Techniques of Tooth Surface Assessment- Indications for Sealant Placement Margherita Fontana, DDS, PhD Domenick Zero, DDS, MS Indiana University School of Dentistry Department of Preventive and Community Dentistry Caries? Active? Arrested? How big? To Seal or Not To Seal?

“Prevention works”  Professional dental care  Community water fluoridation  School-based dental sealant programs  Role of “non-dentists” –Physicians, NPs, RNs, PAs –Social workers –WIC counselors –HeadStart teachers –and others…

Presentation Outline n Overview of Caries Detection/Diagnosis n Traditional Caries Detection Methods n Hidden Caries n New Methods of Caries Assessment  Visual  Technology-based n Caries Lesion Activity Status n Diagnostic Thresholds for Placing Sealants  Sound  Carious  Incipient  Cavitated

n What is the accuracy (sensitivity, specificity) of visual or visual-tactile techniques with and without the use of other adjunctive diagnostic techniques, such as radiographs, dyes, and lasers. What degree of accuracy in assessing caries is necessary before sealants can be placed?  How important are missed diagnoses, e.g. “hidden” caries? What do we know about “hidden” caries? What should we do about “hidden caries”?  What visual signs (color, opacity, stain, translucency or other physical characteristics structure) determine dental caries status of the surface and classification into established categories of disease state (sound/caries-free, questionable, enamel caries, and dentin caries)?

“Improved caries detection and diagnostic methods would help determine the appropriate cutpoint or threshold separating the clinical decisions to do nothing or preventively seal, or to therapeutically seal or surgically treat and restore” “Theoretically, laser fluorescence could be useful for determining whether a tooth is sound and does not require intervention, has evidence of a low level of caries ACTIVITY and is appropriate candidate for a sealant application, or has a higher degree of disease severity that requires surgical intervention. Ideally it could subsequently be used to monitor sealant effectiveness…” (Weintraub, 2001)

diagnosis early non-cavitated lesions “At this time the panel senses a paradigm shift in the management of dental caries toward improved diagnosis of early non-cavitated lesions and treatment for prevention and arrest of such lesions. Diagnosis and Management of Dental Caries Throughout Life (March 26-28, 2001) NATIONAL INSTITUTES OF HEALTH CONSENSUS DEVELOPMENT CONFERENCE Diagnosis and Management of Dental Caries Throughout Life (March 26-28, 2001) Restorations repair the tooth structure, do not stop caries, and have a finite life span. They are themselves susceptible to disease.”

Management of Dental Caries Diagnosis Risk Assessment Preventive + Non- Surgical Intervention (Medical Model) Restorative (Surgical) Intervention Oral Health Outcome Assessment Detection

Nigel Pitts The “iceberg of dental caries” Diagnostic thresholds in surveys, research & practice

Progress of Mineral Loss/Detection (White Spot)Disease Treatment?Disease Treatment

White Spot Lesion: It is a subsurface lesion External (outer) surface Internal loss of minerals

Diagnose Detection active, progressing rapidly or slowly, or already arrested. To Diagnose implies not only finding a lesion (Detection), but, most importantly, to decide if it is active, progressing rapidly or slowly, or already arrested. Without this information a logical decision about treatment is impossible (Kidd, 2001)

Visual Examination n Most widely used method, in dental offices, in clinical research and in epidemiological studies. n Quick, cheap and easy. dry, clean tooth n Should be performed on a dry, clean tooth, with good light, with a mirror. n Useful on all surfaces and on all types of caries. n The basis of most other detection, and most often compared to new methods. occlusal n Standard on occlusal, smooth surface and root caries. n Mostly dichotomous decisions: presence or absence. n Usually no quantification of lesions and therefore difficult to monitor lesions.

