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Caries diagnosis Presentation Transcript


What is diagnosis?

Diagnosis is an art and science that results from the

synthesis of scientific knowledge, clinical experience,
intuition & common sense

Caries diagnosis implies deciding whether a lesion is

active, progressing rapidly or slowly or whether is already


Stepwise progression toward diagnosis & treatment

planning depends on thorough assessment of the following

Patient History

Clinical examination

Nutritional analysis

Salivary analysis

Radiographic assessment

HIGH RISK LOW RISK Social History Socially deprived High

caries in siblings Low knowledge of caries Middle class Low caries
in sibling High dental aspirations Medical History Medically
compromised Xerostomia Long-term cariogenic medicine No such
problem Dietary habits Sugar intake: frequent Infrequent

HIGH RISK LOW RISK Use of fluoride Non-fluoridated area No

fluoride supplements Fluoridated area Fluoride supplements used
Plaque control Poor oral hygiene maintenance Good oral hygiene
maintenance Saliva Low flow rate& buffering capacity
S.mutans & lactobacillus counts Normal flow rate& buffering
capacity S.mutans & lactobacillus counts

HIGH RISK LOW RISK Clinical evidence New lesions Premature

extractions Anterior caries restorations Multiple/repeated
restorations No fissure sealants Multi-band orthodontics No new
lesions No extraction for caries Sound anterior teeth No/few
restorations Fissure sealed No appliances








Visual methods:

Detection of white spot, discoloration / frank cavitations

Without aids, unreliable

Magnification loupes- Head worn prism loupes (X 4.5) or

surgical microscopes(X 16) may be used

comfort, relatively inexpensive, available in various


Use of temporary elective tooth separation

Tactile methods:

Explorers are widely used for the detection of carious tooth


- Right angled probe- no.6

- Back action probe- no.17


- Shepherd's crook- no. 23

- Cowhorn with curved ends- no.2

Dental floss

Use of explorer is not advocated because;

Sharp tips physically damage small lesions with intact


Probing can cause fracture & cavitation of incipient lesion.

It may spread the organism in the mouth

Mechanical binding may be due to non-carious reasons

Shape of fissure

Sharpness of explorer

Force of application

Path of explorer placement

Use of explorer

Explorer is useful to remove plaque and debris and check

the surface characteristics of suspected carious lesions.

gentle pressure just required to blanch a fingernail without

causing any pain or damage

All surfaces of a tooth are cleaned of debris and plaque,

using an air syringe and examined visually. Suspicious
areas are explored to check for the surface texture.



Non- cavitated:

No signs of cavitation after visual or tactile examination.

Location: where dental plaque accumulates (gingival


Surface characteristics: Matted (not glossy) when a tooth

is dried.

Areas of demineralization

not in close proximity to the gingival margin

not covered by plaque

smooth and glossy

are non-cavitated

not active non-cavitated carious lesions .

Visual enamel opacity under sound marginal ridge indicate

undermined enamel due to dental caries

non-cavitated carious lesion in dentin

Non-cavitated carious lesion ENAMEL DENTIN

Cavitated Lesions:

Where there is visual breakdown of a tooth surface, it is

classified as cavitated carious lesion. An active cavity on a
smooth surface has soft walls or floors shown below:

Questionable Area:

All stained smooth coronal tooth surfaces that do not have

the characteristics of non-cavitated or cavitated lesions are
classified as questionable shown below

Non-Carious Enamel Opacities Opacity not fluorosis Mild

Fluorosis Moderate Fluorosis Severe Fluorosis

Caries in Pit or Fissure Surfaces


All discolored areas should be explored using gentle


There is no need to penetrate a suspected lesion with an


If a discolored and non-cavitated area is soft when

explored, it is recorded as non-cavitated carious pit or
fissure .

A cavity is detected when there is an actual hole in the

tooth in which an explorer could easily enter the space.

