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Review Article Dental Caries Diagnostic Methods Zangooei booshehry, M. * Fasihinia, H. ** Khalesi, M. *** Gholami, L. **** *Assistant Professor of Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences , Yazd, Iran. *General Physicion **Student of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran ***Post-graduate student of Prosthodontics, Faculty of Dentistry, Hamadan University of Medical Sciences. **** Post-graduate student of Periodontics, Faculty of Dentistry, Hamadan University of Medical Sciences. ABSTRACT Dental caries, a progressive bacterial damage to teeth, is one of the most common diseases that affects 95% of the population and is still a major cause of tooth loss. Unfortunately, there is currently no highly sensitive and specific clinical means for its detection in its early stages. The accurate detection of early caries in enamel would be of significant clinical value. Since, it is possible to reverse the process of decay therapeutically at this stage, i.e. operative intervention might be avoided. Caries diagnosis continues to be a challenging task for the dental practitioners. Researchers are developing tools that are sensitive and specific enough for the current presentation of caries. These tools are being tested both in vitro and in vivo; however, no single method will allow detection of caries on all tooth surfaces. Therefore, the purpose of the present review was to evaluate different caries diagnostic methods. Keyword: Dental Caries, Diagnosis, Radiography possibility of reversal. Rather, clinicians are INTRODUCTION A diagnostic method for dental caries forced to measure a dynamic process as a should allow the detection of the disease in dichotomous variable of the presence or its earliest stages and for all pathologic absence of disease using clinical criteria (e.g. changes attributable to the disease to be color, softness, resistance to removal), which determined from early demineralization to are all rather subjective, and tools (e.g. sharp cavitations. Unfortunately, explorer and dental radiographs) which are none of the currently accepted clinical caries diagnostic becoming less useful. methodologies have the ability to account for Although, no single method is currently the dynamics of dental caries, including the developed that will allow detection of caries Corresponding Author: M. Khalesi, Address: on all tooth surfaces, these technologies have Department of Prosthodontics, Faculty of Dentistry, the potential to offer higher specificity and Hamadan University of Medical Sciences. +989126778160 Fax:+98(351)6250344, [email protected] DJH 2010; Vol.2, No.1 Tel: Email: sensitivity with respect to caries detection and quantification as well as to facilitate the 1 Khaleis et al. Dental Caries… development of more effective preventive interventions. some (1) dental The technique of temporary elective tooth This article aims to review separation as an aid to diagnosis of caries in caries proximal smooth surfaces is now regaining diagnostic methods available including: popularity, albeit with less traumatic methods CLINICAL VISUAL INSPECTION that seem acceptable to most patients and The coronal carious lesion starts as a clinically undetectable subsurface dentists. This method permits a more definite assessment of whether radiographically demineralization. With further progression, it detectable proximal enamel (D1, D2) and will dentin lesions (D3) are cavitated. (eventually) become clinically detectable, and can, then, be classified Temporary according to type, localization, size, depth, complemented by a localized impression of and shape. the opened interproximal space, allows a The visual method, a combination of light, mirror, and the probe for detailed examination of every tooth surface, is by far the most commonly applied method in general practice worldwide. Although sensitivity is low and specificity is high, it may be possible to detect noncavitated enamel lesions (D1) on the free smooth surfaces (buccal and lingual), most anterior proximal surfaces, and the opening of some fissures; clinically detected cavities limited to the enamel (D1, D2); dentin lesions (D3) with cavitations into the dentin on the buccal and lingual surfaces, but there is limited detection of posterior approximal and occlusal lesions. A major shortcoming is this method was very limited for detecting noncavitated lesions in dentin or posterior proximal and occlusal surfaces. elective tooth separation, more sensitive diagnosis of cavitations than does the purely visual separation method. (2) Ekstrand et al. evaluated the visual and tactile assessment of arrested initial enamel carious lesions and showed that dentists were not able to reliably and reproducibly determine the subtle visual and tactile differences between active and inactive enamel lesions.