1、D R.K AU SER SADI A FAKH RU D D INCARIES DIAGNOSISWhy is diagnosis important?It forms the basis for a treatment decision.Active lesions require some form of active management,whereas arrested lesions do not.?Informing the patient?Advising health service plannersDiagnosis?Diagnostic tests needs to be
2、 both valid and reliable.?VALID:means that the test measures what it is intended to measure,e.g.,white spot lesion with a matt surface indicates an active lesion which has not yet cavitated.?RELIABLE:or reproducibility means the test can be repeated with the same result(intra-examiner reproducibilit
3、y and inter-examiner reproducibility)Lesions into pulp D4+clinically detectable lesion in dentine D3+clinically detectable“cavities”limited to enamel D2+clinically detectable enamel lesions with“intact”surface D1?NAC(No active care advised)+lesions detectable only with traditional diagnostic aids?NA
4、C(No active care advised)+sub-clinical initial lesions in a dynamic state of progression/regression PREREQUISITES FOR DETECTION AND DIAGNOSISREQUIRES GOOD LIGHTINGCLEAN AND DRY TEETH clean deposits of calculus or plaque.Remember,to brush plaque out of the fissure coz its easy to miss a white spot le
5、sion at the entrance to a fissure Each quadrant of the mouth is isolated with cotton rolls to prevent saliva wetting the tooth and thorough drying with gentle blast of air from three in one syringe Sharp eyes or dental loupesLight probing.Sharp probes should never be used to detect the“tacky”feel of
6、 early cavitationGood bitewing radiographsDiagnostic tools?Visual?Tactile?Visual tactile?Radiographs _?Conventional Intrao ral Periapical radiograph&bitewing?Digital radiograph-enhancement,subtraction,tuned aperture computed tomography(TACT)Based on Visual Light?Optical caries monitor?FOTI&DIFOTI?QL
7、F&Diagnodent?UltravioletBased on Electrical Current?Electrical conductance?Electrical Impedence?Ultrasound?Dyes-Enamel&DentineNewer Technology:?Terahertz?Multiphoton imaging?Optical coherence tomography?Infrared flourescence?Infrared thermographyEarly Caries Detection?Electrical conductivity measure
8、ments(ECM)?Laser fluorescence using the Diagnodent unit (KaVo-IR)?Ultrasound measurements(UM)?Quantitative light fluorescence(QLF)(watch this video carefully showing different techniques for caries detection)Early Caries Detection?Optical Coherence tomography(OCT)?Fibreoptic transillumination(FOTI)?
9、Digital imaging fibreoptic transillumination(DIFOTI)?Direct Digital radiography(DDR)DETECTION AND DIAGNOSIS ON INDIVIDUAL SURFACESFREE SMOOTH SURFACESENAMEL?CAN BE DIAGNOSED WITH SHARP EYE,SAT THE STAGE OF THE WHITE OR BROWN SPOT LESION BEFORE CAVITATION HAS OCCURRED PROVIDED THE TEETH ARE CLEAN,DRY
10、 AND WELL LIT.?Although the white spot lesion is the earliest visual sign of disease,it has been preceded by destructive processes which arent seen macroscopic.Free smooth surface caries Smooth surface dental caries is recognized by white or brown lesions.In this photograph,the white areas are early
11、 evidence of disease.At this stage the lesions are not detectable by radiographs.Radiographic examination of the mandibular first molar and the maxillary second bicuspid reveals that considerable dentin destruction has taken place.ROOT SURFACE?In its early stages,appears as one or more small,well de
12、fined,discolored areas located in an area of plaque stagnation close to the gingival margin.?Lesion may vary in color from yellowish,or light brown,through mid-brown to almost black.FREE SMOOTH SURFACES?Active lesions are plaque covered,soft or leathery in consistency and may be cavitated.?Arrested
13、lesions are hard and are often located in a plaque free area coronal to the gingival margin.Arrested lesions may be cavitated.?Although lesion consistency is important in diagnosing activity,but great care should be taken when using a sharp instrument on these surfaces.?IT MAY BE SAFER TO TEST CONSI
14、STENCY OF THE LESION BY GENTLE USE OF A PERIODONTAL PROBE OR THE BACK OF AN EXCAVATOR.?IT SHOULD BE NOTED THAT COLOR OF THE LESION IS NOT A GOOD INDICATOR OF LESION ACTIVITY.?Root surface lesions tend to spread LATERALLY and coalesce with minor neighboring lesions and may thus eventually encircle th
15、e tooth.?Commonly,the lesions extend only 0.25-1mm in depth.?They do not always spread apically as the gingival margin recedes,but new lesions may develop later at the level of the new gingival margin.PITS AND FISSURESClinical-Visual Examination?Clean,dry well lit the surface?The active,un-cavitated
16、 lesion is white,often with a matt surface.?The corresponding inactive lesion may be brown?The enamel lesion are not visible on radiograph.?The enamel lesion that is only visible on a dry tooth surface is in outer enamel.?The lesion visible on a wet surface is all the way through enamel and may be i
