Cariology Lecture 6

What characterized traditional approaches to caries diagnosis?

Focused on visual detection of obvious cavitation, often with an explorer; all lesions were treated restoratively ("extension for prevention").

Why did traditional diagnosis rarely require staging?

Because most decay was extensive and easily visible—disease was widespread, and treatment was aimed at pain relief and restoration.

How did the explorer traditionally function in diagnosis?

It was used aggressively to detect "catch" or soft areas, which often damaged early lesions that could have been arrested.

What defines the modern/current approach to caries diagnosis?

Emphasizes biological understanding—recognizing early, non-cavitated lesions that can be arrested or reversed with preventive measures.

Why is staging of caries now essential?

Because identifying the lesion's stage (sound, incipient, frank) determines whether prevention, monitoring, or restoration is appropriate.

What is the main purpose of an epidemiological exam?

To determine disease trends and compare populations—not to treat individuals.

What setting and methods are used in epidemiological exams?

Field settings (chair, light, no air or suction), short duration, no radiographs, standardized criteria.

How does an epidemiological exam affect detection rates?

Less disease is identified, and over-diagnosis is less likely.

What is the purpose of a clinical caries exam?

To diagnose and plan treatment for an individual patient.

What features define a clinical exam setting?

Office setting, use of radiographs, longer exam time, patient-specific findings, and higher detection rates (more likely to over-diagnose).

What qualities make a diagnostic approach ideal for patients and providers?

Acceptable, easy to use, inexpensive, quick, and accurate.

What are the three key qualities of accuracy in diagnosis?

Validity, Sensitivity (true positives), Specificity (true negatives).

What additional characteristic ensures consistent results across clinicians and times?

Reliability (reproducibility).

Why must an ideal approach be "sensitive"?

To detect small or early changes in enamel before cavitation occurs.

What are the main traditional diagnostic methods?

Visual, tactile (explorer), and radiographic.

What are strengths of visual diagnosis?

Non-invasive, quick, and easy to repeat.

What are weaknesses of visual diagnosis?

Subjective and dependent on lighting, clinician acuity, and lesion visibility.

What are strengths of tactile diagnosis?

Helps detect surface roughness and cavitation that are hard to see.

What are weaknesses of tactile diagnosis?

Can cause iatrogenic damage (forceful probing can break surface and create a lesion).

What are strengths of radiographic diagnosis?

Detects approximal and occlusal lesions invisible to the naked eye.

What are limitations of radiographs?

Limited sensitivity to early enamel lesions; 40-60% mineral loss needed before visible.

What are examples of newer diagnostic tools?

QLF, FOTI, DIAGNOdent, ECM, NIRT, AI-assisted systems (Overjet, Pearl, Dentrix).

How should newer technologies be used in diagnosis?

As adjuncts to, not replacements for, clinical judgment.

What is over-diagnosis in caries detection?

Identifying sound or early-stage lesions as carious, leading to unnecessary treatment.

What is the risk of over-diagnosis?

Overtreatment—drilling and restoring intact surfaces unnecessarily.

What is under-diagnosis?

Failing to identify active or deeper carious lesions.

What is the risk of under-diagnosis?

Undertreatment—allowing disease progression or missed preventive intervention.

How can clinicians minimize both errors?

Use multiple diagnostic methods (visual, tactile, radiographic, risk assessment) and avoid forceful probing.

What determines whether over- or under-diagnosis is more likely?

The cutoff point of the diagnostic test—lower thresholds increase sensitivity but reduce specificity.

What are the stages of caries progression (Burt & Eklund system)?

0 = Sound surface, D1 = Initial lesion, D2 = Enamel caries, D3 = Dentin caries, D4 = Pulpal involvement.

Why are staged systems (like ICDAS) preferred today?

They recognize the full continuum of disease and support preventive, minimally invasive care.

Extension for Prevention

would extend past the area of the cavity when removing

What do we want to make sure to avoid when checking for caries related to the explorer?

Dont want to push too hard to break the enamel and let in more bacteria

Characteristics of epidemiological

population

field setting

exam with no xrays

less disease identified

clinical characteristics

individual patient

office setting

long exams with xrays

more disease identified 

more likely to over diagnose

0 - Surface Sound

No evidence of treated or untreated clinical caries (slight staining allowed in an otherwise sound fissure)

D1 - Initial Caries (Pits and Fissures)

May be significant staining, discoloration, or rough spots

Cannot positively disgnose loss of substance

D1 - Initial Caries (Smooth Surfaces)

Whote, opaque areas with loss of luster

D2 - Enamel Caries

Demonstrable loss of tooth substance in pits, fissures, and smooth surfaces, but no softened floor or wall enamel

In D2 Enamel Caries, has the decay extended into the dentin?

no

In D2 Enamel Caries, the texture of the material within the cavitiy may be ____ or _____.

chalky, crumbly

D3 - Caries of Dentin

Detectably softened floor

Undermined enamel, or softened tooth

On approximal edges, explorer point must enter a lesion with certainty

D4 - Pulpal Involvement

Deep cavity with probable pulpal involvement

What are the 3 approaches to caries diagnosis

Visual 

Tactile (side of explorer)

Radiographs

Visual Diagnosis 

Individual variation in visual acuity

Visual diagnosis aids

transillumination (interproximal look in radiographs)

Magnification

Caries detection dyes

Tactile Diagnosis

Different explorers

Variation used in forces used in explorer probing

Sensitivity

detection rate of true diseased teeth

(True positive)/ (true positive)+ (false negative)

Specificity

detection rate of true sound teeth

(true negative)/ (false positive)+(true negative)

what variables do we want to be as small as possible?

false positives and negatives