(3) In another study, Sheehy performed a comparison between visual examination and a laser fluorescence system for In vivo diagnosis of occlusal caries and concluded that since the laser fluorescence instrument can not be expected to differentiate caries from hypomineralizations, it should be used as an adjunct to a clinical examination. (4) On the other hand, there are some questions about the use of dental explorer to probe suspected carious lesions. Hamilton reported that until to the time those facts emerge from acceptable long-term clinical trials, dentist 2 DJH 2010; Vol.2, No.1 Khaleis et al. Dental Caries… should feel comfortable using the dental explorer to probe suspected carious lesions. (5) allows instantaneous images to be made and projected, and images taken during different FIBER OPTIC TRANSILLUMINATION examination can be compared for clinical METHODS changes among several images of the same Fiber optic transillumination (FOTI) tooth over time. (1) allows for the detection of carious lesion However, Caution must be taken, when because of the changes in the scattering and interpreting a proximal DIFOTI image that is absorption of light photons resulting from a taken at a view similar to that of a local decrease of transillumination due to the conventional bitewing radiograph. Although, (6) the images may look similar, proximal Enamel lesions appear as gray shadows and lesions can be detected using DIFOTI only dentin lesions appear as orange-brown or by careful angulation, remembering that the characteristics of the carious lesion. bluish shadows. (7) In an in vitro study, FOTI, resulting image is that of a surface or what is performed along with visual examination, near the surface. This also may explain why had higher specificity both for enamel and the DEJ is not always seen with conventional dentinal lesions and had a better correlation radiography, when the incident beam is with histology. (8) Rousseau reported on the transmitted through the entire tooth, often development of a fiber-optics-based confocal masking early changes in imaging and However, this method is much better for potential diagnosis of early dental caries. A evaluating lesion depth at the proximal novel surface. system optical for the detection instrument, capable of In addition, the surface. another possible recording axial profiles through caries lesions drawback of DIFOTI is the inability to using single-mode optical fibers has been quantify lesion progression, even though developed which may provide additional images can be compared over time. diagnostic in- vitro study indicated that the method has practitioner. Digital information for a general (9) Imaging (10) One higher sensitivity than does a radiographic Fiber Optic examination for detecting occlusal lesions Transillumination (DIFOTI) is a relatively interproximal, and new methodology that was developed in an surfaces.(11) attempt to reduce the perceived shortcomings CARIES INDICATOR DYES on smooth of FOTI by combining FOTI and a digital In 1972, it was suggested that caries- CCD camera. Images captured by the camera detector dyes could help differentiate infected are sent to a computer for analysis using dentin from affected dentin. However, more dedicated algorithms. The use of the CCD recent studies have shown that these dyes are DJH 2010; Vol.2, No.1 3 Khaleis et al. Dental Caries… non specific protein dyes that stain with a depth of only 25 m have been collagen in the organic matrix of less measured in vitro. The restriction of light mineralized dentin, whether it is infected or scattering for caries diagnosis to smooth not, rather than being specific for the surfaces is a significant drawback to this pathogenic bacteria. (10) technique, although, there is continuing Al-Sehaibany et al. evaluated the use of research to develop a QLF system to detect caries detector dye in the diagnosis of occlusal caries. occlusal carious lesions. The purpose of their Kuhnisch et al. evaluated the in vivo study was to compare the accuracy of detection of non-cavitated caries lesions on diagnosis of carious lesions in the occlusal the occlusal surfaces by visual inspection and pit, fissure, and groove system of lower quantitative light-induced fluorescence. It molars examined by two methods: the caries was concluded that QLF detects more non- detector tactile cavitated occlusal lesions and smaller lesions explorer. compared to visual inspection. However, Histological cross sections confirmed a ratio taking into consideration time-consuming of 1:1 (100%) accuracy by caries detection image capturing and dye in diagnosing decay underlying the understand that QLF is not really of practical occlusal surface. Concurrent examination of use in the dental office. the same occlusal surface by traditional Laser induced fluorescence dye examination versus using traditional a dental explorer examination was only reliable in a (13) analysis, we can (14) In 1998, Hibst and Gall described the 1:4 ratio (25%). (12) successful use of red light (655nm) to FLUORESCENT METHODS differentiate between sound and carious Quantitative light induced fluorescence tissues and on this basis, the Diagnodent (QLF) system (DD) was developed. When using QLF is based on the auto-fluorescence of light with an excitation wavelength of teeth. When teeth are illuminated with high 655nm, we can detect that more intense intensity blue light, they will start to emit fluorescence in the 700-800nm wavelength light in the green part of the spectrum. The region is observed from a carious lesion fluorescence of the dental material has a compared with a sound spot on enamel. DDS direct relation with the mineral content of the utilizes