17、nto dentine.?Cavitated lesions may present as micro-cavities with or without a grayish discoloration of the enamel.?The micro-cavity is easily missed on visual examination?Careful examination of bitewing radiographs is important and serve as a useful safety net to avoid missing micro-cavities.Hidden
18、 caries?A lesion that has been missed on visual examination but found on radiograph has been called hidden caries.?More advanced lesions may present as cavities exposing dentine?Cavitated lesions are usually visible in dentine on bitewing radiograph?Cavitated occlusal lesions,whether micro-cavities
19、or cavities down to dentine,are usually active because the patient cannot clean plaque out of the cavity.Laser Fluorescence method(DIAGNOdent)APPROXIMAL SURFACESClinical-Visual examination:?It is difficult to see the white spot lesion on an approximal surface because the lesion forms just cervical t
20、o the contact area and vision is obscured by the adjacent tooth.?The lesion is usually only discovered at a relatively late stage when it has already progressed into the dentine and is seen as a pinkish-grey area shining up through the marginal ridge.?The teeth should be isolated,clean and dry.?In c
21、ontrast,an approximal lesion on the root surface may be diagnosed visually but gingival health is mandatory for such a diagnosis to be reliable.?Thus,if the gingival are red,swollen and tending to bleed,caries diagnosis in these areas should be deferred until improved oral hygiene has been institute
22、d and the inflammation is resolved.Tactile examination:?A sharp curved probe(Briault)can be used gently to try to determine whether an approximal lesion is cavitated.Bitewing radiograph?It is of paramount importance in the diagnosis of the approximal carious lesion.?Caries on the approximal root sur
23、face is also visible on a bitewing radiograph,although this appearance is sometimes confused with the cervical radiolucency.Transmitted light?Can also be of considerable assistance in the diagnosis of approximal caries.?This technique consists of shining light through the contact point.?A carious le
24、sion has a lowered index of light transmission and therefore appears as a dark shadow that follows the outline of the decay through the dentine.FOTI(fiber optic transillusion)?In posterior teeth a stronger light source is required and fibre-optic lights,with the beam reduced to 0.5mm in diameter,hav
25、e been used.?It is important that the diameter of the light source is small so that glare and loss of surface detail are eliminated.The technique FOTI.?It is particularly advantages in patients with posterior crowding where bitewing radiographs will produce overlapping images and in pregnant women w
26、here unnecessary radiation should be avoided.Tooth separationSECONDARY OR RECURRENT CARIES?Is primary caries at the margin of a restoration.?The clinical diagnostic criteria are thus identical to those for primary caries as described above.Clinical-visual examination?A particular problem with amalga
27、m restorations is marginal breakdown or fracture,often called ditching.?Ditching occurs occlusally in an area that is easy to clean.Recurrent caries usually occurs approximally and cervically in areas of plaque stagnation?Ditching does not reliably predict infected dentine beneath the ditched area u
28、nless the ditch is an obvious cavity that would admit the tip of a periodontal probe(over 0.4mm)?Discoloration around restoration with clinically intact margins also does not reliably predict new caries beneath the restoration?Staining around an amalgam restoration should not trigger its replacement
29、 unless a carious cavity,or a very wide ditch that traps plaque,is also present.?Stain around a tooth-colored filling can also present as grey or brown discolored dentine shining up through intact enamel.This appearance probably represents residual caries left when the cavity was originally repaired
30、.?Clinical studies indicates that this appearance does not reliably indicate infected dentine(and presumably active demineralization)beneath the filling.?If the margin of the filling is clinically intact it is unlikely that active caries is present beneath and the filling does not need to be replace
31、d.Bitewing radiographs?Are important in the diagnosis of recurrent caries because this usually occurs cervically in the area of plaque stagnation.?Sometime a radiolucency on radiograph indicates residual caries left when the restoration was placed?This appearance represents residual demineralized de
32、ntine left when the filling was originally placed.?Tin and zinc ions from the amalgam have passed into the demineralized area to give the radio-dense appearance.?THIS RESTORATION DOES NOT NEED TO BE REPLACED.CATEGORIZING CARIES ACTIVITY STATUS?Following history,clinical and radiographic examination the dentist should categorize the patient as:?CARIES ACTIVE?CARIES INACTIVECaries active:active lesions and or an annual increment of two or more new,progressing or filled lesionCaries inactive:no active lesions or history of recent restorations
