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Caries Diagnosis

and How to Use

the DIAGNOdent

E-mail: [email protected]

Website: www.advancedental-ltd.com


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INDEX

To exit. Press Esc.

Traditional caries diagnostic model

Current caries model

Caries detection dye (CDD)

How to use the DIAGNOdent

Interpreting the results

False positives

Hypomineralized (hypocalcific) enamel

Hidden caries

Variable readings

E-mail: [email protected]

Website: www.advancedental-ltd.com

Fissure sealants


Traditional fissure caries and diagnostic model l.jpg

Traditional Fissure Caries and DiagnosticModel


Traditional diagnostic model l.jpg

Traditional DiagnosticModel

Low sensitivity

High specificity


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Low Sensitivity

Conventional diagnosis can miss significant amounts of decay

High Specificity

Conventional diagnosis does not produce a lot of false positive diagnoses


Traditional fissure caries model l.jpg

Traditional fissure caries model

Probe does not stick

“No caries”


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Traditional fissure caries model

Probe will now stick

Enamel decalcification


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Traditional fissure caries model

Continuing decalcification finally leads to cavitation of the enamel


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Traditional fissure caries model

Continuing decalcification finally leads to cavitation of the enamel


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Traditional fissure caries model

Continuing acid attack leads to dentin caries and further cavitation


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Traditional fissure caries model


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Traditional fissure caries model


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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

in finding fissure caries”


Black g v operative dentistry vol i henry kimpton london 7 th ed p32 1924 l.jpg

Black, G.V. Operative Dentistry. Vol. I Henry Kimpton, London. 7th 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.”


Rock wp kidd eam br dent j 164 8 243 47 1988 l.jpg

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 l.jpg

Not diagnosed by mirror, probe and Xray examination


1mm deep cavity l.jpg

1mm deep “cavity”


2mm deep cavity l.jpg

2mm deep “cavity”


3mm deep cavity l.jpg

3mm deep “cavity”


4mm deep total decalcification cavity was widened to 1 3 occlusal width to show on xray l.jpg

4mm deep, total decalcification.Cavity was widened to 1/3 occlusal width to show on Xray

4mm

1/3 occlusal width


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X-RAY

Contact point caries is much easier to detect radiographically

1/3rd

Digitally created


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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

Frequently the diagnosis of occlusal caries is less than straightforward


Al sehaibany white rainey j clin pediatr dent 20 4 293 298 1996 l.jpg

AL-SEHAIBANY, WHITE & RAINEYJ 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%.

______________________________

A seemingly intact occlusal enamel surface may conceal an extensive lesion of the dentin


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We are just guessing...

when we apply the

current standards

of care

in 21st century

operative dentistry


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The traditional fissure caries diagnosticmodel is very crudeLOW SENSITIVITY


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Current caries model


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Modern fissure caries model

Organic plug


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Modern fissure caries model

Decalcified or hypocalcific enamel

Organic plug

Acid percolation through porous, hypocalcific enamel can lead to failure of the organic plug


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Modern fissure caries model

Enamel may be developmentally hypomineralized, and consequently porous through its full thickness

Consequently, dentin can be exposed to acid without cavitation of the enamel leading to developmental dentin caries

ACID


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Modern fissure caries model

OR

by the time the tooth has emerged from under the operculum, the fissure enamel can already be carious

ACID


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Modern fissure caries model

These areas may not be decalcified, and a probe won’t stick


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Modern fissure caries model

Fissure walls are in close apposition

Once the organic plug fails, bacteria have access to the depths of the fissure

A probe will be unable to detect caries here

Decalcification


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Modern fissure caries model

Presentation is inverted compared to the traditional model

Continuing decalcification +dentin caries


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Modern fissure caries model

Can’t diagnose this with a probe or Caries

Detection Dye (CDD)

Defects in the fissure walls can lead to dentin caries with NO enamel decalcification


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Modern Fissure CariesAnatomy Model(Summary of realistic ‘coke bottle ‘ shape)

Organic plug

Decalcified or hypocalcific enamel (caries in this zone is undetectable by probe)

