Lecture 12 Caries Diagnosis and Caries Risk Assessment (copy)

CAMBRA

caries management by risk assessment

what is caries

Dental caries is a multitactorial, transmissible, infectious oral disease caused primarily by the complex interaction of cariogenic oral flora (biofilm) with fermentable dietary carbohydrates on the tooth surface over time

caused y transmitted infectious bact. through

vertical and horizontal transmission

teeth have biofilm with certain bact. types that if fed w/ fermentable carbs

overtime bact. will degrade surface by demineralizing

enamel, dentin, causing lesion, break down with cavitation

caries balance: protective factors

remineralization

Saliva & sealants

Antibacterials

Fluoride/Ca2+/PO43-

Effective lifestyle habits

Risk-based reassessment

caries balance: risk factors

demineralization

Bad bacteria

Absence of saliva

Destructive lifestyle habits

caries balance: disease indicators

White spots

Restorations < 3years

Enamel lesions

Cavities in dentin

what happened when patients with high oral bacteria were given CHX and fluoride?

lower oral bacteria

disease indicators and salivary status - high risk: disease indicators

Visible cavities

Radiographic enamel and/or dentin lesions (clinical signs of disease)

Demineralizations (smooth surfaces, pits & fissures)

Restored caries in last 3 years (new patients)/

1 year (patients on file) [caries history]

Reduced salivary function

high risk CDT code

D0603

environmental/risk factors: moderate risk

Visible heavy plaque on teeth

Deep pits and fissures

Exposed roots

Appliances present

Frequent snacking (>3x daily between meals)

Recreational drug use

Saliva reducing factor

moderate risk factors: deep pits and fissures

determined at birth; can place sealants; deep pits/fissures on occlusal, buccal, palatal, can have increase plaque accumulation in these fissures; increase likelihood of caries

moderate risk factors: exposed roots

cervical areas with gum recession, plaque on dentin is more dangerous with demineralization

elderly patients with recession are at higher risk of developing root caries

moderate risk factors: frequent snacking (>3x daily between meals)

feeds bacteria

moderate risk factors: salivary reducing factor

medications can decrease salivary flow; radiation therapy; autoimmune diseases (Sjögren's syndrome)

is visible heavy plaque an indicative factor of caries disease?

not always, is a risk factor placing the patient at moderate risk

moderate risk CDT code

D0602

low risk CDT code

D0601

protective factors: low risk

Fluoridated community

Fluoride toothpaste x1/x2 daily

Fluoride rinse/gel daily CHX in last 6 months

Xylitol 4x daily in last 6 months

Adequate salivary flow

low risk protective factors

Fluoridated community

Fluoride toothpaste

toothpaste with higher fluoride concentration can be prescribed

what are some other sources of fluoride?

CA water, milk, salt

chlorhexidine (CHX)

anti-bacterial agent in a rinse (common after extractions; can stain teeth if used for long time)

low risk protective factor

Xylitol

sugar alcohol; bacteria can take it in but not ferment it

low risk protective factor if taken 4x daily in last 6 months

plaque stagnation areas

pits and fissures (need sealants)

root (exposed root)

cervical

interproximal

restorations

ortho appliances

(where caries are more likely to occur; first place to look, then look at other areas for abnormalities; without proper care, plaque can accumulate in these areas)

visual tactile

thin instruments to touch surface for irregularities, lesion

impedance

electric current to measure presence and depth of lesion

radiography

see between teeth shadows, sign of disease

transillumination

light, visible light, infrared, blue light to detect shadows

fluorescence

cause biofilm to fluoresce

can measure the activity

dyes

ink to put on teeth, dentin colored areas to remove colored dentin --> diseased dentin

sensitivity

True positive rate. Measures the proportion of actual positives that are correctly identified as such.

