Caries Diagnosis

Dental caries

Why restore teeth

Four conditions which result in defective tooth

structure?

Unless the dentist understands the processes it

will not be possible to decide whether treatment

is necessary at all

Severity or rapidity of attack

Rampant caries

Infants

Teenagers

Dry mouth

Arrested caries

Changing in oral invironment

Root caries

Secondary or recurrent caries

Residual caries

Dental caries

Carious process in enamel

Earliest clinically visible evidence is white spot lesion

No cavitation, enamel overlying is intact

Shiny, brown??

Histologically is seen to be a cone shaped

Kidney shape between the contact and the gingival

margin

If the lesion progresses, the intact surface break down

(cavitation)

Carious process in dentine

Histologically, in dentine before an enamel

cavity forms

Lesion widen as it approaches the EDJ, guided

by prim direction

Undermined enamel is brittle, in due to fracture

if subjected to occlusal forces

Pits and fissures

Enamel smooth surfaces

Enamel at the cervical

margins

Margins of restorations

Plaque retention and susceptible

sites

Objectives of caries diagnosis

To identify patients with lesions that require restorative treatment.

Those require non restorative treatment. Persons who are at high risk for

developing carious lesions.

Caries diagnosis

Assessment tools:

Patient history.

Clinical examination.

Nutritional analyses.

Salivary analyses.

Radiographic assessment.

Diagnosis of dental caries

The prerequisites for caries diagnosis are:

Good lighting

Clean teeth

A three-in-one syringe

Sharp eyes with vision aided by magnification

Bitewing radiograph

The minimal depth of a detectable lesion on a radiograph is 500 µm.

Radiographs tend to underestimate the histologic extent of a carious lesion.

Many lesions evident radiographically are not cavitated and should be remineralized rather than restored.

Radiographic Assessment

Radiographic Assessment

Technical difficulties with radiograph include: Exposure, Angulation, Tooth position, Presence of restoration, Interpretation bias.

Caries diagnosis

If failure to detect caries in its earliest stage, caries diagnosed by the presence of cavitation visually or tactilely.

Visual evidence of caries include: Cavitation, Surface roughness Discoloration.

Caries diagnosis

Tactile evidence include: Roughness and softness is determined by

probing the suspected areas with a sharp explorer.

Both penetration and resistance to removal of an explorer tip (a catch) have been interpreted as evidence of demineralization.

Patients, lay person.

Clinical examination.

Reflected light.

Periapical or bitewing radiogarphs.

Transillumination with a composite curing light.

Lazer equipments

A single test for caries diagnosis cannot used alone because such test may not be sufficient for accurate caries diagnosis.

Gross carious lesion

Caries diagnosis, Reflected light.

Caries diagnosis, bitewing radiograph

Bitewing Radiograph

Preferable to periapicals for assessment:

Reducing radiation to the patient.

More accurate assessment of bone level.

Coronal area is likely to be less distorted.

Not essential to detect carious lesions in the anterior teeth.

Bitewing radiograph:

Detecting caries, provide other useful information including:

Size and position of the pulp chamber.

Interdental bone levels and quality

Existence of amalgam excess.

Calculus (if substantial).

Cervical fits of inlays and crowns.

Periapical radiograph

Healthy tooth exhibits little fluorescence, resulting in very low scale readings on the display.Cavities, exhibit fluorescence in

proportion to the size of the cavity, ↑ scale readings on the

display + an audio signal allows, dentist to hear changes in the scale values.

Lazer equipments

Caries diagnosis, pits and fissures: The pits and fissures provide excellent

mechanical shelter for organisms and harbor a community dominated by S. sanguis and other streptococci.

Cavitation at the base of a pit or fissure can be detected: Tactilely as softness. By binding of the explorer tip.

Caries diagnosis, pits and fissures

Mechanical binding of an explorer in the pits or fissures may be due to non carious causes, such as: The shape of the fissure. Sharpness of the explorer. Force of application.

Remember, injudicious use of the explorer may actually cause cavitation!

Probing with the dental probe was judged to find only 58% of cavities

Caries diagnosis, pits and fissures:

Nowadays it is not recommended to probe occlusal fissures to diagnose caries for fear of:

Creating a cavity where one did not previously exist.