An active cavity has soft walls or floors (detected using

gentle exploring).

If there is visual enamel opacity under an ostensibly sound

or stained pit or fissure, then the enamel is undermined
because of dental caries and the tooth surface is classified
with a non-cavitated carious lesion in dentin .

Pit and Fissure Caries Non-cavitated carious lesion Enamel

Enamel Dentin Enamel

If a discolored area is hard when gently explored then it

should be marked as questionable .

Cavitated Carious lesion

Root Caries

Root surface caries comprises of a continuum of changes

ranging from minute discolored areas to cavitation that
may extend into the pulp

For diagnostic purpose; they may be:

Active root surface lesion:

well-defined area showing yellowish or light brown


covered by visible plaque

presence of softening/ leathery consistency on

probing with moderate pressure

Inactive root surface lesion (arrested):

well-defined dark brown/ black discoloration

smooth and shiny

hard on probing with moderate pressure

Active lesion Questionable

Arrested Caries

Arrested (remineralized) lesions can be observed clinically

as intact, but discolored, usually brown or black spots.

The change in color is presumably due to trapped organic

debris and metallic ions within the enamel.

These discolored, remineralized lesions are intact and are

highly resistant to subsequent caries . The arrested caries
need not be removed.

Recurrent caries

It is diagnosed whenever there is softness due to caries at

a defective margin, and when the tip of a periodontal
probe can enter the defect without any resistance.

A restoration with a discolored margin or a small marginal

ditch (<0.5 mm or the head of the probe) is recorded as

an early recurrent carious area . A larger defect should be

classified as advanced recurrent carious area

There are two valid indicators of recurrent

(secondary) caries:

softness at the margin of a filling that is

detected using an explorer or

presence of a large defect (a minimum

diameter of 0.4 mm) at a margin of a filling
with softness in the area.

Large defects are associated with a high level of

colonization with cariogenic bacteria. Marginal
discoloration by itself is not a valid sign for dental

Advanced Recurrent Carious lesions

Nursing bottle caries Vs Rampant caries

Specific form of rampant caries Acute, widespread caries with

early pulpal involvement of teeth that are usually immune to
decay Primary dentition affected Both dentitions affected C/F:
specific pattern- maxillary incisor molars Mandibular incisors
not affected Rapid appearance of new lesions Mandibular incisors
also affected


Carious lesions are detectable radiographically when there

has been enough demineralization to allow it to be
differentiate from normal

They are valuable in detecting proximal caries which may

go undetected during clinical examination.

On average they have around 50% to 70% sensitivity in

detecting carious lesions.

40% demineralization is required for definitive decision on


Radiographic examinations include;

Bitewing radiographs

IOPA radiographs using paralleling technique

Dental panoramic tomograph

The two important decisions related to radiographic

examination are (1) when to take a radiograph and (2)
how to evaluate a radiograph for presence of signs of
dental caries.

Incipient occlusal lesions:

Not very effective.

Caries starts on the walls of the pits & fissures and tends
to spread perpendicular to the DEJ

Only detectable change is a fine gray shadow at the DEJ.


Moderate occlusal lesions:

First to induce specific changes helping in a definitive


Broad based, thin radiolucent zone in dentin with minimal

or no changes in enamel

Presence of a band of increased opacity between the lesion

and the pulp chamber due to calcification within primary

This feature is not seen in buccal caries

Severe occlusal lesions:

Readily observed both clinically and radiographically

Appear as large cavities in the crowns of the teeth

However pulp exposure cannot be determined


Incipient lesions:

Commonly seen in the caries-susceptible zone

Presents as a notch on the outer surface not involving

more than half of enamel

Diagnosis can be missed, best viewed under a magnifying


Density along the proximal surface is high which does not permit
the detection of loss of small amounts of mineral content

Moderate proximal lesions:

Involve more than outer half of enamel but do not extend

into DEJ

May have one of type of appearance:

67% - triangle with broad base towards outer surface

16% - a diffuse radiolucent image

17% - combination of both

Advanced proximal lesions:

Radiolucent triangular cone invading into the dentin

In addition, it spreads along the DEJ and subsequently into


This forms a 2 nd cone with base at DEJ

Does not involve more than half of dentin

In some cases, lesions penetrated into dentin may appear

not to have penetrated enamel

Severe proximal lesions:

Penetrating more than half of dentin

Narrow path through enamel, an expanded radiolucency at

DEJ, with a progress towards pulp

Lesions may or may not appear to involve pulp

Undermined enamel fractures under masticatory load

leaving a large cavity

Facial & Lingual Caries


They start as round lesions and enlarge to become

elliptical or semilunar

Presence of well defined non-carious enamel around


When superimposed on DEJ, they may mimic occlusal


Clinical examination helps in definitive diagnosis



Also called cemental caries with an incidence of 40%- 70%

of the aged population

Buccal, lingual, proximal

Usually it is a lesion of dentin associated with recession

Ill-defined, saucer-like radiolucency


Occurs immediately next to restorations

Results from microleakage or residual caries

Incidence- 16%

Radiolucency depends on amount of demineralization &

extent of restoration

Mesio/disto-gingival & occlusal margins- clearly seen

Under facial/ lingual restorations-difficult to detect

Materials like Ca(OH),composite & silicate cements



Radiolucent Cervical Burn out:

- Evident at the neck of tooth well demarcated above by

enamel cap& below by alveolar bone level

- It is triangular in shape being less apparent at the center

of tooth

- good alveolar bone height will enhance cervical burn-out

Radiopaque zone beneath amalgam restorations

Tin & zinc ions are released into underlying dentin

Pitfalls Of Radiography


2 dimensional view of 3 dimensional object

Radiographic depth of a lesion is often less than actual


Overlapping of proximal surfaces on a radiograph

Occlusal (incipient) caries of enamel difficult to detect

Dental anomalies like hypoplastic pits mimic proximal


Cervical burnout often confused with root caries


It is similar to photocopy machine

Consists of Aluminum plate coated with selenium which

provides a uniform electrostatic charge

X- rays selective discharge of particles Latent image

Processing unit: Latent image positive image

Very good Edge enhancement i.e., differentiating areas

with different densities

Twice more sensitive than D speed film, but equivalent to E

speed film


Electrostatic charge may cause patient discomfort

Processing to be completed by 15 minutes


A digital image is an image formed & represented by a

spatially distributed set of discrete sensors & pixels

2 types of non- film receptors


Direct digital imaging digital image receptor

Indirect digital imaging video camera for forming digital

images of a radiograph

Two types of detectors are used in Direct digital imaging

Photostimulable phosphor ( PSP) barium fluorohalide

Charged couple device (CCD) silicon

Image is stored on a computer

DIGITAL IMAGING Schick System Digora System Trophy System

Manipulation of images

1. Magnification

2.Variable contrast

3. variable density

4. Labeling important information

5. Highlighting and colorization


1.Images are available in seconds

2. Exposure is reduced 50-90%

3. Image size, contrast and density can be manipulated to

improve interpretation

4. Record keeping is vastly improved. All films are labeled,

filed and retrieved easily. Duplicate hard copies are the
same as originals and simple to make

5. Provision of teletransmission



Structured noise is reduced in order to increase the

detectablity of changes in the radiograph

Structured noise refers to the information on the

radiograph which have not diagnostic value

It requires 2 identical images. The subtracted image is a

composite these two, representing a difference in their

Sensitive enough to detect changes of 0.12 mm

90% accurate in detecting mineral loss of 5%

Black end of gray scale suitable for proximal & recurrent


Contrast can be enhanced with color aid.



