, use of medication , & sucrose intake risk for caries development

caries risk Children and elderly adults Lower economic status Lower education fluoride exposure Poor general health

A past history of caries experience is the best predictor of future caries activity

Clinical examination (visual & tactile) Salivary functioning (adequate or inadequate) Plaque accumulation Inflammation of soft tissue Poor oral hygiene Cavitated lesions Existing restorations Risk to caries development

The more factors present The greater the risk

Assessing individual tooth surfaces for cavitation important Assessing individual tooth surfaces for cavitation Noncavitated lesions (preventive treatment indicated)

If cavitation occurred (restorative treatment indicated)

How to assess ? Visual assessment of discoloration. translucency or opacity Proper cleaning & drying of teeth together with adequate illumination

Tactile assessment Determining the roughness or softness of the tooth surface

Probing of the suspected lesion Penetration and resistance to removal of explorer tip (a “catch”) evidence of demineralization ??

But It may not be necessarly decay It could be the local anatomic features of the tooth Sharpness of the explorer Force of application

There is no need to apply too much pressure on an explorer

noncavitated incipient lesions could cause cavitation The use of sharp dental explorer noncavitated incipient lesions could cause cavitation

also entrance of bacteria lesion susceptibility

Nutritional analysis Frequent exposure to sucrose e.g. candy (cariogenic MS organisms) plaque development caries activity

But not all patients with high sugar intake will develop caries. However, its unusual to find a patient with multiple carious lesions who does not have a high sugar intake.

Salivary analysis Helps to identify high patients Secretion rate Buffering capacity Number of both mutans streptococci (MS) and lactobacilli Helps to identify high patients

Salivary rate (salivary flow): High level of salivary flow cariostatic effect Xerostomia or dry mouth favorable environment for caries development Buffering and remineralization Antidepressants, tranquilizers & diuretics Radiation therapy

With reduced salivary flow Less “washing” action allowing acid & plaque to accumulate

Saliva is a buffer solution Buffering capacity: Saliva is a buffer solution Helps to neutralize acid produced by bacteria saliva contains calcium and phosphorous remineralization

Mutans streptococci & lactobacilli: High S.mutans count high risk Low S.mutans count low risk

How? Thick plaque on tooth surface enhance carious process By shielding the bacteria from the buffering effects of saliva at tooth-plaque interface By preventing remineralization

At chairside several Kits are available (e.g. Patient Check-up Kit from GC) that can be used to test for: Salivary flow rate Buffering capacity & Mutans streptococci & lactobacilli

Salivary flow Patient chews paraffin wax to stimulate saliva, then pt spits into a measuring Cylinder (mL /min)

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

To estimate the number of S.mutans & lactobacilli can be estimated in reference to the manufacturer’s chart S.mutans lactobacilli

radiographic assessment Radiographs shows carious lesions that are not visible clinically but they tend to under estimate the histologic extent of the carious lesion

Conventional radiography What kind of x-ray ? Bite-wing radiographs Detection of occlusal caries in dentin although enamel caries cannot be seen “hidden” caries Diagnosis of proximal caries in both E & D

“white chalky” appearance Proximal lesions develops slowly it may take more than a year before it becomes evident on radiograph “white chalky” appearance

Radiographically A small radiolucent notch is evident below the contact area in enamel

Advanced proximal caries Very advanced

Noncavitated And should be remineralized and not restored Approximately 60 % of teeth with radiographic proximal lesions in the outer half of dentin are likely to be Noncavitated And should be remineralized and not restored

“hidden” or “occult’’ caries Caries in dentin with sound enamel “hidden” or “occult’’ caries

Why ?? bite-wing radiographs cannot be used solely for complete caries diagnosis without additional clinical examination and history Why ?? Overlaps & false-positive diagnosis Positioning mistakes of the cone Curvature of the dental arch

patient is at high risk to caries Prior caries activity Frequent sucrose intake Minimal exposure to fluoride Young or old age Decrease in salivary functioning High number of cariogenic bacteria Presence of existing carious lesion patient is at high risk to caries

Is the patient still at risk of caries?? The answer is yes If a patient presents with many cavitated lesions & were skillfully restored Is the patient still at risk of caries?? The answer is yes Biological environment that caused caries was not changed

A change in diet or oral hygiene habits in combination with optimal fluoridation may stop the progression of a lesion and possibly allow its remineralization.

“Risk” is the probability that some harmful event will occur “Caries risk” Is probability that an individual will develop carious lesion during a specified period

Cariogram It’s a computer program that serves as a new risk assessment model It assesses and graphically illusrates the caries risk for a patient It is expressed as the “chance to avoid new caries” in the coming year It can demonstrate how and to what extent the various caries-causing factors may affect this “chance”

The original purpose of the program was educational but it helps the dentist in making correct decisions.