enamel. No threshold for the detection of excitation light source that is modulated to white spot lesions using light scattering differentiate it from ambient light. The light a 655-nm 1-mW laser diode techniques has been determined, but lesions 4 DJH 2010; Vol.2, No.1 Khaleis et al. Dental Caries… is transmitted though a descending optical fiber to a hand-held probe. The probe is placed close to the measured surface, two instruments were developed and tested in thereby illuminating it with the laser light. the 1980. The Vanguard Electronic Caries Carious tooth structures emit fluorescence Detector above 680 nm when encountering this light Corp., InterLeuven laan, Cambridge, MA) and and and the Caries Meter L (G-C International quantified by the DD unit as a number Corp., Leuven, Belgium). Both instruments this fluorescence between 0-99. (15) is detected (Massachusetts Manufacturing The laser fluorescence measure the electrical conductance between device represents high reliability in the the tip of a probe placed in the fissure and a detection of occlusal caries in teeth and its connector attached to an area of high performance is similar to direct visual and conductivity (e.g. gingiva or skin). The radiographic measured examination. So, the conductance, which was a DIAGNOdent may be a useful adjunct to continuous variable, was ,then, converted to conventional methods for occlusal caries an ordinal scale: 0 to 9 for the vanguard detection. (16-18) system and four colored lights for the caries ELECTRICAL CONDUCTANCE Meter L (green = no Caries, yellow = enamel caries, orange = dentine caries and red = MEASUREMENTS (ECM) The idea of an electrical method of caries pulpal involvement). To prevent polarization, detection dates back to 1878, while it is both believed to have first been proposed by alternating Magitot. The basis of the use of ECM is respectively. observations which show that sound surfaces removed by a continuous stream of air in the possess limited or no conductivity, whereas vanguard carious or demineralized enamel should have conductance. Conversely, to assure a good a measurable conductivity that will increase electrical contact and minimize the effect of with the increase of demineralization. By saliva, the Caries Meter L requires that the decreasing thickness and increased porosity, pits and fissures be moistened with saline. the performance of electrical resistance has Electrical conductivity has been shown to been reported to be as valid as or better than have an overall satisfactory performance in traditional detecting occlusal caries in vitro and in vivo means of diagnosing fissure caries. (19) systems used a voltage, 25Hz Moisture system low- to and frequency- and saliva prevent 400Hz, were surface and approximal caries in vitro. (13) Based on the differences in the electrical conductance of carious and sound enamel, DJH 2010; Vol.2, No.1 5 Khaleis et al. Dental Caries… X RAY- BASED IMAGING DIAGNOdent is very high and its diagnostic Intra Oral Radiography (INR) validity is higher than that of bitewing The history of dental radiography begins radiography for proximal caries detection in (21) with the discovery of the x- ray. The x- ray primary teeth. revolutionized the methods of practicing Now, for the purpose of carious lesion medicine and dentistry by making it possible detection, intra oral radiography is a standard (17) procedure and is essential for diagnosing to visualize internal body structures. (22, 23) Radiography is useful for the detection of inter proximal caries. dental caries because the caries process Extra Oral Radiography (EOR) causes tooth demineralization. The lesion is Extraoral radiographic techniques for darker than the unaffected portion and may proximal caries detection have been studied be detected in radiographs. An early carious and proven to be inferior to intraoral lesion may not have yet caused sufficient techniques. However, the main focus was on demineralization conventional panoramic radiography. to be detected in radiographs. It is often useful to mount Clifton successive sets of bitewing radiographs in tomography and panoramic radiography as one film holder to facilitate comparison and well as intra-oral D-speed film for combined evaluation of evidence of progression. assessment of proximal and occlusal caries. It Intra oral radiography can reveal carious was concluded that when proximal surfaces lesions that otherwise might go under were evaluated alone, D-speed film was detection significantly better. For occlusal caries, there during a thorough clinical et al. used multidirectional examination. was no statistically significant difference On the other hand, early carious lesions are between multi directional tomography and difficult D-speed film. (24) to detect with radiographs, particularly, when they are small and limited One study has demonstrated that scanogram to the enamel. Therefore, clinical and x-ray images have the potential to be the first examinations are necessary in the detection practical extraoral imaging modality for of dental caries. proximal caries detection. Influencing factors Posterior bitewing radiographs are the most to be discussed are the sample, exposure useful x-ray projections for detecting caries techniques, in the distal