Review Article

Dental Caries Diagnostic Methods Zangooei booshehry, M. * Fasihinia, H. ** Khalesi, M. *** Gholami, L. **** *Assistant Professor of Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Shahid Sadoughi University of Medical Sciences , Yazd, Iran. *General Physicion **Student of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran ***Post-graduate student of Prosthodontics, Faculty of Dentistry, Hamadan University of Medical Sciences. **** Post-graduate student of Periodontics, Faculty of Dentistry, Hamadan University of Medical Sciences.

ABSTRACT Dental caries, a progressive bacterial damage to teeth, is one of the most common diseases that affects 95% of the population and is still a major cause of tooth loss. Unfortunately, there is currently no highly sensitive and specific clinical means for its detection in its early stages. The accurate detection of early caries in enamel would be of significant clinical value. Since, it is possible to reverse the process of decay therapeutically at this stage, i.e. operative intervention might be avoided. Caries diagnosis continues to be a challenging task for the dental practitioners. Researchers are developing tools that are sensitive and specific enough for the current presentation of caries. These tools are being tested both in vitro and in vivo; however, no single method will allow detection of caries on all tooth surfaces. Therefore, the purpose of the present review was to evaluate different caries diagnostic methods.

Keyword: Dental Caries, Diagnosis, Radiography possibility of reversal. Rather, clinicians are

INTRODUCTION A diagnostic method for dental caries

forced to measure a dynamic process as a

should allow the detection of the disease in

dichotomous variable of the presence or

its earliest stages and for all pathologic

absence of disease using clinical criteria (e.g.

changes attributable to the disease to be

color, softness, resistance to removal), which

determined from early demineralization to

are all rather subjective, and tools (e.g. sharp

cavitations. Unfortunately,

explorer and dental radiographs) which are

none of the

currently accepted clinical caries diagnostic

becoming less useful.

methodologies have the ability to account for

Although, no single method is currently

the dynamics of dental caries, including the

developed that will allow detection of caries

Corresponding Author: M. Khalesi, Address:

on all tooth surfaces, these technologies have

Department of Prosthodontics, Faculty of Dentistry,

the potential to offer higher specificity and

Hamadan University of Medical Sciences. +989126778160

Fax:+98(351)6250344,

[email protected]

DJH 2010; Vol.2, No.1

Tel: Email:

sensitivity with respect to caries detection and quantification as well as to facilitate the

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Khaleis et al.

Dental Caries…

development of more effective preventive interventions. some

(1)

dental

The technique of temporary elective tooth

This article aims to review

separation as an aid to diagnosis of caries in

caries

proximal smooth surfaces is now regaining

diagnostic

methods

available including:

popularity, albeit with less traumatic methods

CLINICAL VISUAL INSPECTION

that seem acceptable to most patients and

The coronal carious lesion starts as a clinically

undetectable

subsurface

dentists. This method permits a more definite assessment

of

whether

radiographically

demineralization. With further progression, it

detectable proximal enamel (D1, D2) and

will

dentin lesions (D3) are cavitated.

(eventually)

become

clinically

detectable, and can, then, be classified

Temporary

according to type, localization, size, depth,

complemented by a localized impression of

and shape.

the opened interproximal space, allows a

The visual method, a combination of light, mirror,

and

the

probe

for

detailed

examination of every tooth surface, is by far the most commonly applied method in general

practice

worldwide.