The aims of the cariogram are to: Illustrate the chance to avoid caries Illustrate the interaction of caries-related factors Express caries risk graphically Recommend preventive action Motivate patient in clinical setting Provide an educational program

How does it works?? 1- Patient examined & data collected Factors of direct relevance to caries (Bacteria, diet ) Indirect factors (susceptibility-related factors)

0-3 or (0-2 for some factors) & entered into computer program 2- factors are given a score from 0-3 or (0-2 for some factors) & entered into computer program Score “0” is the most favorable values & maximum score “3” (or “2”) indicates high ,unfavorable risk value

The pie-circle diagram is divided into 5 sectors Red “bacteria” Dark blue “diet” Light blue “susceptibility” Yellow “circumstances” The four sectors are mapped out and what is left is the Green “chance to avoid caries”

“Chance to avoid caries” & caries risk are inversely related High risk low chance small green sector

Low risk high chance large green sector

both clinical skill and experience Risk assessment needs both clinical skill and experience

Patient should realize that caries risk status can change and that the dentist can detect this change

Advanced diagnostic tools 1-Intraoral camera 2-Digital radiograph 3-Laser based devise 4-Fibroptic trans-illumination 5-Electric caries monitor 6-dye penetration

1-Intra oral camera -Camera placed inside oral cavity to display Intra oral images on a computer -Has improved visual access to dental cavity -Improved lightening -Improved magnification -Demonstrate the pt needs for treatment

2-Digital radiography -Image recorded with non film receptor -The film replaced by flat electronic pad or sensor -Images sent to computer displayed on monitor screen

Advantages 1-Lower exposure of radiation for the pt 2-Absence of dark room 3-Convenience of image enhancement, magnification and color coding 4-Diagnosis of initial caries lesion adequately

Disadvantages 1-Under estimate the size of the lesion 2-High false positive results in occlusal caries detection

Radiographic classification for proximal caries 0-Sound surface 1-lesion in outer half of enamel 2-lesion in inner half of enamel 3-lesion in outer half of dentin 4-lesion in inner half of dentin

Value of classification To dictate the line of treatment Score 1,2 and possibly 3 treated with mineralization Other scores treated by cavity and restoration

Laser-based device [DIAGNODENT] -Laser light passed via optical fiber to the area of decay -the decayed area fluorescence -The fluorescence passes back to the probe -The decay displayed and indicated both visually and audibly

Advantages 1-No sharp probe of the teeth 2-lesse exposure to radiation 3-Great for children and anxious patient 4-Catching decay in early stages so minimal Treatment is necessary 5-Visual and acoustic measurement 6-Results are documented

3-Fibroptic transillumination[FOTI] -Works under principle that caries has lower Index of light transmission -area of caries appears as darkened shadow -Initially designed for detection of proximal caries

Consists of: -halogen lamp -Rheostat to produce light of variable intensity -And two attachments -Mouth mirror -Fibroptic probe 0.5mm diameter

Produce narrow beam of light for transillumination Displayed in computer screen for diagnosis

Advantages 1-No hazards of radiation 2-Simple and comfortable 3-Lesion can not diagnose by radiation diagnosed by this method 4-Not time consuming

Disadvantages 1-Permanent records are difficult to maintain 2-Subjected to observer variation 3-Difficult to place probe in certain areas

4-Electrical caries monitor [ECM] -Based on difference of electrical conductivity Between sound and carious dental tissues -Works effectively for detection of occlusal caries -Resistance should be recorded in absence of saliva

-High measurements indicates well mineralization -Low measurements indicates demineralized tissues -Has potential to monitor lesion progression

Dye penetration 7-Dye Penetration Method coloring by a dye may differentiate between several objects which have a similar appearance

qualitative or quantitative observation of the coloring can be: qualitative or quantitative Presence or absence Intensity of color

In caries diagnosis qualitative examination is sufficient observation of colored dye signifies presence of caries

Dyes should fulfill the following criteria : 1) Dyes should be absolutely safe for intra oral use 3) Dyes should be easily removed and not lead to permanent staining

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

0.5% Basic Fuchsin in propylene glycol

Denatured collagen is stained while the inner zone remains unstained

Basic Fuchsin dye was considered to be carcinogenic replaced by Acid Red and Methylene Blue Methylene blue is also slightly toxic so Acid red is preferred

Management of caries By two measures:- a-Preventive:-To prevent occurans of caries B-control & treatment:-To stop progress of active lesion and restore it

Caries prevention 1-By the patient a-Low intake of carbohydrates B-Removal of plaque by brushing & flossing C-Use fluoridated tooth past d-Maintenance of good health e-Stimulation of circulation of gengival tissues

2-By the dentist:- a-Periodic cleaning of teeth B-application of fluoride C-Fissure sealant in pits & fissures D-Educating & motivating the patient E-repairing early lesions

Treatment of early caries a-fluoride exposure:- Action of fluoride -Precipitated into tooth structure -remineralization -Inhibit enzyme production -Decrease surface energy of enamel leads to decrease retention of micro organisms

B-Anti microbial agent:-(chemoprophylaxis) - fluoride -chlorhexidine:-is antiseptic ,bactericidal, fungicidal -Triclosan:- is broad spectrum anti microbial agent - antibiotics

Removal of the plaque by:- C-Oral hygiene:- Removal of the plaque by:- -Dental flossing -dental brushing -rinsing

D-Xylitol gums -Reduces streptoccocus mutans by Altering their metabolic pathways -Enhance demineralization -Arrest dental caries Used as chewing gum for 5-30 minutes

E-shewing sugar free gum -Reduces acidogenicity of plaque by stimulation of salivary flow -Buffering of the ph

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

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

Early detection of Digital radiography Quantitative light-induced fluorescence Electrical conductivity Ultrasonography