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INDEX Traditional caries diagnostic model Caries detection dye (CDD) False positives Hypomineralized (hypocalcific) enamel Hidden caries Variable readings Current caries model How to use the DIAGNOdent To exit. Press Esc. Fissure sealants Interpreting the results E-mail: email@example.com firstname.lastname@example.org Website: www.advancedental-ltd.com www.advancedental-ltd.com
Penning C, van Amerongen JP, Seef RE & ten Cate JM. Validity of probing, for fissure caries diagnosis. Caries Res 26(6):445-9, 1993 Probing found unreliable Probing found unreliable in finding fissure caries
Black, G.V. Operative Dentistry. Vol. I Henry Kimpton, London. 7 th Ed, p32, 1924 A sharp explorer should be used with some pressure and if a very slight pull is required to remove it, the pit should be marked for restoration even if there are no signs of decay. A sharp explorer should be used with some pressure and if a very slight pull is required to remove it, the pit should be marked for restoration even if there are no signs of decay.
ROCK WP, KIDD EAM. Br Dent J. 164(8): 243-47, 1988. … decay is difficult to detect in radiographs unless larger than 2mm to 3mm deep into dentin, or 1/3 the bucco-lingual distance.
Not diagnosed by mirror, probe and Xray examination
4mm deep, total decalcification. Cavity was widened to 1/3 occlusal width to show on Xray 4mm 1/3 occlusal width
Contact point caries is much easier to detect radiographically X-RAY 1/3rd Digitally created
Chan DCN. Current methods and criteria for finding decay in North America. J Dent Ed 57(6):422-425, 1993 Caries is regularly found beneath a seemingly intact enamel surface Caries is regularly found beneath a seemingly intact enamel surface Frequently the diagnosis of occlusal caries is less than straightforward Frequently the diagnosis of occlusal caries is less than straightforward
AL-SEHAIBANY, WHITE & RAINEY J Clin Pediatr Dent 20(4):293-298 1996 The reliability of carious lesion diagnosis by sharp explorer compared to diagnosis of carious lesion by histological cross section was 25%. The reliability of carious lesion diagnosis by sharp explorer compared to diagnosis of carious lesion by histological cross section was 25%. ______________________________ ______________________________ A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin
Decalcified or hypocalcific enamel Organic plug Acid percolation through porous, hypocalcific enamel can lead to failure of the organic plug Modern fissure caries model
Consequently, dentin can be exposed to acid without cavitation of the enamel leading to developmental dentin caries Enamel may be developmentally hypomineralized, and consequently porous through its full thickness ACID
Modern fissure caries model OR by the time the tooth has emerged from under the operculum, the fissure enamel can already be carious ACID
These areas may not be decalcified, and a probe wont stick Modern fissure caries model
Once the organic plug fails, bacteria have access to the depths of the fissure Fissure walls are in close apposition Decalcification A probe will be unable to detect caries here Modern fissure caries model
Continuing decalcification +dentin caries Continuing decalcification +dentin caries Presentation is inverted compared to the traditional model Modern fissure caries model
Defects in the fissure walls can lead to dentin caries with NO enamel decalcification Cant diagnose this with a probe or Caries Detection Dye (CDD) Modern fissure caries model
Organic plug ( This area may not be decalcified thus a probe wont stick) Enamel defects in fissure wall Decalcified or hypocalcific enamel (caries in this zone is undetectable by probe) De-mineralizing dentin Modern Fissure Caries Anatomy Model (Summary of realistic coke bottle shape)
The DIAGNOdent can diagnose this zone in the fissure
Fissure Caries ä The DIAGNOdent can read 2mm into the tooth ä As long as the fissure is cleaned of debris, readings will detect changes in the underlying enamel and dentin ä The use of caries detection dye (CDD) to stain porous, carious enamel will help identify carious tooth structure that needs removing
How Does Caries Detection Dye Work Fusayama T. A Simple Pain –Free Adhesive Restorative System.1:18 1993 Fusayama T. A Simple Pain –Free Adhesive Restorative System.1:18 1993 The mechanism of differential staining does not involve selective chemical bonding of the dye in usual staining, but the selective penetration of the solvent
How Does Caries Detection Dye Work It is simply filling the voids in enamel and dentin that are created by acid attack, or filling voids present in hypomineralized enamel It is simply filling the voids in enamel and dentin that are created by acid attack, or filling voids present in hypomineralized enamel Fusayama T. A Simple Pain –Free Adhesive Restorative System.1:18 1993