Although

sensitivity is low and specificity is high, it may be possible to detect noncavitated enamel lesions (D1) on the free smooth surfaces (buccal and lingual), most anterior proximal surfaces, and the opening of some fissures; clinically detected cavities limited to the enamel (D1, D2); dentin lesions (D3) with cavitations into the dentin on the buccal and lingual surfaces, but there is limited detection

of

posterior

approximal

and

occlusal lesions. A major shortcoming is this method was very limited for detecting noncavitated lesions in dentin or posterior proximal and occlusal surfaces.

elective

tooth

separation,

more sensitive diagnosis of cavitations than does the purely visual separation method. (2) Ekstrand et al. evaluated the visual and tactile assessment of arrested initial enamel carious lesions and

showed that dentists were not

able to reliably and reproducibly determine the subtle visual and tactile differences between active and inactive enamel lesions.(3) In another

study,

Sheehy performed

a

comparison between visual examination and a laser fluorescence system for In vivo diagnosis of occlusal caries and concluded that since the laser fluorescence instrument can not be expected to differentiate caries from hypomineralizations, it should be used as an adjunct to a clinical examination.

(4)

On

the other hand, there are some questions about the use of dental explorer to probe suspected carious lesions. Hamilton reported that until to the time those facts emerge from acceptable long-term clinical trials, dentist

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DJH 2010; Vol.2, No.1

Khaleis et al.

Dental Caries…

should feel comfortable using the dental explorer to probe suspected carious lesions.

(5)

allows instantaneous images to be made and projected, and images taken during different

FIBER OPTIC TRANSILLUMINATION

examination can be compared for clinical

METHODS

changes among several images of the same

Fiber

optic

transillumination

(FOTI)

tooth over time. (1)

allows for the detection of carious lesion

However, Caution must be taken, when

because of the changes in the scattering and

interpreting a proximal DIFOTI image that is

absorption of light photons resulting from a

taken at a view similar to that of a

local decrease of transillumination due to the

conventional bitewing radiograph. Although,

(6)

the images may look similar, proximal

Enamel lesions appear as gray shadows and

lesions can be detected using DIFOTI only

dentin lesions appear as orange-brown or

by careful angulation, remembering that the

characteristics of the carious lesion.

bluish shadows.

(7)

In an in vitro study, FOTI,

resulting image is that of a surface or what is

performed along with visual examination,

near the surface. This also may explain why

had higher specificity both for enamel and

the DEJ is not always seen with conventional

dentinal lesions and had a better correlation

radiography, when the incident beam is

with histology.

(8)

Rousseau reported on the

transmitted through the entire tooth, often

development of a fiber-optics-based confocal

masking early changes in

imaging

and

However, this method is much better for

potential diagnosis of early dental caries. A

evaluating lesion depth at the proximal

novel

surface.

system

optical

for

the

detection

instrument,

capable

of

In

addition,

the surface.

another

possible

recording axial profiles through caries lesions

drawback of DIFOTI is the inability to

using single-mode optical fibers has been

quantify lesion progression, even though

developed which may provide additional

images can be compared over time.

diagnostic

in- vitro study indicated that the method has

practitioner. Digital

information

for

a

general

(9)

Imaging

(10)

One

higher sensitivity than does a radiographic Fiber

Optic

examination

for

detecting occlusal

lesions

Transillumination (DIFOTI) is a relatively

interproximal,

and

new methodology that was developed in an

surfaces.(11)

attempt to reduce the perceived shortcomings

CARIES INDICATOR DYES

on

smooth

of FOTI by combining FOTI and a digital

In 1972, it was suggested that caries-

CCD camera. Images captured by the camera

detector dyes could help differentiate infected

are sent to a computer for analysis using

dentin from affected dentin. However, more

dedicated algorithms. The use of the CCD

recent studies have shown that these dyes are

DJH 2010; Vol.2, No.1

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Khaleis et al.

Dental Caries…

non specific protein dyes that stain

with a depth of only 25 m have been

collagen in the organic matrix of less

measured in vitro. The restriction of light

mineralized dentin, whether it is infected or

scattering for caries diagnosis to smooth

not, rather than being specific for the

surfaces is a significant drawback to this

pathogenic bacteria.