Wet Dry

Detection of Lesions n Sturdevant’s (1985) textbook in Operative Dentistry: –Defects are best detected when an explorer placed into a pit or fissure provides tug-back or resistance to removal. n Subject of controversy: –Use of the explorer does not add anything to the detection yield of the examination. –The use of the explorer may at best be misleading and at worst be potentially damaging. –Use a BLUNT probe, proper lighting, dry, clean teeth and sharp eyes

Probing with Sharp Explorer… Ekstrand et al., 1987 Traditional probing with a sharp explorer has come into question as the ultimate determinant of caries activity. The exclusive use of a “catch” by the sharp explorer to diagnose caries in pit and fissure sites should be discontinued and clinicians are being called upon to use “sharp eyes and a blunt explorer.” Also non- cavitated lesions can become cavitated simply through pressure from the explorer during the typical examination. Thus, penetration by a sharp explorer can actually cause cavitation in areas that are remineralizing or could be remineralized. Treating caries as an infectious disease. JADA 125 (June): 2-S to 15-S (1995)

Validationmethod Detection method CariesN=50 No Caries N=950TotalsN=1000 Caries Present TP True Positive N=20FP False Positive- Overtreatment N=57N=77 Caries Not present FN False Negative- Undertreatment N=30TN True Negative N=893N=923 Specificity: 94% Sensitivity of Visual Examination Sensitivity: 40% Alwas-Danowska et al., 2002 Occlusal surfaces: Typically low sensitivity, ~ 0.30, and high specificity

Appropriate Ways to Use the Explorer for Sealant Placement Clean debris from fissures and interproximal spaces Confirm and assess cavitations (breaks in the continuity of the surface) Feel the texture (roughness) of non-cavitated lesions, if they extend well beyond the opening of the fissure (if the program desires to consider surface activity in their risk decision making process) Once sealed, help assess the quality and integrity of the sealant.

Core ICDAS Criteria For use on coronal and root surfaces, as well as caries adjacent to restorations and sealants These unifying, predominantly visual, criteria code a range of the characteristics of clean, dry teeth in a consistent way that promotes the valid comparison of results between studies, settings & locations ICDAS criteria record both enamel and dentine caries and explore the measurement of caries activity in all three of the domains below Epidemiology / Public Health Clinical Research Clinical Practice  The ICDAS Detection codes are in use now and are recommended  The ICDAS Assessment codes are part of a developing research agenda  The ICDAS System provides an evidence based framework to validate and explore the impact of existing and new-technology aids to caries “diagnosis”

2 A. VISUAL APPEARANCE ICDAS-2 Score 5 DISTINCT CAVITY Score 6 EXTENSIVE CAVITY SOUND Score 0 2. ACTIVITY DETECTION AND SEVERITY OF THE LESION SURFACE INTEGRITY LOSS Score 3 OPACITY without air-drying: WHITE, BROWN Scores 2W,2B Ekstrand et al., modified by ICDAS (Ann Arbor), 2002; further modified by ICDAS (Baltimore) 2005 OPACITY with air- drying: WHITE, BROWN Scores 1W,1B UNDERLYING GREY SHADOW Score 4 Lesion in DentinLesion in Enamel Lesion in Enamel/ Dentin

n It must be emphasized that cleaning of the tooth surface and use of air are essential components in the use of these criteria, especially if differentiation between the lower categories (e.g., 0, 1 and 2) is considered necessary. –If cavitation is the threshold for sealant placement, then for surface assessment teeth can be dried with cotton rolls, gauze, or compressed air n No magnification is required to make these calls. –Magnification may be useful for surface assessment; sealant application; and retention checks; however, there is limited evidence in the scientific literature to support the adoption of magnification for visual assessment of tooth surfaces for sealant placement

n Lussi (1993) compared unaided VE with that using 2x magnification, VE with bitewings, bitewings alone, and visual/tactile with gentle probing, and found that magnification did NOT significantly improve sensitivity. n Forgie et al. (2002) found that using 3.25x loupes for occlusal and interproximal assessment sensitivity was significantly higher than unaided vision. Specificity and PPV were similar to unaided vision. n However, although magnification is not necessary to detect lesions using the ICDAS-2 criteria, its use may affect the interpretation of the histological findings in relation to the criteria developed to correlate with it. - For example, a category 2 tooth could be viewed as a category 3 under magnification, and this would result in more teeth being eliminated from consideration of sealants.