Enamel prisms remain, but with some mineral loss P Loss of interprismatic enamel creates a micro-pore effect S Slow onset caries Caries Detection Dye SEM Haikel et al.1983
AL-SEHAIBANY F, WHITE G & RAINEY J.T. J Clin Pediatr Dent 20(4):293-298, 1996 CDD is a reliable diagnostic tool for occlusal carious lesions. Ratio of occlusal grooves stained by dye, to underlying carious lesions, is 1:1 by histological x-section in extracted teeth CDD is a reliable diagnostic tool for occlusal carious lesions. Ratio of occlusal grooves stained by dye, to underlying carious lesions, is 1:1 by histological x-section in extracted teeth 75% of occlusal carious lesions missed by probing were found using CDD
ä 655 nm diode laser ä Reads 2mm into the tooth ä Detects fluorescence in ANYTHING you aim it at High sensitivity Low specificity
It responds to… ä High natural fluorescence of the tooth ä Plaque and organic plug ä Composite and stained margins ä Calculus ä Food (particularly greens) ä Hypocalcific enamel, carious enamel / dentin
However, the decay could be found with a diagnostic laser A probe would not stick in these fissures DIAGNOdent Laser Sectionedtooth
DIAGNOdent Sleeve Denticator 600 – 800 HL 1000 High Long Sleeve You can use a sleeve so that you dont need to autoclave the tips all the time Simply calibrate the unit through the sleeve
Scanning the Fissures Do not apply pressure. It is not a probe!!
Scanning the Fissures Rotate the tip to read the fissure walls
Techniques Thorough sodium bicarbonate prophy before scanning. If debris is missed, false positives can still occur. Thorough sodium bicarbonate prophy before scanning. If debris is missed, false positives can still occur. These areas then require further cleaning with the PROPHYflex to ensure an accurate second reading. These areas then require further cleaning with the PROPHYflex to ensure an accurate second reading. There are two main techniques
PROPHYflex (KaVo) Sodium Bicarbonate for cleaning fissures
Techniques Scan the mouth and note areas with positive readings >15 Scan the mouth and note areas with positive readings >15 Many will have no debris or organic plug, and the reading will be reliable If there is a plug or debris with a high reading, selectively clean these fissures and re-scan If there is a plug or debris with a high reading, selectively clean these fissures and re-scan Negative readings <10 are almost always reliable Negative readings <10 are almost always reliable A more time-efficient technique
PROPHYflex (KaVo) Sodium Bicarbonate for cleaning fissures DO NOT use the RONDOflex (air abrasion) to clean fissures prior to using the DIAGNOdent Air abrasion with Aluminum Oxide cuts tooth structure Unnecessary removal of sound enamel is NOT indicated for diagnostic purposes
PROPHYflex (KaVo) - to ensure trouble-free use Use a second powder container After use, remove the powder container and replace it with the empty one Operate the unit for 10 secs to flush out the internal lines and tip, then run for 10 secs with water turned off before autoclaving
Interpreting the Results A sound knowledge is required of ä Fissure anatomy and developmental defects ä The caries process ä Enamel morphology in relation to ä Developmental hypocalcific enamel ä Carious enamel ä Sources of false positives
ä When scanning carious enamel, the DIAGNOdent reacts to intensity of demineralization rather than the depth of the lesion ä An understanding of the way caries develops in enamel allows for a better interpretation of the information provided by the DIAGNOdent Interpreting the Results
ä Slow onset caries leads to loss of interprismatic enamel that becomes micro- porous through to the dentin ä This allows acid to dissolve mineral content from the dentin without any macroscopic cavitation of the overlying enamel ä This is the most common type of damage that occurs in the walls of fissures Interpreting the Results
Early Carious Enamel SEMS Thylstrup and Fejerskov 1981 Enamel is micro-porous but macroscopically sound
Carious Enamel Rapid onset Intraprismatic enamel is lost. Chalky and prone to cavitation. Slow onset Interprismatic enamel is lost. Enamel is porous without cavitation. SEMS Haikel et al.1983
Enamel prisms remain, but with some mineral loss P Loss of interprismatic enamel creates a micropore effect S Slow Onset Carious Enamel Acid infiltration SEMS Haikel et al.1983
Smooth surface dentin caries Cusp implosion due to non-cavitated lingual decalcification in a 15yr. old Microporous enamel
Smooth surface dentin caries Acid infiltration through porous, but macroscopically sound lingual enamel lead to demineralization of the underlying dentin
Rapid onset caries 13 yr old patient. Rapid onset contact point caries.