(10)

technique, although, there is continuing

Al-Sehaibany et al. evaluated the use of

research to develop a QLF system to detect

caries detector dye in the diagnosis of

occlusal caries.

occlusal carious lesions. The purpose of their

Kuhnisch et al. evaluated the in vivo

study was to compare the accuracy of

detection of non-cavitated caries lesions on

diagnosis of carious lesions in the occlusal

the occlusal surfaces by visual inspection and

pit, fissure, and groove system of lower

quantitative light-induced fluorescence. It

molars examined by two methods: the caries

was concluded that QLF detects more non-

detector

tactile

cavitated occlusal lesions and smaller lesions

explorer.

compared to visual inspection. However,

Histological cross sections confirmed a ratio

taking into consideration time-consuming

of 1:1 (100%) accuracy by caries detection

image capturing and

dye in diagnosing decay underlying the

understand that QLF is not really of practical

occlusal surface. Concurrent examination of

use in the dental office.

the same occlusal surface by traditional

Laser induced fluorescence

dye

examination

versus using

traditional a

dental

explorer examination was only reliable in a

(13)

analysis, we can (14)

In 1998, Hibst and Gall described the

1:4 ratio (25%). (12)

successful use of red light (655nm) to

FLUORESCENT METHODS

differentiate between sound and carious

Quantitative light induced fluorescence

tissues and on this basis, the Diagnodent

(QLF)

system (DD) was developed. When using

QLF is based on the auto-fluorescence of

light with an excitation wavelength of

teeth. When teeth are illuminated with high

655nm, we can detect that more intense

intensity blue light, they will start to emit

fluorescence in the 700-800nm wavelength

light in the green part of the spectrum. The

region is observed from a carious lesion

fluorescence of the dental material has a

compared with a sound spot on enamel. DDS

direct relation with the mineral content of the

utilizes

enamel. No threshold for the detection of

excitation light source that is modulated to

white spot lesions using light scattering

differentiate it from ambient light. The light

a

655-nm

1-mW

laser

diode

techniques has been determined, but lesions

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DJH 2010; Vol.2, No.1

Khaleis et al.

Dental Caries…

is transmitted though a descending optical

fiber to a hand-held probe. The probe is

placed close to the measured surface,

two instruments were developed and tested in

thereby illuminating it with the laser light.

the 1980. The Vanguard Electronic Caries

Carious tooth structures emit fluorescence

Detector

above 680 nm when encountering this light

Corp., InterLeuven laan, Cambridge, MA)

and

and

and the Caries Meter L (G-C International

quantified by the DD unit as a number

Corp., Leuven, Belgium). Both instruments

this

fluorescence

between 0-99.

(15)

is

detected

(Massachusetts

Manufacturing

The laser fluorescence

measure the electrical conductance between

device represents high reliability in the

the tip of a probe placed in the fissure and a

detection of occlusal caries in teeth and its

connector attached to an area of high

performance is similar to direct visual and

conductivity (e.g. gingiva or skin). The

radiographic

measured

examination.

So,

the

conductance,

which

was

a

DIAGNOdent may be a useful adjunct to

continuous variable, was ,then, converted to

conventional methods for occlusal caries

an ordinal scale: 0 to 9 for the vanguard

detection.

(16-18)

system and four colored lights for the caries

ELECTRICAL

CONDUCTANCE

Meter L (green = no Caries, yellow = enamel caries, orange = dentine caries and red =

MEASUREMENTS (ECM) The idea of an electrical method of caries

pulpal involvement). To prevent polarization,

detection dates back to 1878, while it is

both

believed to have first been proposed by

alternating

Magitot. The basis of the use of ECM is

respectively.

observations which show that sound surfaces

removed by a continuous stream of air in the

possess limited or no conductivity, whereas

vanguard

carious or demineralized enamel should have

conductance. Conversely, to assure a good

a measurable conductivity that will increase

electrical contact and minimize the effect of

with the increase of demineralization. By

saliva, the Caries Meter L requires that the

decreasing thickness and increased porosity,

pits and fissures be moistened with saline.

the performance of electrical resistance has

Electrical conductivity has been shown to

been reported to be as valid as or better than

have an overall satisfactory performance in

traditional

detecting occlusal caries in vitro and in vivo

means

of

diagnosing

fissure

caries. (19)

systems

used

a

voltage,

25Hz

Moisture

system

low-

to

and

frequency-

and saliva

prevent

400Hz, were

surface

and approximal caries in vitro. (13)

Based on the differences in the electrical conductance of carious and sound enamel,

DJH 2010; Vol.2, No.1

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Khaleis et al.