E.g., teeth/surfaces that have caries lesions

specificity

True negative rate. Measures the proportion of actual negatives that are correctly identified as such

identify healthy conditions

e.g. teeth/surface that are healthy/sound

what does it mean if there is a specificity of 99% out of 100 patients without caries?

means 99 patients are caries-free

visual-tactile

Visual inspection only:

Sensitivity: 0.12

Specificity: 0.93

Visual inspection + probing: Sensitivity: 0.14-0.80

Specificity: 0.93

explain what it means that Visual inspection only has a Sensitivity of 0.12 and Specificity of 0.93?

out of 100 lesions, might pick up 12 but miss 88 --> sensitivity

out of 100 lesions, 93 are healthy and do not have caries --> specificity

what can increase visual inspection's sensitivity?

when used with probing

explain what it means that Visual inspection with probing has a Sensitivity of 0.14-0.80 and Specificity of 0.93?

out of 100 lesions, should be detecting 14 to be carious (higher if professional is more experienced)

out of 100 lesions, 93 are correctly identified as healthy, only 7 of healthy sires are erroneously identified as diseased

why does visual-tactile caries detection have a low sensitivity

miss a lot just visually, especially in interproximals

what instruments should be used for visual-tactile caries detection?

perio-probe with round end, not sharp explorer (use blunt end; can use round explorer)

caries detection: visual-tactile

use instrument to feel cavitation, roughness, demineralization

alone is insufficient

enamel lesion

damage with sharp explorer

demineralization around fissure area, sharp explorer can further weaken the enamel

demineralized enamel is softer, loses 90% of original hardness, and can be more easily scratched by sharp tools

what effect does visual magnification have on sensitivity and specificity?

sensitivity increased

specificity decreased (improves)

transillumination

Visible Light (LED light shine through enamel, tooth)

Sensitivity: 50-85%

Specificity: 95%

Best: dentin, fractures, white spots, fillings

tip attachment

transillumination indications

detecting cracks, existing fillings

transillumination

Near Infrared Digital Imaging Transillumination (NIDIT)

Near infrared light - 780 nm

Sensitivity: 68%

Specificity: 93% (high)

do caries appear dark or light in transillumination?

dark --> don't let light through

fillings also don't let light through

caries detection: fluorescence

Laser Light 655 nm (red)

DiagnoDent

fluorescence by caries-induced changes in teeth

0-10 Healthy tooth structure

11-20 Outer half of enamel

21-30 Inner half of enamel

>31 Dentin caries

describe how caries detection with fluorescence works

laser light hits tooth if caries causing bact/calculus present will fluoresce

red porforins- metabolic products with bacteria which will fluoresce and be detected

what mode of caries detection is Diagnodent used for?

fluorescence

Diagnodent (laser induced fluorescence)

fluorescence

glass tip contacts tooth laser fluoresces when activity is detected

angle it to see whole lesion

peak reading if high number, high activity, high frequency of tone

Qantitative Light Fluorescence (QLF)

Blue Light

makes tooth fluoresce green

reduced to no fluorescence in carious areas

can show plaque/biofilm

reading demineralization

SIROInspect

caries detection by fluorescence

Laser Light 405 nm with 530 nm filter

FACE

blue laser light causes cavitated dentin to fluoresce

fluorescence: blue light

see on computer for documentation

can see demineralized dentin

caries detection: impedance

AC Impedance spectroscopy technique (ACIST)

tip contacts tooth

Sensitivity: 0.67-0.96 Specificity: 0.71-0.98

impedance sensitivity and specifity

Sensitivity: 0.67-0.96 Specificity: 0.71-0.98

radiography sensitivity and specificty

Sensitivity: 0.45-0.70 Specificity: 0.70-0.97

caries detection: radiography

ionizing radiation (x-rays) through teeth to film behind teeth to cpature

x-rays go through more easily when there's demineralization => shadows

Sensitivity: 0.45-0.70 Specificity: 0.70-0.97

how do restorations appear in an x-ray?