Rapid mineral loss of intraprismatic enamel and associated cavitation Rapid onset caries
Enamel cavitation has occurred before any mineral loss in the dentin Rapid onset caries Compare this to…
Slow onset caries … slow onset, non-cavitated contact point caries This is also the usual presentation of caries in the depths of a fissure complex
Interpreting the Results ä The DIAGNOdent reacts equally to either form of enamel damage and cannot differentiate between slow onset and rapid onset caries ä Treatment decisions are related to an understanding of the caries process and the recognition of the type of enamel damage present
Interpreting the Results DIAGNOdent readings of smooth surface caries Enamel cavitation beginning
Interpreting the Results DIAGNOdent readings of smooth surface caries 20 36 48 99 65
Interpreting the Results ä The readings are related to the degree and intensity of demineralization, rather than the depth of the lesion ä As the enamel becomes more porous, from right to left, the reading increases ä Dentin damage is more intense under the more porous enamel, and is worst where cavitation of the enamel has commenced
Interpreting the Results Dentin caries was at its deepest where the DIAGNOdent readings were the highest
Interpreting the Results ä Therefore, there is a correlation between the dentin caries and the DIAGNOdent reading, but this is related to the intensity of the damage to the overlying enamel, rather than the DIAGNOdent giving a numerical reading that is indicative of depth of the lesion
Relating DIAGNOdent readings of smooth surface caries to fissure caries By understanding that the DIAGNOdent indicates intensity of demineralization rather than depth, fissure caries presents the potential to generate misleading responses By understanding that the DIAGNOdent indicates intensity of demineralization rather than depth, fissure caries presents the potential to generate misleading responses
Carious or hypocalcific enamel Severe, but superficial demineralization in this zone will give a high reading, even though there is not significant caries present in the depths of the fissure DIAGNOdent readings
Fissure walls in this zone are sound Caries developing in the depths of the fissure will give a lower reading than the previous case, even though the enamel damage may be more severe, because the laser is now scanning through a layer of sound enamel DIAGNOdent readings
Caries in this site will also give a lower reading, compared to a similar lesion on a smooth surface, due to the filtering effect of the overlying sound enamel
As the lesion progresses, the demineralization in the enamel fissure walls becomes more severe This gives a higher reading, but this is still not totally predictive of the depth of the dentin caries DIAGNOdent readings
Dentin caries developing under enamel defects in the depths of the fissure will give lower readings because of the thickness of the overlying sound enamel This is a form of hidden caries
If a reading is obtained that causes concern, yet there is no visible evidence to support the reading, minimally invasive techniques are essential when investigating the fissure Step down technique
Carefully open the fissure entrance with Air-abrasion Step down technique
Re scan the fissure. If the reading drops, the enamel damage was present in the fissure opening. If the reading remains constant, or increases, there is caries deeper in the fissure complex. Step down technique
Sudden increase in reading while rotating the tip in a fissure If there is fissure caries developing in one wall of a fissure, the initial angulation of the beam may completely miss the lesion. As an example, the reading at this point the reading may only be 5-10
As the beam approaches the carious wall, the reading will begin to increase Sudden increase in reading while rotating the tip in a fissure
Once the beam is directed at the lesion, there will be a rapid increase in the reading. The reading could now be 30-40, yet there is no external evidence of a lesion. Sudden increase in reading while rotating the tip in a fissure