third of a canine and the enhancement. In this study, the performance interproximal of and premolar and molars. occlusal (20) surfaces of However, Virajsilp V et al. reported that the reliability of 6 resolution screen-film and and enhanced contrast digital scanograms were not statistically different from Insight film for proximal caries DJH 2010; Vol.2, No.1 Khaleis et al. Dental Caries… detection. Unenhanced digital scanograms exhibited a statistically significant lower diagnostic accuracy than Insight film. (25) including image manipulation and a reduction in radiation required to obtain a diagnostic image. (1) Digital radiography The use of digital radiography addresses two primary disadvantages of dental film, periapical diseases as it was previously thought. In addition, Alkurt MT Increasing the diagnostic yield for caries may showed that the diagnostic performance of E- be possible with three-dimensional (3D) and F- speed films and direct digital imaging methods. However, general dentists radiography are similar for proximal caries currently use two-dimensional (2D) images, detection. (26) and although CT/MRI modalities exist for Three dimensional x-ray imaging hospitals, there are no systems for general Since the discovery of the x-ray in 1895 practitioner caries diagnosis. The choices for and its application to dentistry, radiographic 3D imaging of dentoalveolar diagnostic tasks imaging of oral anatomy has consisted are currently limited to different forms of primarily of viewing 3-D structures collapsed local CT including x-ray microtomography onto a two-dimensional (2-D) plan. This form (XMT), of tomography (TACT) and super-ortho-cubic imaging, known as transmission tuned aperture radiography, is characterized by a point CT. (27) source of radiation producing a beam which X-ray microtomography computed passes through the patient and strikes a X-ray microtomography is a miniaturized relatively flat image receptor (usually a film). version of computerized axial tomography This produces essentially an attenuation map with a resolution of the order of micrometres. of the structures through which the beam has In the biomedical field, it is particularly been transmitted. While the dental profession useful in the study of hard tissue because of has relied on this method for obtaining its ability to accurately measure the linear information about the hard tissues of the oral attenuation coefficient. From this, the mineral cavity, it inevitably superimposes anatomy concentration can be computed, which is one and metallic restorations which confound the measure problem of identifying and/or localizing microtomography diseases or objects in three dimensions. dimensional images of bone from which Moreover, studies have shown that intra-oral structural parameters can be derived which films produced in this way are not sensitive could not be measured using conventional for the detection of caries, periodontal, and histomorphometry. DJH 2010; Vol.2, No.1 of bone we quality. can form Using three- (28) 7 Khaleis et al. Dental Caries… Daatselaar et al. described the development mineral content in the lesion area (Delta Z/ of a bench top local CT device which is able Lesd in Vol %), the mineral Vol % and of producing spatial and contrast resolutions position of the subsurface layer and lesion necessary of body.The accuracy of TMR for enamel and other dentine in lesion depth is about 200 Vol %. authors m in deltea Z. With mineral details of concluded that ‘local CT reconstruction are approximately 2-3 µm can be detected. The feasible’ and ‘the resolution of the local CT time required for making 5 scans plus images produced from basis projections that evaluation is 3-4 minutes (which is less than were acquired using standard dental CCD 1 minute for a scan). The time required for sensor was diagnostically suitable. This acquiring step wedge data is one minute or makes local CT a potential technique for the less depending on the number of step wedge for interproximal improved caries dentoalveolar as conditions. detection well as The diagnosis of interproximal caries. (29) Transverse microadiography(TMR) steps. Statistical analysis of many scans is supported. (30) TMR or contact- microradiography is the Longitudinal Micro Radiography (LMR) most practical and widely accepted method LMR is a method to determine mineral used to assess de- and re- mineralization of loss in tooth slice samples in vitro. In this dental hard tissues in studies. It is a highly method, a microradiogram of a slice of a sensitive method to measure the change in tooth is prepared. Mineral content is then mineral content of enamel and dentine computed by performing measurements of samples. In TMR, the tooth sample to be the optical density of the microradiogram and investigated is cut into thin slices (about 80 by comparing these values with that of an m and 200 m for dentine samples). A aluminum step wedge. LMR is based on the microradiographic image is made on high same principle as TMR. In contrast to TMR, resolution X-ray exposure of the where a transversal slice of the tooth is sections together with a calibration step created, LMR is based on longitudinal slices. wedge. The microradiogram is digitized by a The LMR system is highly automated. video camera