radio-opaque

how do caries appear in an x-ray

radio-opaque

burn-out effect

thinner tooth structure, more x-rays go through

caries detection: dyes

Stains matrix of less mineralized dentin, but not bacteria

E.g., methylene blue or fuchsin red in propylene glycol

Sensitivity: 0.71-0.74

Specificity: 1.00

red dye enters demineralized dentin and stains

only stains demineralized areas, not healthy areas

dyes sensitivity and specificity

Sensitivity: 0.71-0.74

Specificity: 1.00

caries dye: caries infected

place dye for 5s, rinse, intense colors need cleaning

caries dye: caries affected

less intense colors --> can remove

caries dye: clean

dye can enter cracks in teeth, might over-reduce the tooth

3º dentin, where pulp chamber used to be, as caries was progressing, dentin reacted against it, causing sclerosis of tubule, turning 1º dentin into 2º dentin and build protective 3º dentin in pulp chamber to avoid opening the nerve chamber

lesion activity: inactive/arrested

location of lesion: Lesion not in plaque stagnation area

Plaque over lesion: Not thick or sticky

Surface appearance: Shiny; color: brown-black

Tactile feeling: Smooth, hard enamel/hard dentin

Gingival status: No inflammation, no bleeding on probing

active lesions appearance

look dull/yellowish, darken with time

dull surface, no luster, white lesion

lesion activity: active

location of lesion: Lesion in plaque stagnation area (pit, fissure, interproximal, gingival)

Plaque over lesion: Thick and/or sticky

Surface appearance: Matte/opaque/loss of luster; color: white, yellow

Tactile feeling: Rough enamel/soft dentin

Gingival status: Inflammation, bleeding on probing

fluorosis

during tooth development, increase F- consumed; too much F- causes streaks

developmental ws

during tooth development, 1º tooth might have had trauma, bumped into underlying developing tooth

how can underlying lesions be seen?

enamel is transluscent so underlying lesions will show through

disease progression

initial lesion

micro-cavitation

decay

ICDAS stage 0

E0

healthy

what is the relationship between deepness of interproximal lesion and radioluscency on a radiograph?

increased deepness of interproximal lesion, increased radiolucency on radiograph

ICDAS stage 1

E1

demineralization

white spot, not visible when tooth is wet

ICDAS stage 2

E2

white spot scar, permanent, deeper into DEJ

demineralization

ICDAS stage 3

D1

demineralization

pores of white spot lesion widen

discoloring particle accumulation in pores to make white spot brown

lesion reached dentin

ICDAS stage 4

D2

localized enamel breakdown

shadow under enamel

ICDAS stage 5

D2

enamel broke out down, dentin exposed

caries into mid-1/3 of dentin towards pulp

breakdown is less than 50% of tooth surface

what is the difference between stage 5 and 6?

stage 5- breakdown is less than 50% of tooth surface

stage 6- breakdown is more than 50% of tooth surface

pulpitis

inflammation of pulp; painful

ICDAS stage 6

D3

lesion progress up to the nerve --> painful

breakdown is more than 50% of tooth surface

ICDAS 0/E0

ICDAS 1/E1

ICDAS 2/E2

ICDAS 3/D1

ICDAS 4/D2

ICDAS 5/D2

ICDAS 6/D3

ICDAS 0

Sound surface: no change after air drying

ICDAS 1

First visual change in enamel: seen only after air drying

ICDAS 2

Distinct visual change in enamel when viewed wet: opacity or discoloration

ICDAS 3

Initial enamel breakdown with no visible dentin or underlying shadow; discontinuity of surface enamel

ICDAS 4

Underlying dark shadow from dentin, with or without localized enamel breakdown

ICDAS 5

Distinct cavity with visible dentin; involving less than half of tooth surface

ICDAS 6

Extensive cavity with visible dentin; deep and involving more than half of the tooth surface

what ICDAS stages typically require treatment?

stage 5 and 6

ICDAS stage 0 (occlusal)

Sound surface: no change after air drying

ICDAS stage 1 (occlusal)

First visual change: seen only after air drying,color change limited to pit & fissure

• monitor, seal, noninvasive

ICDAS stage 2 (occlusal)

Distinct visual change: seen when wet, wider than fissure

• monitor, seal, noninvasive

ICDAS stage 3 (occlusal)

Localized enamel breakdown with no visible dentin or underlying shadow; discontinuity of surface enamel, widening of fissure

• monitor, seal, noninvasive