Many of these lesions are very localized and subtle and if the fissure is not entered with minimally invasive techniques like Air- abrasion, they will not be observed and the reading from the DIAGNOdent is consequently discredited. Sudden increase in reading while rotating the tip in a fissure
Readings that oscillate with simple rotation of the tip are generally very reliable. If there was something present in the fissure entrance to cause a false positive, the reading would remain constantly high, rather than oscillate with the rotation of the tip
False Positives Some prophy pastes ä If you are not using sodium bicarbonate prophylaxis (PROPHYflex), check if your prophy paste causes a high reading by placing the DIAGNOdent tip into the prophy paste you are using ä Impacted paste in the fissures will give a high reading, particularly with green coloured pastes
False Positives Some polishing pastes ä If you are not using sodium bicarbonate prophylaxis (PROPHYflex), check if your prophypaste casues a high reading by placing the DIAGNOdent tip into the prophypaste you are using ä Impacted paste in the fissures will give a high reading, particularly with green coloured pastes
False Positives Naturally fluorescent enamel Naturally fluorescent enamel ä Calibrate by placing the tip on a smooth surface and hold the ring switch for two beeps to auto-calibrate for the fluorescence Initial DIAGNOdent readings3458 20 Latest model is one beep
False Positives ä After deducting the natural fluorescence reading of 10, the display indicated the following Natural fluorescence reading 102448 103458 20
False Positives ä What was in there? 24 48 10 No caries in the mesial fissures
What about this fissure? Heavily stained fissure Is it carious or not? Images courtesy R Ehrlich
What about this fissure? The fissure was stained, but there was no active caries present (Dormant caries) Images courtesy R Ehrlich
Laser Diagnosis Diagnodent 6 Cautious, minimally invasive techniques are essential when there is doubt Images courtesy R Ehrlich
Smooth surface DIAGNOdent 99 Caries potential is related to the site Low risk ä Found in newly erupted teeth ä Higher level of pores ä Highly substituted enamel NO Treatment!!
Fissures High risk DIAGNOdent 99 ä Caries potential is related to the site ä Plaque retention (acid) will mean caries WILL develop under this hypocalcific enamel
Fissures High risk ä This is an extreme example. Most often, the presentation of developmental hypocalcific enamel is much more subtle ä The caries establishes in the dentin via the porous, developmentally defective enamel
High risk ä Defects existed that led directly to the dentin Conclusion Conclusion Developmental hypocalcific enamel is of significance if it is detected in the pit and fissure system
High risk ä Defects existed that led directly to the dentin The DIAGNOdent will alert you Use CDD to confirm it CDD will stain porous hypocalcific enamel that is becoming carious
Hypocalcific enamel and carious fissure enamel The fluorotic or hypocalcific enamel on the cusps has remineralized. It is hard and shiny. 15 yr old. High caries risk DIAGNOdent 45 DIAGNOdent 65
HOWEVER In the fissure, the enamel has been continually exposed to plaque acid. It has the dull chalky appearance associated with active caries. 15 yr old. High caries risk Hypocalcific enamel and carious fissure enamel
Fissure caries alongside developmentally defective enamel A SITE SPECIFIC PROBLEM 15 yr old. High caries risk Hypocalcific enamel and carious fissure enamel
The porous, actively carious fissure enamel absorbs CDD The remineralized hypocalcific enamel does not A SITE SPECIFIC PROBLEM 15 yr old. High caries risk Hypocalcific enamel and carious fissure enamel
15 yr old. High caries risk Hypocalcific enamel and carious fissure enamel Do not treatTreat
Arrested caries/remineralization 35 yr old Eruption phase, smooth surface caries has remineralized. It is hard and shiny and does not absorb CDD. DIAGNOdent 55
Arrested caries/remineralization concepts 35 yr old Eruption phase, smooth surface caries has remineralized. It is hard and shiny and does not absorb CDD. Diagnodent 55 NO Treatment!!