(This area may not be decalcified thus a probe won’t stick)

Enamel defects in fissure wall

De-mineralizing dentin


The diagnodent can diagnose this zone in the fissure l.jpg

The DIAGNOdent can diagnose this zone in the fissure


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Fissure Caries

  • The DIAGNOdent can “read” 2mm into the tooth

  • As long as the fissure is cleaned of debris, readings will detect changes in the underlying enamel and dentin

  • 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 l.jpg

How Does Caries Detection Dye Work

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”


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How Does Caries Detection Dye Work

Fusayama T. A Simple Pain –Free Adhesive Restorative System.1:18 1993

It is simply filling the voids in enamel and dentin that are created by acid attack, or filling voids present in hypomineralized enamel


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Slow onset caries

Caries Detection Dye

SEM Haikel et al.1983

Enamel prisms remain, but with some mineral loss P

Loss of interprismatic enamel creates a “micro-pore” effect S


Al sehaibany f white g rainey j t j clin pediatr dent 20 4 293 298 1996 l.jpg

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

75% of occlusal carious lesions missed by probing were found using CDD


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Carious fissure walls in very close apposition


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Carious fissure walls in very close apposition

Fissure appears totally sound


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Carious fissure walls in very close apposition

Fissure appears totally sound

Carious (decalcified) enamel in the depths of the fissure

Stained with Caries Detection Dye


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CDD

Carious fissure walls in very close apposition


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Occlusal fissure caries


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Stained with CDD

This tooth was partially erupted under an operculum for 18 months.

CDD has stained the carious enamel.


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Carious enamel and dentin stained

Note diffusion of the dye into demineralized occlusal enamel, as well as into the fissure


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Fissure Caries

DIAGNOdent

Demineralized, opaque carious enamel in the opening of the fissures

Stained pits

45

38


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Fissure Caries

DIAGNOdent

Stained with Caries Detection Dye

45

38


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Fissure Caries

DIAGNOdent

What the DIAGNOdent detected

None of this was detected using a probe and X-rays

45

38


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How to use the

DIAGNOdent


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KaVo DIAGNOdent laser


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KaVo DIAGNOdent laser

  • 655 nm diode laser

  • Reads 2mm into the tooth

  • Detects “fluorescence” in ANYTHING you aim it at

High sensitivity

Low specificity


It responds to l.jpg

It responds to…

  • High natural fluorescence of the tooth

  • Plaque and organic plug

  • Composite and stained margins

  • Calculus

  • Food (particularly greens)

  • Hypocalcific enamel, carious enamel / dentin


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DIAGNOdent Laser

A probe would not stick in these fissures

However, the decay could be found with a diagnostic laser

Sectioned

tooth


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DIAGNOdent Sleeve

Denticator 600 – 800 HL 1000 High Long Sleeve

You can use a sleeve so that you don’t need to autoclave the tips all the time

Simply calibrate the unit through the sleeve


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Scanning the Fissures

Do not apply pressure. It is not a probe!!


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Scanning the Fissures

Rotate the tip to “read” the fissure walls


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Techniques

There are two main techniques

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.


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PROPHYflex (KaVo)Sodium Bicarbonate for cleaning fissures


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Techniques

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

Negative readings <10 are almost always reliable

A more time-efficient technique


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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 l.jpg

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


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Interpreting

the results


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Interpreting the Results

A sound knowledge is required of

  • Fissure anatomy and developmental defects

  • The caries process

  • Enamel morphology in relation to

    • Developmental hypocalcific enamel

    • Carious enamel

  • Sources of false positives


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Interpreting the Results

  • When scanning carious enamel, the DIAGNOdent reacts to intensity of demineralization rather than the depth of the lesion

  • An understanding of the way caries develops in enamel allows for a better interpretation of the information provided by the DIAGNOdent


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Interpreting the Results

  • Slow onset caries leads to loss of interprismatic enamel that becomes micro-porous through to the dentin

  • This allows acid to dissolve mineral content from the dentin without any macroscopic cavitation of the overlying enamel

  • This is the most common type of damage that occurs in the walls of fissures


Early carious enamel l.jpg

Early Carious Enamel

Enamel is micro-porous but macroscopically sound

SEMS

Thylstrup and Fejerskov 1981


Carious enamel l.jpg

Carious Enamel

SEMS

Haikel et al.1983

Rapid onset Intraprismatic enamel is lost. Chalky and prone to cavitation.

