Session 3: Caries detection

dental caries are a (?)-mediated , (?)-modulated process

biofilm-mediated, diet-modulated process that can lead to an imbalance in the cycle of demineralization and remineralization causing localized destruction of tooth structure

microscopic communities of bacteria and slimy matrix

biofilm mediated

in the presence of sugars, the bacteria can produce acid thereby lowering the pH

diet modulated

when is the microbiome in dysbiosis?

in extended low pH

what are some examples of dental caries?

• DMFT1938- WHO Classification- standardized method for conducting oral health survey

• NYVAD 1999

• ICDAS 2005/2011

• ADA CCS- convened a group of experts – published in 2015 in JADA

• PUFA (pulpal, ulcer, f istula, abscess) 2010

• CAST (Caries assessment spectrum and treatment)- instrument2011

which classification system is used at TUSDM?

ADA CCS

describes how much tooth structure is involved—not whether the lesion is active

severity

ADA Caries Classification System (ADA CCS) categorizes caries lesions according to (what two things?)

• extent/severity

• activity status

with goal to describe the lesion clinically and support minimally invasive tx decisions

common sites of pit and fissure caries

• Occlusal surfaces

• Buccal pits of mandibular molars

• Lingual pits of maxillary incisors

common sites of smooth surface caries

• proximal surfaces

• buccal/lingual smooth surfaces

common sites of root surface caries

• gingival recession

• exposed root surfaces

• older adults

smooth and leathery

active

shiny and hard

inactive, arrested

which caries severity/extent clinical appearance:

• First visible evidence of mineral loss

• White or brown opacity

• No cavitation

initial

White spot lesions Early enamel changes

initial

which caries severity/extent clinical appearance:

• More advanced enamel breakdown

• Localized enamel surface discontinuity

• (dentin involvement - not visually - but histologically and radiographically)

moderate

characteristics and management of moderate lesions

which caries severity/extent clinical appearance:

• Cavitation with dentin involvement

• Structural compromise

• Difficult to maintain plaque control

advanced

characteristics and management of advanced lesions

signs of active caries

• Chalky/matte appearance

• SOFT - WHITHISH/YELLOWISH

• Rough surface

• Plaque stagnation area Near gingival margin

• Recent change in size/appearance

signs of arrested caries

• Shiny appearance

• BLACKISH / DARKER BROWN

• Smooth surface

• Hard texture

• Not associated with plaque

• Smooth Surface Lesions

• Whitish/yellowish appearance

• Matte/chalky surface

• Rough texture

• Plaque accumulation

• Location associated with stagnation areas

active lesions

• Shiny surface

• Smooth texture

• Hard surface

• No plaque stagnation

• Darker discoloration may be present

inactive/arrested lesions

what are the tools used for detecting and assessing caries?

visual:

• mouth-mirror

• reflected light - fiber optic transilluminator for extent, (foti/difoti-microlux)

• air-water syringe on a clean tooth surface

• WHO probe bc less sharp

• AI is decent

radiographs:

• BWs bc angulation standardized due to open contacts

what is QLF

quantitative light-induced fluorescence

• measures the amnt of fluorescence emitted by tooth structure when exposed to a specific wavelength of light (often blue or violet light)

• Healthy enamel emits a measurable amount of fluorescence, while carious lesions emit less

• the system quantifies this difference and displays it as a grayscale image, with darker areas indicating higher fluorescence (often sound enamel) and lighter areas indicating lower fluorescence (often carious tissue)

do carious lesions emit more or less fluorescence than healthy enamel?

less

on display the darker areas indicate higher fluorescence

NIRI

Near InfraRed Imaging

• an advanced diagnostic tool used primarily in dentistry to detect cavities and monitor dental health without exposing patients to harmful radiation