Softwares have been developed for automated procedures

which are able to overcome the short coming of human

Software supports an operation whereby a threshold is set

up by the examiner which determines the programs
display of lesion probability

Tuned Aperture Computed Tomography (TACT) involve the

tomosynthesis of structures in 3D thereby increasing the
accurate detection of caries

Useful for monitoring carious lesion

Increased sensitivity but decreased specificity



They selectively complex with carious tooth structure

which is later disclosed with the help of fluorescence


Aids in both quantitative & qualitative analysis of the lesion


Procion: N2 & (OH) groups irreversibly complex with caries

Acts as a fixative

Calcein: complexes with calcium & remains bound to the


Zyglo ZL-22: fluorescent tracer dye, not used in vivo

Brilliant blue: 10% aqueous Brilliant Blue , not used in vivo


1% acid red 52 in propylene glycol complexes specifically

with denatured collagen, hence used to differentiate
infected and affected dentin

Iodine penetration method (Pot iodide) for evaluating

enamel permeability


Dye staining and bacterial penetration are independent

phenomena, hence no actual quantification

They also stain food debris, enamel pellicle, other organic


Dye aided carious removal- laborious

Stains DEJ


Different index of light transmission for decayed & sound

tooth. Decayed tooth structure has decreased index &
appears dark


The tooth is illuminated using fiberoptics

Have a high level intra & inter-examiner variability

Digital imaging FOTI introduced, images captured by a

CCD camera & fed into the computer for image analysis

DIFOTI can detect caries on all types of teeth & also detect
incipient & recurrent caries before their visibility on



First proposed by Magitot in 1878

Tooth demineralization due to caries process causes

increased porosity of tooth structure. This porosity
contains fluid containing ions. This leads increased
electrical conductivity, conversely, leads to decreased
electrical resistance or impedance

ECM device uses a fixed-frequency (23 Hz)alternating

current which measures bulk resistance of tooth

Two systems

Vangaurd system 25 Hz ordinal scale of 0 9

Caries meter L 400 Hz 4 colored lights

green no caries yellow enamel caries

orange dentin caries red pulp involvement

ECM limited to occlusal sites.ECM to H/P- 97% accuracy

Cannot be used where amalgam filling is present

Materials have different responses at different frequencies.

Electrical Impedance Spectroscopy (EIS) operates over
different frequencies & thus determine more accurately


these differences. EIS can be used on both occlusal &

proximal surfaces

Factors affecting electrical measurements


Surface area

Thickness of the tissues

Hydration of enamel


Concentrations of ions in the dental tissue fluids



Research in the past two decades has lead to the

development of new technologies that asses changes in
fluorescence of enamel & dentin due to loss of mineral

Benedict- 1929, normal teeth fluorescence

Optical methods used are

Quantitative light- induced fluorescence- QLF

Infrared laser fluorescence - DIAGNOdent



Clinical examination neither predicts caries activity nor


Certain simple reliable lab tests can facilitate this,which is

important because;

- need & extent of personalized preventive measures

- index for therapeutic measures


- patient education

- manage progress of restorative procedures

- identify high risk groups / individuals

Requisites of tests

Correlation between predicted & actual caries development

Reliability & validity

Simple to perform

Quick results

Measurement of mechanism involved in caries process

Caries activity Vs Caries susceptibility

Caries activity refers to the increment of active lesions

Susceptibility refers to inherent propensity of the host &

target tissue affected by caries

Most of the tests measures the former

Caries activity tests measure either the quantity of specific

bacterial group or their ability to produce acids. Hence this
must be coupled with clinical examination prior to
treatment planning.

Caries Activity Tests


Lactobacillus colony count test:

Introduced by Hadley in 1933


Stimulated saliva collected & diluted with distilled water.