or photomultiplier. The mineral Scanning the sample is performed using a can be automatically calculated from the gray XY scanning table and all calculations are levels of the images of section and step performed automatically. wedge. Parameters of interest are mineral Tuned Aperture Computed Tomography loss (Delta Z in Vol %. m ), lesion depth (TACT) film (29) (Lesd in m ), ratio or average loss of 8 DJH 2010; Vol.2, No.1 Khaleis et al. Dental Caries… It has been shown in controlled in vitro Computer- aided radiographic method studies that it can enhance the clinician’s exploits ability to computers in assessing and recording lesion detect anatomically and localize significant disease, structures and the measurement potential of size. In the new Trophy 97 system, artificial abnormalities. TACT promises to overcome intelligence some of detector) is integrated: approximal carious and lesions are diagnosed and evaluated with the increases the 3-D information currently aid of unique histologic database, allowing available influence graphic of the conventional current dental in ways limitations technologies that can software visualization (Logicon of the size caries and significantly the diagnosis and management progression of the lesion. of dentoalveolar diseases and abnormalities. At both D1 and D3 thresholds, computer- With TACT, the patient has to remain aided methods offer high levels of sensitivity motionless individual for approximal lesions. Earlier soft wares exposure. The time between exposures is paid some trade off high with specificity, but determined by convenience, diagnostic task, newer methods also have high values for this economics or other factors, because delays measure. have no impact on the accuracy of the that the major advantages may be the reconstruction. This approach also permits significant dose reductions and the ability for the image quality manipulation. only during signal-to-noise interactively examination. to ratio the each to needs be tuned of the (31) (33) Furthermore, Wenzel reported (34) Terahertz Pulse Imaging (TPI) Terahertz pulse imaging (TPI) is s Harse et al. performed a study to compare the relatively new imaging technique that has difference in the accuracy of proximal caries been demonstrated in both non-biological detection by tuned aperture applications. Although, the TPI system is a computed tomography (TACT), intraoral new technique for imaging caries using non TACT, It was ionizing impulses of terahertz radiation, (an concluded that extraoral TACT was not electromagnetic radiation) and its ability to statistically different from intraoral TACT or detect early stages of caries lesions in various film radigraphs for proximal caries detection. sections of teeth and a hope in future when This suggested that extraoral TACT may this technique could indicate caries in all and extraoral film radiography. have some clinical utilities. (32) areas of teeth. Terahertz systems are Computer- Aided Radiographic Method relatively expensive and do not offer the (CARM) resolving power of radiographic examination. This system also needs more researches to DJH 2010; Vol.2, No.1 9 Khaleis et al. Dental Caries… make it possible to be inserted into the mouth the TPI system uses only micro-watts of for in vivo studies, while it is expected that radiation of a type that is non-ionizing. technological developments will improve the Because the exposure levels from this system systems to bring them within easy reach of are dentists. The coherent detection scheme of exposure levels that occur naturally, this system will be safer than those employing X- of TMR depth plus an intercept of micron, rays. Unlike radiography TPI also delivers a whereas further calculations allowed the spectrum of different frequencies for each TMR depths to be determined to within 5% pixel measured. This offers the possibility of using TPI. (36) using that spectrum for diagnosis that goes These are some caries diagnosis methods beyond used today. In this era of evidence based levels. simply measuring mineralization (35) orders of magnitude smaller than dentistry, systematic reviews and validation Pickwell et al. compared terahertz pulsed studies of caries detection methods have been imaging transmission addressed in some studies but there is still for depth need for more studies in the future to clearly measurement of enamel demineralizations. It determine the best and most accurate ways of was caries diagnosis. (TPI) microradiography concluded with (TMR) that TPI measured demineralization in the range of 47% of that REFERENCES 5. Hamilton JC. Should a dental explorer be used 1. Stooky GK, Jackson RD, Ferreira G, Analoui to probe suspected carious lesions? Yes--an M. Dental caries diagnosis. Dent Clin of North explorer is a time-tested tool for caries detection. Amer 1999; 43(4):665-677. J Am Dent Assoc. 2005; 136(11):1526 2. Axelsson Per. Diagnosis and risk prediction of 6. Zandoná AF, Zero DT. 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Accessed October 26, 2010 measurement of enamel demineralisation in vitro. 31. webber RL, Horton RA, Tyndall DA, Ludlow Caries Res 2007; 41(1):49-55. JB. 12 Tuned aperture computed Crawley David A, Longbottom C, Cole microradiography for depth tomography DJH 2010; Vol.2, No.1