Dental Caries…

X RAY- BASED IMAGING

DIAGNOdent is very high and its diagnostic

Intra Oral Radiography (INR)

validity is higher than that of bitewing

The history of dental radiography begins

radiography for proximal caries detection in (21)

with the discovery of the x- ray. The x- ray

primary teeth.

revolutionized the methods of practicing

Now, for the purpose of carious lesion

medicine and dentistry by making it possible

detection, intra oral radiography is a standard

(17)

procedure and is essential for diagnosing

to visualize internal body structures.

(22, 23)

Radiography is useful for the detection of

inter proximal caries.

dental caries because the caries process

Extra Oral Radiography (EOR)

causes tooth demineralization. The lesion is

Extraoral radiographic techniques for

darker than the unaffected portion and may

proximal caries detection have been studied

be detected in radiographs. An early carious

and proven to be inferior to intraoral

lesion may not have yet caused sufficient

techniques. However, the main focus was on

demineralization

conventional panoramic radiography.

to

be

detected

in

radiographs. It is often useful to mount

Clifton

successive sets of bitewing radiographs in

tomography and panoramic radiography as

one film holder to facilitate comparison and

well as intra-oral D-speed film for combined

evaluation of evidence of progression.

assessment of proximal and occlusal caries. It

Intra oral radiography can reveal carious

was concluded that when proximal surfaces

lesions that otherwise might go under

were evaluated alone, D-speed film was

detection

significantly better. For occlusal caries, there

during

a

thorough

clinical

et

al.

used

multidirectional

examination.

was no statistically significant difference

On the other hand, early carious lesions are

between multi directional tomography and

difficult

D-speed film. (24)

to

detect

with

radiographs,

particularly, when they are small and limited

One study has demonstrated that scanogram

to the enamel. Therefore, clinical and x-ray

images have the potential to be the first

examinations are necessary in the detection

practical extraoral imaging modality for

of dental caries.

proximal caries detection. Influencing factors

Posterior bitewing radiographs are the most

to be discussed are the sample, exposure

useful x-ray projections for detecting caries

techniques,

in the distal third of a canine and the

enhancement. In this study, the performance

interproximal

of

and

premolar and molars.

occlusal (20)

surfaces

of

However, Virajsilp

V et al. reported that the reliability of

6

resolution

screen-film

and

and

enhanced

contrast

digital

scanograms were not statistically different from Insight

film for proximal

caries

DJH 2010; Vol.2, No.1

Khaleis et al.

Dental Caries…

detection. Unenhanced digital scanograms exhibited a statistically significant lower diagnostic accuracy than Insight film.

(25)

including image manipulation and a reduction in radiation required to obtain a diagnostic image.

(1)

Digital radiography The use of digital radiography addresses two

primary disadvantages of dental film,

periapical diseases as it was previously thought.

In addition, Alkurt MT

Increasing the diagnostic yield for caries may

showed that the diagnostic performance of E-

be possible with three-dimensional (3D)

and F- speed films and direct digital

imaging methods. However, general dentists

radiography are similar for proximal caries

currently use two-dimensional (2D) images,

detection.