Role of Magnification in Determining Cavitation

Hidden Caries or Mis-Diagnosis? When no lesion is detected by visual examination, but radiographic methods reveal a lesion into the dentin. Noted in several reports in the 1980’s and 90’s (changes in histopathology of disease, slower progression, increased use of fluoride). Most studies at that time (that report a criteria) use cavitation as a threshold for caries. Prevalence: Ranges from 3% to 50% of lesions only detected on radiographs, usually 8-15% in adolescent population (Ricketts et al, 1997) Hidden caries does not seem to be a major problem when the clinical caries diagnostic criteria include non-cavitated diagnoses (Machiulskiene et al., Caries Res 1999)

Hidden Caries: Of the clinically ‘sound’ surfaces, between 26%-50% in year olds showed a radiolucency in the radiograph (Weerheijm et al., 1992) Should we use other methods to aid in the visual detection? Note: Sound teeth included everything except those with dentine caries clearly present-cavitation “decalcification at the entrance of a discolored fissure or a dim white aspect in enamel”: Sound

Radiographic Examination Radiographs show that demineralization is present, but when looked at in one period of time they cannot determine ACTIVITY Sealants can arrest active lesions and prevent further demineralization. However, the radiolucency will remain. <2% of sound surfaces diagnosed with dentin lesions on radiographs when non-cavitation was used as a threshold (Machiulskiene et al, 1999).

n Fluorescence methods –QLF –Infra-red Fluorescence n Transillumination –FOTI –DiFOTI n Electrical Conductance –ECM n Digital Radiography –DDR A New Way to “Look” at Dental Caries

Why new methods Goals:  Detect lesions early  More reliably than before  Quantification Lesion Progression: Occlusal surface at 0, 4, 8, 12 months (QLF)

Fluorescence Example White Spot Reflections obscuring image

QLF in Vivo System Light CCD camera with Filter Dental mirror

QLF; scattering, absorption and fluorescence in sound and carious enamel with sound dentin underneath Van der Veen and de Josselin de Jong‘00

QLF Examination

At a follow-up visit a second image it taken with an innovative repositioning software, specifically made for this technique.

Images can be taken and analyzed over time to monitor non-cavitated lesions

QLF, summary of studies Studies of natural caries on extracted teeth: SensitivitySpecificity Smooth Surfaces Occlusal Root caries 0.59 – – 0.88 Secondary Caries

Infra-Red Fluorescence: Diagnodent ® ValuesInterpretationRecommendation 0-13Soundno treatment 14-20Enamel lesionpreventive treatment >20Dentin Lesionpreventive or restorative treatment depending upon risk >30Dentin Lesionrestorative treatment Lussi et al, 2001 Note: As you lower the threshold, you increase Sens. and decrease Spec.(more false positives-more overtreatment)

Validationmethod Detection method CariesN=50 No Caries N=950TotalsN=1000 Caries Present TP True Positive N=46FP False Positive- Overtreatment N=133N=179 Caries Not present FN False Negative- Undertreatment N=4TN True Negative N=817N=821 Specificity: 86% Lussi et al., 2001 Sensitivity of a Detection System- Low Caries Prevalence Population Sensitivity: 92%

 Limitations  Stain in fissures (e.g., tea)  Calculus and plaque  Some dental materials, e.g. some sealants  Adjacent to fillings, some resin materials give signal  Not a good correlation between high score and depth of lesion  Irresponsible to let a machine do the diagnosis (“It is not a stand alone diagnostic tool” )  Bader and Shugars (2004): Systematic review conclusions for dentinal caries:  Sensitivity is almost always higher than traditional visual methods (range )  Specificity is almost always lower (range ).  “The increased likelihood of false positives compared with visual methods limits is usefulness as a principal diagnostic tool” Performance of Infra-Red Fluorescence

