Lecture 18 - Caries Diagnosis and Caries Risk Assessment

caries

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

Dysbiosis

an imbalance in the composition and function of the body's microbial communities, typically referring to the gut microbiota

caries diagnosis

1. diagnosis

2. treatment plan 

3. management 

4. recall/ outcome

1. diagnosis (patient level) use:

CAMBRA and caries balance

Caries balance: protective factors

S.A.F.E.R

• Saliva & sealants

• Antibacterials

• Fluoride/Ca2+/PO43-

• Effective lifestyle habits

• Risk-based reassessment

Caries balance: Environmental factors

B.A.D

• Bad bacteria

• Absence of saliva

• Destructive lifestyle habits

Caries Balance: Disease Indicators

W.R.E.C

• White spots

• Restorations < 3years (Caries history)

• Enamel lesions (cavities visible)

• Cavities in dentin (radiographic)

saliva reducing factors (and causes in pic):

Effects of salivary hypo-function (also known as xerostomia, is a condition characterized by a reduced production of saliva):

• Dental and oral health:

  • Increased risk of dental caries

  • Erosion of teeth

  • Periodontitis

  • Oral infections

  • Halitosis (bad breath)

  • Burning mouth sensation

  • Oral soreness

• Functional difficulties:

  • Difficulty in mastication (chewing)

  • Speech dysfunction

  • Dyspepsia (digestive discomfort)

  • Dysphagia (difficulty swallowing)

1. Diagnosis (tooth level) : caries detection:

1. Visual–Tactile – inspection and probing of tooth surfaces

2. Radiography – X-rays to detect interproximal or hidden lesions

3. Transillumination – using light to reveal changes in enamel or dentin

4. Dyes – staining to highlight carious areas

5. Impedance – measuring changes in electrical resistance of tooth tissue

6. fluorescence - the emission of light by a substance that has absorbed light

caries detection: sensitivity

True positive rate. Measures the proportion of actual positives that are correctly identified as such. (teeth with caries)

caries detection: specificity

True negative rate. Measures the proportion of actual negatives that are correctly identified as such. (healthy vs non healthy teeth)

Caries detection: 1) visual tactile

Visual inspection only:

• Sensitivity: 0.12

• Specificity: 0.93

Visual inspection + probing:

• Sensitivity: 0.14-0.80

• Specificity: 0.93

*clean, dry, well illuminated

*NO sharp explorer bec will break soft enamel

*with magnification: Sensitivity: increased & Specificity: decreased

Caries detection: 2) transillumination 

if no radiographs use this: 

• Visible Light

• Sensitivity: 50-85%

• Specificity: 95%

Best: dentin, fractures, white spots, fillings

Near Infrared Digital Imaging Transillumination (NIDIT)

• Near infrared light - 780 nm

• Sensitivity: 68%

• Specificity: 93%

*more sensitivity detects more lesions but high specificity is important to avoid false-positive

Caries detection: 3) radiographic

• bitewing/ PA

• Sensitivity: 0.45-0.70

• Specificity: 0.70-0.97

1. E0 – Healthy tooth: No visible decay; enamel is intact.

2. E1 – Initial enamel decay: Slight demineralization in outer enamel; faint radiolucency.

3. E2 – Deeper enamel decay: Radiolucency extends toward inner enamel; damage more noticeable. (inner ½ of enamel)

4. D1 – Early dentin involvement: Decay breaks through enamel into outer dentin; triangular shape.

5. D2 – Moderate dentin decay: Lesion spreads deeper into dentin; larger radiolucent area.

6. D3 – Severe decay near pulp: Radiolucency reaches close to pulp chamber; may need root canal.

Caries detection: 4) fluorescence

• Qantitative Light Fluorescence (QLF)

  • Blue Light

  • Laser Light 405 nm with 530 nm filter with 530 nm (orange) filter

• diagnodent (655 nm): red laser light

• byproducts of cariogenic biofilm called porphyrins are illuminated by diagnodent

; SIROInspect: fillings have higher fluorescence

Caries detection: 5) impedance

• AC Impedance spectroscopy technique (ACIST)

• Sensitivity: 0.67-0.96

• Specificity: 0.71-0.98

higher electric current -> caries

*dont sell these anymore

Caries detection: 6) Dyes

• stains matrix of less mineralized dentin (not bacteria)
  - if stained purple, demineralization: must remove
  - if stained pink, affected, can remineralize: can leave behind

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

• Sensitivity: 0.71-0.74

• Specificity: 1.00

Lesion prograssion

white spot -> white/ brown spot -> micro cavitation -> cavitation

ICDAS smooth surface appearance

0. Sound surface: No change after air drying.

1. First visual change in enamel: Seen only after air drying.

2. Distinct visual change in enamel: When viewed wet, shows opacity or discoloration.

3. Initial enamel breakdown: Discontinuity of surface enamel; no visible dentin or underlying shadow.

4. Underlying dark shadow: From dentin, with or without localized enamel breakdown.

5. Distinct cavity: Visible dentin; involves less than half of the tooth surface.

6. Extensive cavity: Visible dentin; deep and involves more than half of the tooth surface.

ICDAS occulsal apperance:

0. Sound surface: No change after air drying.

1. First visual change: Seen only after air drying; color change limited to pit and fissure.

2. Distinct visual change: Seen when wet; wider than fissure.

3. Localized enamel breakdown: No visible dentin or underlying shadow; discontinuity of surface enamel; widening of fissure.

4. Underlying dark shadow: From dentin, with or without localized enamel breakdown.

5. Distinct cavity: Visible dentin; involves less than half of the tooth surface.

6. Extensive cavity: Visible dentin; deep and involves more than half of the tooth surface.

ADA Caries Classification system

caries diagnosis: root caries

lesion activity: active vs inactive

flow chart of diagnosis: clinical assessment

flow chart of diagnosis: radiographic assessment

flow chart of diagnosis: activity assessment (for plaque/ gingival inflammation)

final diagnosis step

• Initial active or inactive

• Moderate active or inactive

• Advanced active or inactive.

Sjögren's syndrome causes

xerostomia (dry mouth) because the immune system attacks and damages the glands that produce moisture, leading to reduced saliva