(26)

and although CT/MRI modalities exist for

Three dimensional x-ray imaging

hospitals, there are no systems for general

Since the discovery of the x-ray in 1895

practitioner caries diagnosis. The choices for

and its application to dentistry, radiographic

3D imaging of dentoalveolar diagnostic tasks

imaging of oral anatomy has consisted

are currently limited to different forms of

primarily of viewing 3-D structures collapsed

local CT including x-ray microtomography

onto a two-dimensional (2-D) plan. This form

(XMT),

of

tomography (TACT) and super-ortho-cubic

imaging,

known

as

transmission

tuned

aperture

radiography, is characterized by a point

CT. (27)

source of radiation producing a beam which

X-ray microtomography

computed

passes through the patient and strikes a

X-ray microtomography is a miniaturized

relatively flat image receptor (usually a film).

version of computerized axial tomography

This produces essentially an attenuation map

with a resolution of the order of micrometres.

of the structures through which the beam has

In the biomedical field, it is particularly

been transmitted. While the dental profession

useful in the study of hard tissue because of

has relied on this method for obtaining

its ability to accurately measure the linear

information about the hard tissues of the oral

attenuation coefficient. From this, the mineral

cavity, it inevitably superimposes anatomy

concentration can be computed, which is one

and metallic restorations which confound the

measure

problem of identifying and/or localizing

microtomography

diseases or objects in three dimensions.

dimensional images of bone from which

Moreover, studies have shown that intra-oral

structural parameters can be derived which

films produced in this way are not sensitive

could not be measured using conventional

for the detection of caries, periodontal, and

histomorphometry.

DJH 2010; Vol.2, No.1

of

bone we

quality. can

form

Using three-

(28)

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Khaleis et al.

Dental Caries…

Daatselaar et al. described the development

mineral content in the lesion area (Delta Z/

of a bench top local CT device which is able

Lesd in Vol %), the mineral Vol % and

of producing spatial and contrast resolutions

position of the subsurface layer and lesion

necessary

of

body.The accuracy of TMR for enamel and

other

dentine in lesion depth is about 200 Vol %.

authors

m in deltea Z. With mineral details of

concluded that ‘local CT reconstruction are

approximately 2-3 µm can be detected. The

feasible’ and ‘the resolution of the local CT

time required for making 5 scans plus

images produced from basis projections that

evaluation is 3-4 minutes (which is less than

were acquired using standard dental CCD

1 minute for a scan). The time required for

sensor was diagnostically suitable. This

acquiring step wedge data is one minute or

makes local CT a potential technique for the

less depending on the number of step wedge

for

interproximal

improved caries

dentoalveolar

as

conditions.

detection well

as

The

diagnosis of interproximal caries.

(29)

Transverse microadiography(TMR)

steps. Statistical analysis of many scans is supported.

(30)

TMR or contact- microradiography is the

Longitudinal Micro Radiography (LMR)

most practical and widely accepted method

LMR is a method to determine mineral

used to assess de- and re- mineralization of

loss in tooth slice samples in vitro. In this

dental hard tissues in studies. It is a highly

method, a microradiogram of a slice of a

sensitive method to measure the change in

tooth is prepared. Mineral content is then

mineral content of enamel and dentine

computed by performing measurements of

samples. In TMR, the tooth sample to be

the optical density of the microradiogram and

investigated is cut into thin slices (about 80

by comparing these values with that of an

m and 200 m for dentine samples). A

aluminum step wedge. LMR is based on the

microradiographic image is made on high

same principle as TMR. In contrast to TMR,

resolution

X-ray exposure of the

where a transversal slice of the tooth is

sections together with a calibration step

created, LMR is based on longitudinal slices.

wedge. The microradiogram is digitized by a

The LMR system is highly automated.

video camera or photomultiplier. The mineral

Scanning the sample is performed using a

can be automatically calculated from the gray

XY scanning table and all calculations are

levels of the images of section and step

performed automatically.

wedge. Parameters of interest are mineral

Tuned Aperture Computed Tomography

loss (Delta Z in Vol %. m ), lesion depth

(TACT)

film

(29)

(Lesd in m ), ratio or average loss of

8

DJH 2010; Vol.2, No.1

Khaleis et al.