Fissure Caries An understanding of the fissure caries process is essential to be able to interpret the information provided by the DIAGNOdent. An understanding of the fissure caries process is essential to be able to interpret the information provided by the DIAGNOdent.
Organic plug ( This area may not be decalcified thus a probe wont stick) Enamel defects in fissure wall Decalcified or hypocalcific enamel (caries in this zone is undetectable by probe) De-mineralizing dentin Hidden Caries or Hypo-calcification
Hidden Fissure Caries ä The DIAGNOdent can detect these lesions up to 2mm into the tooth ä Low readings may occur if the caries is developing at the bottom of an otherwise sound fissure ä Readings in the following tooth increased as the fissure was opened up
Hidden Fissure Caries Step down technique Step down technique No visible demineralization No visible demineralization DIAGNOdent 40
Hidden Fissure Caries DIAGNOdent Fissure minimally investigated with Air-abrasion and re-stained with Caries Detection Dye 48
Hidden Fissure Caries DIAGNOdent Reading has increased. The caries developing in the depths of the fissure has not been reached. The enamel in the fissure entrance was non carious. 48
Hidden Fissure Caries Fissure opened and re-stained with CDD Significant lateral spread of dentin caries was encountered
Stained with Caries Detection Dye. NO CDD stain. DIAGNOdent 24 Hidden Fissure Caries
Conservatively investigated and rechecked with the DIAGNOdent The DIAGNOdent tip is now 1mm closer to the dentin, and is reading the caries better DIAGNOdent 38
Conclusion ä If the fissure is clean and unstained, and CDD is not staining carious enamel then…. the DIAGNOdent is probably reading deeper, hidden caries the DIAGNOdent is probably reading deeper, hidden caries
Conclusion To use the DIAGNOdent in this step- down technique requires the use of a minimally invasive technology To use the DIAGNOdent in this step- down technique requires the use of a minimally invasive technology -the best of which is Air-abrasion, due to its ability to selectively dissect out damaged tooth structure -the best of which is Air-abrasion, due to its ability to selectively dissect out damaged tooth structure
Non-probeable stained fissure DIAGNOdent 20 Photo courtesy A Brostek
NO Caries! Cautious investigation with Air Abrasion meant a fissure sealant could be placed without undue cutting of the tooth. What if a high speed fissure bur had been used instead? Photo courtesy A Brostek
The result was a fissure sealant Photo courtesy A Brostek
Stained Pits and Fissures Non-probeable pits and fissures (32yr old) 6 21
WHAT HAPPENED HERE!!! The early enamel caries has remineralized. Hence the low reading of 6. However, there was a defect at the bottom of the fissure that allowed dentin caries to progress. It was more than 2mm inside the tooth and the DIAGNOdent could not see it. 6 21
Stained enamel does not always give positive DIAGNOdent readings The mesial pit had enamel fissure caries and dentin caries not on X-rays. From the history of the distal pit, it was only going to be time before the mesial grew. The dilemma of stained fissures.
Cautious, minimally invasive techniques like the step-down technique are required at marginal DIAGNOdent readings Under 30 because…
.. you might be scanning very shallow, intensely demineralized enamel, or it might be deep caries developing under 2mm of sound enamel
Laser fluorescence basically responds to the intensity of the damage to the enamel rather than the depth of damage. There is a basic correlation to intensity of demineralization and depth, but it is not consistent in the caries process.
It is NOT a traffic light for when to treat a tooth!