Spread evenly on Rogasas SL agar plate. Incubated at 37
C for 3-4 days. No.of colonies developed counted

No.of org/ ml Degree of caries activity 0 1000 Little / none

1000 5000 Slight 5000 10,000 Moderate > 10,000 marked

Calorimetric Snyder test:

Measures the ability of micro organisms to form organic

acids in carbohydrate

0.2 ml of patients saliva is pipetted into melted medium at

50 C. Incubated for 72 hrs. medium contains bromocresol
green which changes color from green to yellow in the
range of pH5.4 3.8

24 hrs 48 hrs 72 hrs If yellow Marked caries activity If

yellow Definite caries activity If yellow Limited caries activity If
green Observe 48hrs If green Observe 72hrs If green Caries

Swab Test:

Developed by Grainger in 1965

Based on the principle of Snyder test

Swab is taken from the teeth & incubated in medium

pH change after 48 hrs is read on a pH meter

pH 4.1or less Marked caries activity pH 4.2 4.4 Active pH 4.5

4.6 Slightly active pH 4.6 0r more Caries inactive

Salivary buffer capacity:

Tests the buffering capacity of bicarbonate ion in saliva


2 ml of stimulated saliva + 4 ml of distilled water

Set up is placed under paraffin seal to prevent loss of

volatile bicarbonate ion

Micro-burette & micro glass electrode are introduced under

the seal & the amount of 0.5 N HCl required to bring saliva
to pH 5 is measured

Samples requiring less than 0.45 ml of HCl indicate low

buffering capacity & vice-versa

Saliva-Check BUFFER:

Checking pH level & salivary buffering capacity of resting &

stimulated saliva

The kit consists of pH strips 5.0 8.0 & buffering strips

Resting salivary analysis is made by asking the patient to

expectorate any pooled saliva

Stimulated saliva is obtained by asking the patient to chew

paraffin wax for 30 sec

Samples collected are tested with the strips available in

the kit

Buffer strips contain 3 rows test pads. Salivary sample is

pipetted onto each of these pads. Color change noted after
5 min

pH analysis: Results in 10 seconds

Buffering capacity analysis: Results 5 min Color change on each

of the test pad is noted & points are assigned accordingly Green
4 pts Blue/ Red 1 pt Green/ blue 3 pts Red 0 pt Blue 2
pts Color change pH range Red 5.0 5.8 Yellow 6.0 6.6 Green
6.8 7.8


Interpreting results:

Combined total Buffering ability 0 5 Very low 6 9 Low 10

12 Normal/ high

Alban test:

Simplified substitute of Snyder test

Alban test medium 60 g Snyder test agar + 1 liter water

Patient to expectorate saliva in test tube containing Alban

test medium. Incubated at 37 C upto 4 days

Tubes are observed daily for:

- change of colour from green to yellow

- depth in the medium to which change has occurred

Scale for scoring:

color change is noted After 72 hrs/ 96 hrs of incubation

No color change

Beginning of color change = +

(from top to bottom)

One half color change = ++

color change = +++

Total color change = ++++

Caries Susceptibility Test


Enamel solubility test:

When glucose is added to saliva containing powdered

enamel, organic acids are formed. This will decalcify
enamel leading to an increase in soluble Ca ions

Amount of Ca obtained gives a direct measure of caries


Salivary reductase test:

Measures the activity of reductase enzyme in salivary


Kit commercially available- Treatex

Salivary sample mixed with Diazoresorcinol dye

Color changes are tabulated after 15 min

Color Caries conduciveness Blue in 15 min Non- Conducive

Orchid in15 min Slightly Conducive Red in 15 min Moderately
Conducive Red immediately on mixing Highly Conducive
Colorless in 15 min Extremely Conducive


Introduced by Bratthall to assess factors contributing to

development of caries

Consists of a pie diagram divided into 5 sector

- Green estimation of the chance to avoid caries

- Dark blue Diet

- Red bacteria- amt of plaque & S. mutans

- Light Blue Susceptibility- combination of F program

Saliva secretion & buffering capacity


- Yellow Circumstances- past caries experience & related






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