Dental Caries…

It has been shown in controlled in vitro

Computer- aided radiographic method

studies that it can enhance the clinician’s

exploits

ability to

computers in assessing and recording lesion

detect

anatomically

and

localize

significant

disease,

structures

and

the

measurement

potential

of

size. In the new Trophy 97 system, artificial

abnormalities. TACT promises to overcome

intelligence

some

of

detector) is integrated: approximal carious

and

lesions are diagnosed and evaluated with the

increases the 3-D information

currently

aid of unique histologic database, allowing

available

influence

graphic

of

the

conventional

current

dental

in

ways

limitations

technologies

that

can

software

visualization

(Logicon

of

the

size

caries

and

significantly the diagnosis and management

progression of the lesion.

of dentoalveolar diseases and abnormalities.

At both D1 and D3 thresholds, computer-

With TACT, the patient has to remain

aided methods offer high levels of sensitivity

motionless

individual

for approximal lesions. Earlier soft wares

exposure. The time between exposures is

paid some trade off high with specificity, but

determined by convenience, diagnostic task,

newer methods also have high values for this

economics or other factors, because delays

measure.

have no impact on the accuracy of the

that the major advantages may be the

reconstruction. This approach also permits

significant dose reductions and the ability for

the

image quality manipulation.

only during

signal-to-noise

interactively examination.

to

ratio the

each

to needs

be

tuned

of

the

(31)

(33)

Furthermore, Wenzel reported

(34)

Terahertz Pulse Imaging (TPI) Terahertz pulse imaging (TPI) is s

Harse et al. performed a study to compare the

relatively new imaging technique that has

difference in the accuracy of proximal caries

been demonstrated in both non-biological

detection

by

tuned

aperture

applications. Although, the TPI system is a

computed tomography (TACT),

intraoral

new technique for imaging caries using non

TACT,

It

was

ionizing impulses of terahertz radiation, (an

concluded that extraoral TACT was not

electromagnetic radiation) and its ability to

statistically different from intraoral TACT or

detect early stages of caries lesions in various

film radigraphs for proximal caries detection.

sections of teeth and a hope in future when

This suggested that extraoral TACT may

this technique could indicate caries in all

and

extraoral

film

radiography.

have some clinical utilities.

(32)

areas

of

teeth.

Terahertz

systems

are

Computer- Aided Radiographic Method

relatively expensive and do not offer the

(CARM)

resolving power of radiographic examination. This system also needs more researches to

DJH 2010; Vol.2, No.1

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Khaleis et al.

Dental Caries…

make it possible to be inserted into the mouth

the TPI system uses only micro-watts of

for in vivo studies, while it is expected that

radiation of a type that is non-ionizing.

technological developments will improve the

Because the exposure levels from this system

systems to bring them within easy reach of

are

dentists. The coherent detection scheme of

exposure levels that occur naturally, this

system will be safer than those employing X-

of TMR depth plus an intercept of micron,

rays. Unlike radiography TPI also delivers a

whereas further calculations allowed the

spectrum of different frequencies for each

TMR depths to be determined to within 5%

pixel measured. This offers the possibility of

using TPI. (36)

using that spectrum for diagnosis that goes

These are some caries diagnosis methods

beyond

used today. In this era of evidence based

levels.

simply

measuring

mineralization

(35)

orders

of

magnitude

smaller

than

dentistry, systematic reviews and validation

Pickwell et al. compared terahertz pulsed

studies of caries detection methods have been

imaging

transmission

addressed in some studies but there is still

for

depth

need for more studies in the future to clearly

measurement of enamel demineralizations. It

determine the best and most accurate ways of

was

caries diagnosis.

(TPI)

microradiography

concluded

with (TMR)

that

TPI

measured

demineralization in the range of 47% of that

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