Accurate caries diagnosis requires…. Consistent use of magnification with illumination An understanding of the caries process and the variability of fissure anatomy Elimination of debris Laser caries diagnosis CDD to guide caries removal Quality radiography
.... the consistent use of ALL the modern diagnostic modalities because caries can have varied presentations in a mouth Accurate caries diagnosis requires….
Caries initiation factors 2 factors are considered important for plaque accumulation and caries initiation on occlusal surfaces -The stage of eruption / functional status -Tooth specific anatomy
Caries initiation factors Studies have shown that due to the chemical immaturity of the newly erupted enamel -almost all molar occlusal caries is initiated in the long eruption period (12-18 months) -premolars are the opposite, with a short eruption period and consequent low incidence of occlusal caries
Caries initiation factors Per Axelsson DDS PhD. Diagnosis and Risk Prediction of Dental Caries, Vol 2; Ch 5: Development and diagnosis of carious lesions: p182. Quint Pub, 2000. Cavalho et al (1989) showed that most occlusal lesions in molars are initiated during eruption… (12-18 months)
Caries initiation factors Kotsanis N, Darling A. Influence of post-eruptive age of enamel on it's susceptibility to artificial caries.Caries Res. 25:241-250 1991. … in addition, susceptibility to caries is strongly correlated to the post-eruptive age of the enamel The enamel is most susceptible to dental caries during and just after eruption, until secondary maturation is completed, after some years exposure to the oral environment
Slow eruption phase This is when most fissure caries becomes established
Slow eruption phase Combine this with some developmental fissure morphology defects Instant caries
Caries initiation factors Morphology and slow eruption phase Enamel defects What if the defects are in the depths of a fissure? Deep fissures retain plaque and food DIAGNOdent 48 36
Caries initiation factors Morphology and slow eruption phase Sealing these teeth without diagnosis would lead to failure of the sealant DIAGNOdent 4836
Fissure Sealants ä Most often, sealants have been placed without a detailed caries diagnosis ä Consequently, inadvertent attempts are made to resin bond to hypocalcific enamel or carious enamel ä This leads to debonding and staining at the margins which the DIAGNOdent will react to
Fissure Sealants ä Opaque sealants cannot be scanned through ä Transparent sealants may allow leakage and caries to be detected ä Test the resin response by scanning an obviously sound area of resin ä If there is no response from the resin, it is safe to scan through the resin
Reliability ä The DIAGNOdent is not reliable in detecting leaking sealants, however, it will give you some assistance when assessing the seal on clear sealants. ä Be careful that you are not reading a high fluorescence resin or organic plug not removed from the fissures prior to palcement of the original sealant.
Diagnose prior to any treatment ä All fissures should be scanned with the DIAGNOdent before placing fissure sealants ä This will alert you to the presence of damaged enamel that could prevent successful resin bonding, which can lead to failure of the sealant ä Removal of diagnosed carious or hypocalcific enamel with Air-abrasion will improve the success rate of sealants
KaVo KaVo DIAGNOdent DO YOU NEED NEED A DIAGNOdent ?
Micro-Dentistry requires a conscious effort to adopt diagnostic, re-mineralization, preparation and restorative techniques that allow for conservation of sound tooth structure
Air-abrasion is the preparation technique of choice once a decision has been made to instigate invasive treatment. It allows the selective removal of defective tooth structure.
KaVo RONDOflex A simple Air-abrasion unit that connects directly to a multiflex coupling
E-mail: email@example.com firstname.lastname@example.org Website: www.advancedental-ltd.com www.advancedental-ltd.com For more information on Microdentistry techniques go to the website link below. There are further CDRoms available covering Patient Microdentistry Education Patient Microdentistry Education Micro restorative techniques Micro restorative techniques Glass Ionomer-Composite Co-cure technique Glass Ionomer-Composite Co-cure technique Postal: G W Milicich, 72 Braid Rd, Hamilton 2001, New Zealand
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