• NIRI technology shines near-infrared light through the teeth. Healthy enamel is transparent to this light, appearing darker on the scan, while dentin and decayed areas scatter the light, making them appear brighter. This contrast helps dentists identify areas of concern effectively

occlusal primary moderate

occlusal primary advanced

occlusal primary initial

chalky white, no E breakdown or microcavitation

buccal sound

vertical crack not a lesion

occlusal primary moderate

cavitation no D exposed but there is shadowing → E breakdown

occlusal sound

buccal primary advanced

irregular; soft mushy D with plaque buildup

occlusal primary moderate

discolored, cavitation, shadowing, looks shiny and is hard → inactive

occlusal primary advanced

occlusal secondary advanced

occlusal primary initial

no E breakdown but chalky, no microcavitation

apply F for rebalance/mineralization

buccal primary advanced (inactive)

lingual primary advanced

root caries active

occlusal secondary initial (active)

chalky no microcavitation but deep grooves

19 O moderate and B moderate

#5 O moderate

#20 D- advanced O-moderate B-advanced

#29 O moderate

#13 O moderate - shadowing and E breakdown

#12 O initial

27, 28, 29: bucal advanced

#30 O - moderate B - initial

#29 O - initial B -moderate

#28 O - moderate

#19 O and B moderate

#18: Occlusal - moderate B - moderate

#19: Occlusal - moderate

#30: Occlusal - moderate - Buccal - moderate

#31: Occlusal - moderate

#18: Occlusal - moderate

#19: Occlusal - moderate

#21: Occlusal - sound

#15: Occlusal - moderate

#14: Occlusal - initial

#11: Facial - initial

occlusal - INITIAL

occlusal - advanced

occlusal - sound

occlusal - moderate

occlusal - ADVANCED

occlusal - ADVANCED

occlusal initial

occlusal - moderate

A 2022 publication analyzing GBD 2017 data explicitly notes: • “The Global Burden of Disease (GBD) 2017 study showed that the prevalence of dental caries in permanent teeth ranked (?) among 328 diseases.” PMC

first

untreated caries in permanent teeth had the highest prevalence globally; most common health condition according to the Global Burden of Disease 2021

It is not determined by a single factor but by the (?) between pathological (risk) factors and protective factors

balance

central to the CariesCare International Consensus and modern caries management

The goal of caries management is to (?) pathological factors while (?) protective factors to shift the balance toward oral health

reduce, strengthen

central to the CariesCare International Consensus and modern caries management

CariesCare 4D cycle

determine caries risk, detect and assess, decide on a personalized care plan, do preventative and tooth-preserving care

what are some caries risk factors?

• Visible plaque accumulation

• Frequent exposure to fermentable carbohydrates

• Reduced salivary flow hyposalivation/xerostomia)

• Exposed root surfaces

• Deep pits and fissures

• Orthodontic appliances or other plaque- retentive factors

• Frequent consumption of sugary foods or drinks (especially between meals)

• Poor oral hygiene

• Inadequate fluoride exposure

• Irregular dental attendance

• Low adherence to preventive recommendations

• Medications causing xerostomia

• Head and neck radiation therapy

• Medical conditions affecting salivary function

• Low socioeconomic status (associated with increased disease burden)

• Limited access to dental care

• Low oral health

what do caries protective factors do?

reduce the likelihood of caries initiation or progression by enhancing remineralization, reducing demineralization, or modifying the oral environment

what are some caries protective factors?

how much of the tooth structure is involved

caries staging

severity of the lesion

stage

lesion management depends on:

• Lesion stage

• Lesion activity

• Cavitation

• Cleansability

• Patient caries risk

• Patient preferences and clinical circumstances

sound surface tx options

Prevention Routine monitoring

initial arrested lesion tx options

• Fluoride varnish

• Sealant (occlusal lesions)

• Resin infiltration

• Active surveillance

initial active lesion tx options

• Fluoride therapy

• Dietary modification

• Oral hygiene improvement

• Active surveillance

moderate lesion tx options

Management depends on whether the lesion can be effectively cleaned and controlled

Possible options:

• Non-operative care

• Micro-invasive treatment

• Minimally invasive restoration

advanced/cavitated lesion tx options

When the lesion cannot be adequately cleaned or maintained, operative care is indicated

Goals:

• Restore function

• Create a cleansable tooth surface

• Preserve as much healthy tooth structure as possible

treatment depends on what three things?

pt risk, lesion stage, lesion activity