ACTIVITY: How to assess over time?  Increase in number of lesions in a certain time period (incidence, increment)  Increase or change in certain lesions (size, etc)… How to assess the caries lesion activity in one appointment?  Relate to appearance of lesion (chalky white, rough, dull, high surface porosity)  Relate to other patient factors (e.g., presence of plaque, closeness to gingival margin, presence of other lesions) (Ekstrand et al., 1998; Nyvad et al., 1999) We do not have yet a way/tool to do this reliably in “real-time” Thylstrup and Fejerskov, 1994 “WATCH”

Caries Detected? Caries Active Lesion? Initial Diagnosis (Based on physical appearance and location) Changes Present? Low Risk Yes No At Risk No Yes High RiskModerate Risk Transmission

 Once a pit and fissure surface is assessed and determined to be sound, questionable or carious (Incipient/enamel to frank/dentin caries), which categories are indicated for sealants? ?  What are the potential benefits and risks of sealing or not sealing sound, questionable or carious surfaces? Does it really matter?

“Clearly, since our diagnostic methods for assessing pit and fissure caries have been up to this time basically an educated guess, we must be placing sealants almost routinely over undetected incipient lesions” (Simonsen, 2002) When we view the low sensitivity of current methods, we have always misdiagnosed a significant number of fissures calling them sound when they are carious (Fiegal, 2002).

Indications for Occlusal Sealants Indications for Occlusal Sealants (Siegel, 1995)  On sound, at risk surfaces  To arrest enamel lesions Should the threshold be questionable or non-cavitated (incipient) caries lesions?

32 Diagnodent score used to find lesions underneath sealants: Takamori et al., 2001: Diagnodent could find 53.5% of lesions under white sealants). False positives? Is that lesion active or not? Was it there to begin with? Do not use it to diagnose secondary caries a.com/download/di agnodent.pdf

 Handelman, 1991 review of radiographic and bacteriologic studies (several years of follow up) on the therapeutic use of sealants  Concluded that “caries is inhibited and may in fact regress under intact sealants”. (Handelman et al. 1976; Handelman 1982; Mertz- Fairhurst et al., 1986, 1995).  Even with partially lost sealants no radiographic evidence of caries progression after 2 years (Handelman et al., 1986; Messer et al., 1997)

Heller et al. (1995) found in a fluoridated community that  initially sound surfaces were unlikely to become carious in 5 years and did not benefit greatly from the application of sealants (caries rate: 13% if not sealed vs. 8% if sealed).  There were, however, clear benefits in sealing incipient caries (52% if not sealed vs. 11% if sealed): Incipient if dark staining; chalky appearance, or if explorer sticks, but no frank caries (cavitation). When in doubt used this classification. Is it ethical to allow disease to occur before instituting a proven, effective preventive procedure?

Professional leadership has advocated that any fissure lesion judged to be limited to enamel is a candidate for sealant therapy (Siegal, 1995, 2002) Can we judge when caries is in enamel? Is it necessary that it be limited to enamel, or is the question whether it is cavitated or not and in need of operative intervention?

The concern with sealing more advanced lesions is that it is believed that the potential for caries to advance when sealants are lost is greater than with incipient lesions (Dentistry for the Child and Adolescent, 2004)

A 10-year clinical study evaluated bonded and sealed composite restorations placed directly over frank cavitated lesions extending into dentin vs. sealed conservative amalgam restorations and conventional unsealed amalgam restorations (Mertz-Fairhurst et al., 1998). Time Susceptibl e Host Carbohydrat e-rich diet Cariogenic Microflora Caries X

n How do we assess cavitated vs. non-cavitated lesions? –Visual assessment is appropriate –Teeth can be dried with cotton rolls, gauze, or compressed air –Explorer may be used to clean the fissures and “gently” confirm cavitations (i.e., breaks in the continuity of the surface); do not use sharp explorer under force –Magnification (2x-4x) can be used, but is not required due to insufficient evidence on its effect in assessing cavitation –Radiographs are unnecessary, especially in programs targeting children in grades 2 – 3 –Insufficient evidence to recommend other technologies to determine presence or absence of cavitation Summary J Pub Health Dent, 1995 * ** Non-CavitatedCavitated

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