1. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands QLF™ Technologies a new approach to caries diagnosis Inspektor Dental Care click or press pagedown to continue

2. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Overview History Principles of operation The Products Results Validation Status quo Conclusion

3. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands History 1978 Effect of lesions on fluorescence first noted by Folke Sundstrom (Karolinska Institutet, Stockholm, Sweden) 1987 Inspektor Research Systems bv founded in the Red- light district of Amsterdam (2 emp.) 1989 Folke Sundstrom asks Inspektor for help 1994 Theory explaining fluorescence effects developed by E. de Josselin de Jong 1996 Correlation between fluorescence and mineral loss established 1997 First clinical trial with QLF prototype 1999 Introduction of QLF/CLIN 2000 First recording of Red fluorescence 2002 Inspektor (10 emp) to enter dental market

4. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Why a new diagnostic method? To create an evidence based pre-invasive dentistry –To identify early lesions long before they develop to frank caries –To track the development of incipient lesions –To evaluate pre-invasive treatment

5. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Pre-invasive lesion detection

6. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands QLF contrast enhancement white light QLF

7. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Early lesion detection with green fluorescence ED Contrast enhancement follows from scattering properties of tooth tissue

8. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Results

9. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands no treatment Standard toothpaste initial demin New toothpaste

10. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Research: QLF/CLIN QLF/InVitro

11. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Dentistry: QLF-SCAN, QLF-PRO

12. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Acquisition software

13. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Caries mapping

14. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Longitudinal monitoring

15. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Red Fluorescence: how ED

16. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Examples of bacterial activity

17. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Danger zones: bacterial activity Defective sealant.Sealant applied over unprepared carious tooth Red fluorescence indicating caries at the edges of a restoration. The restoration was replaced, yet secondary caries remains. sealantsrestorationshidden caries Discolored fissure in a molar identified as ‘sensitive’. Note the res hue around the fissure When the fissure was opened, a dentinal lesion was found.

18. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Before brushing Area = 30.6 mm 2 ΔR = 51.8 % Red Fluorescence: quantification R Cutoff = 20% clean After Brushing Area = 9.6 mm 2 ΔR = 30.5 % White spot lesion

19. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Area = 2.2 mm 2 ΔR = 32.4 % Area = 3.2 mm 2 ΔR = 47.5 % Area = 0.7 mm 2 ΔR = 25.3 % Red Fluorescence: caries excavation R Cutoff = 20% P. Sas 2003

20. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Red Fluorescence: sealants No RF Sound sealant Leaking sealant R. Heinrich et al. 2001

21. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Clinical validation 1994 Øgaard and ten Bosch: demonstration of lesion tracking by measuring scattering properties 1995 de Josselin de Jong ea: Improvement of QLF system 1997 Al-Khateeb ea: detection of remin with QLF in weekly intervals consistent with microradiography 1998 Al-Khateeb ea: QLF can be used to evaluate pre- invasive treatment 1998 Connersville study (IU): –QLF appropriate for use on occlusal as well as buccal-lingual surfaces –QLF is practical for large-scale clinical studies –QLF detects 4-9 times as many lesions vs. visual inspection –QLF validity for caries detection supported (ten Cate ea, 1999)

22. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Clinical validation 2001 Tranaeus ea: QLF is a sensitive method for longitudinal monitoring of incipient lesions on smooth surfaces Heinrich ea (to be published): QLF was able to separate groups of high-caries patients (33) that were given prophylaxis with or without the application of fluoride varnish, every 8 weeks for 6 months.

23. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Clinical validation in progress At IUPUI (Dr. George Stookey): –2-Year study to validate QLF for the detection of primary caries –2-Year study to validate QLF for the detection of secondary caries –18-Month study of QLF to monitor caries in orthodontic patients –18-Month study of ability of QLF to detect differences in caries rates in patients provided toothpastes with different concentrations of fluoride At Inspektor: –Correlation between red fluorescence and specific bacterial strains. –Clinical study on bracket related incipient caries

24. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Scientific backing USAProf. George Stookey, IUPUI, IN JapanProf. M. Kambara, Osaka Un. DProf. E. Hellwig, Un. Freiburg SProf. Angmar, Karolinska I. NLProf. J.J. ten Bosch, RUG UKDr. S. Higham, Liverpool

25. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Patents Dehydration (active lesion detection) VidRep (automatic image capturing) ToothCare (home-care device) Red Fluorescence (bacterial activity) 10 patents in preparation All patents filed in USA (Dehydration also in NL) international extension in progress

26. Inspektor Dental Care Inspek © 2003 Inspektor Dental Care bv, Amsterdam, Netherlands Concluding remarks We now live in high-technology world that influences all aspects of our lives. Dentistry is no exception and these new technologies for the early detection of dental caries will have a revolutionary impact on dental research and the practice of dentistry. Every dental practice will have these technologies and professional treatments for caries prevention and control will be the main activities with restorative dentistry being only the means of last resort for dental health. George K. Stookey, PhD, FICD, FACD, Indiana University School of Dentistry, Indianapolis, Indiana U.S.A.