Destroying enamel matrix which might be capable of remineralisation.

Mechanical binding can be caused by factors other than the presence of caries.

Actual penetration of the enamel by an explorer tip at the base of a pit or fissure suggests extensive demineralization and weakening of the enamel.

Porous enamel appears chalky, or opaque, when dried with compressed air.

Lateral-spreading caries undermines more enamel and seen clinically as a brown-gray discoloration

Caries diagnosis, pits and fissures:

Discolored enamel due to undermining caries is distinguished from superficial staining because it is more diffuse and does not affect the surface of the enamel.

Caries diagnosis, pits and fissures:

Caries diagnosis, smooth surface:

An early lesion is detectable radiographically as a localized decrease in the density of the enamel immediately below the proximal contact, a radiolucent area on the radiograph.

Proximal radiolucencies detectable on bitewing radiographs should be examined clinically,

many proximal radiolucencies are not associated with cavitation of the surface.

It is important to detect smooth-surface lesions on facial or lingual surfaces as soon as possible, always seen in individuals with high caries activity.

Arrested lesions found on proximal surfaces are visible clinically as slightly discolored, hard spots in older persons after extraction of an adjacent tooth has occurred.

Caries diagnosis, smooth surface:

Caries diagnosis, root surfaces:

Caries originating on the root is alarming because: It has a comparatively rapid progression. It is often asymptomatic. It is closer to the pulp. It is more difficult to restore.

Root surfaces exposed to the oral environment, because of gingival recession.

Discoloration is associated with remineralization. The darker the discoloration, the greater the

remineralization. Active, progressing root caries shows little

discoloration and is detected by the presence of softness and cavitation.

Caries diagnosis, root surfaces:

Arrested lesion present on the canine, is hard and shiny.

Part of the lesion is active, soft and covered with plaque. The remainder is arrested. Tooth brushing alone will arrest the active part.

Caries diagnosis, root surfaces:

Caries diagnosis for root surfaces: Is usually shallow, is light brown to yellow. Development is rapid because these areas have

no enamel protection and the dentin is less mineralized.

The lesion may undergo a maturation phenomenon, resulting in a remineralized area,

this area is constantly bathed with salivary ions, making the area more resistant to demineralization.

The remineralization of the root caries lesion is likely because the lesion is initially shallow and therefore easier for ions to penetrate and strengthen, and dentists tend to watch rather than restore these areas.

Presence of fluoride ion decreases root caries potential. The potential for remineralization depends on several factors such as the degree of sclerosis of the dentinal tubules, degree of bacterial infection, degree of lesion progression, and location of the lesion.

Caries diagnosis for root surfaces:

Caries activity test:

Rely on samples of salivary bacteria. The reliability of such tests is limited because bacteria

that are free floating in the saliva may not be necessarily representative of the bacteria in plaque.

Other tests measure the plaque index (amount of plaque present).

Krasse" outlines an assessment methods of caries treatment by the Medical Model program that not only consists of microbiologic testing for the presence of MS and lactobacilli, but also is supplemented with analyses of diet and saliva.

Caries activity test:

Can be a useful by guiding the clinician in making decisions concerning: The need for control measures. The timing of recall appointments. The types of indicated restorative procedures and

materials. The determination of a prognosis.

The test results also can be used to motivate patients and to determine patient compliance with treatment regimens.

Rate of caries progression:

The rate of growth of an untreated interproximal lesion is very variable. It is reported by Berman, (1973) as being surprisingly slow. It can however be quite rapid.

The progression rate of lesions varies between individuals as well as between lesions within an individual.

Recurrent caries:

If unsupported

enamel breaks from

the margin.

Color changes indicative of carious dentine through the translucent enamel.

Suspected when a history of pulpitis is given.

Caries diagnosis

It is necessary to rely on bite wing radiograph wherever:

Posterior teeth are in contact.

Small lesions are to be diagnosed.

Whether such lesions should be treated or simply monitored is a matter of judgment.

Often they can be encouraged to arrest or even re-calcify.