Slow onset Interprismatic enamel is lost. Enamel is porous without cavitation.


Slow onset carious enamel l.jpg

Slow Onset Carious Enamel

Acid infiltration

SEMS Haikel et al.1983

Enamel prisms remain, but with some mineral loss P

Loss of interprismatic enamel creates a “micropore” effect S


Smooth surface dentin caries l.jpg

Microporous enamel

Smooth surface dentin caries

Cusp implosion due to non-cavitated lingual decalcification in a 15yr. old


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Smooth surface dentin caries

Acid infiltration through porous, but macroscopically sound lingual enamel lead to demineralization of the underlying dentin


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Rapid onset caries

13 yr old patient. Rapid onset contact point caries.


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Rapid onset caries

Rapid mineral loss of intraprismatic enamel and associated cavitation


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Rapid onset caries

Caries Detection Dye accurately stains demineralized carious enamel


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Rapid onset caries

Enamel cavitation has occurred before any mineral loss in the dentin

Compare this to…

Rapid onset caries


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Slow onset caries

This is also the usual presentation of caries in the depths of a fissure complex

… slow onset, non-cavitated contact point caries


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Interpreting the Results

  • The DIAGNOdent reacts equally to either form of enamel damage and cannot differentiate between slow onset and rapid onset caries

  • 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 l.jpg

Enamel cavitation beginning

Interpreting the ResultsDIAGNOdent readings of smooth surface caries


Interpreting the results diagnodent readings of smooth surface caries83 l.jpg

Interpreting the ResultsDIAGNOdent readings of smooth surface caries

48

65

36

99

20


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Interpreting the Results

  • The readings are related to the degree and intensity of demineralization, rather than the depth of the lesion

  • As the enamel becomes more porous, from right to left, the reading increases

  • Dentin damage is more intense under the more porous enamel, and is worst where cavitation of the enamel has commenced


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Interpreting the Results

Dentin caries was at its deepest where the DIAGNOdent readings were the highest


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Interpreting the Results

  • 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 l.jpg

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


Diagnodent readings l.jpg

DIAGNOdent readings

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


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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


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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


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DIAGNOdent readings

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


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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”


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Step down technique

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


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Step down technique

Carefully open the fissure entrance with Air-abrasion


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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.


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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


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Sudden increase in reading while rotating the tip in a fissure

As the beam approaches the carious wall, the reading will begin to increase


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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 fissure99 l.jpg

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.


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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


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If you are going to

WATCH something,

you have to be very

sure of what you are

watching


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False

Positives


False positives l.jpg

False Positives

  • Organic plug

  • Composites

  • Stained composite margins

  • Calculus

  • Impacted food in the fissures

  • Some prophy pastes

  • Remineralized carious enamel

  • Naturally fluorescent enamel


False positives104 l.jpg

False Positives

Some prophy pastes

  • 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

  • Impacted paste in the fissures will give a high reading, particularly with green coloured pastes


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False Positives

Some polishing pastes

  • 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

  • Impacted paste in the fissures will give a high reading, particularly with green coloured pastes


False positives106 l.jpg

34

58

20

False Positives

Naturally fluorescent enamel

  • Calibrate by placing the tip on a smooth surface and hold the ring switch for two beeps to auto-calibrate for the fluorescence

Latest model is one beep

Initial DIAGNOdent readings


False positives107 l.jpg

34

24

58

48

20

10

False Positives

  • After deducting the natural fluorescence reading of 10, the display indicated the following

Natural fluorescence reading 10


False positives108 l.jpg

24

48

10

False Positives

  • What was in there?

No caries in the mesial fissures


What about this fissure l.jpg

What about this fissure?

Images courtesy R Ehrlich

Heavily stained fissure

Is it carious or not?


What about this fissure110 l.jpg

What about this fissure?

Images courtesy R Ehrlich

The fissure was stained, but there was no active caries present

(Dormant caries)


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Laser Diagnosis

Images courtesy R Ehrlich

Diagnodent 6

Cautious, minimally invasive techniques are essential when there is doubt


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Hypocalcific

Enamel


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Histology: Hypomineralized enamel

NO Treatment!!

Smooth surface

  • Found in newly erupted teeth

  • Higher level of pores

  • Highly substituted enamel

DIAGNOdent 99

Caries potential is related to the site

Low risk


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Histology: Hypomineralized enamel

High risk

Fissures

  • Caries potential is related to the site

  • Plaque retention (acid) will mean caries WILL develop under this hypocalcific enamel

DIAGNOdent 99


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Histology: Hypomineralized enamel

High risk

Fissures

  • This is an extreme example. Most often, the presentation of developmental hypocalcific enamel is much more subtle

  • The caries establishes in the dentin via the porous, developmentally defective enamel


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Histology: Hypomineralized enamel

High risk

  • Defects existed that led directly to the dentin

Conclusion

Developmental hypocalcific enamel is of significance if it is detected in the pit and fissure system


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Histology: Hypomineralized enamel

High risk

  • 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 l.jpg

DIAGNOdent 45

DIAGNOdent 65

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


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Hypocalcific enamel and carious fissure enamel

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


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Hypocalcific enamel and carious fissure enamel

Fissure caries alongside developmentally defective enamel

A SITE SPECIFIC PROBLEM

15 yr old. High caries risk


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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 enamel122 l.jpg

Do not treat

Treat

Hypocalcific enamel and carious fissure enamel

15 yr old. High caries risk


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DIAGNOdent 55

Arrested caries/remineralization

35 yr old

Eruption phase, smooth surface caries has remineralized. It is hard and shiny and does not absorb CDD.


Arrested caries remineralization concepts l.jpg

Diagnodent 55

NO Treatment!!

Arrested caries/remineralization concepts

35 yr old

Eruption phase, smooth surface caries has remineralized. It is hard and shiny and does not absorb CDD.


Slide125 l.jpg

Carious

Enamel


Fissure caries126 l.jpg

Fissure Caries

An understanding of the fissure caries process is essential to be able to interpret the information provided by the DIAGNOdent.


Hidden caries or hypo calcification l.jpg

Hidden Caries or Hypo-calcification

Organic plug

Decalcified or hypocalcific enamel (caries in this zone is undetectable by probe)

(This area may not be decalcified thus a probe won’t stick)

Enamel defects in fissure wall

De-mineralizing dentin


Hidden fissure caries l.jpg

Hidden Fissure Caries

  • The DIAGNOdent can detect these lesions up to 2mm into the tooth

  • Low readings may occur if the caries is developing at the bottom of an otherwise sound fissure

  • Readings in the following tooth increased as the fissure was opened up


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Hidden Fissure Caries

DIAGNOdent

Step down technique

No visible demineralization

40


Hidden fissure caries130 l.jpg

Hidden Fissure Caries

DIAGNOdent

Fissure minimally investigated with Air-abrasion and re-stained with Caries Detection Dye

48


Hidden fissure caries131 l.jpg

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 caries132 l.jpg

Hidden Fissure Caries

Fissure opened and re-stained with CDD

Significant lateral spread of dentin caries was encountered


Hidden fissure caries133 l.jpg

Hidden Fissure Caries

DIAGNOdent 24

Stained with Caries Detection Dye.NO CDD stain.


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Conservatively investigated and rechecked with the DIAGNOdent

DIAGNOdent 38

The DIAGNOdent tip is now 1mm closer to the dentin, and is reading the caries better


And it l.jpg

and it

GREW!!!


Conclusion l.jpg

Conclusion

  • If the fissure is clean and unstained, and CDD is not staining carious enamel then….

    the DIAGNOdent is probably reading deeper, “hidden” caries


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Conclusion

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


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Variable

Readings


Non probeable stained fissure l.jpg

Non-probeable stained fissure

DIAGNOdent 20

Photo courtesy A Brostek


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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 l.jpg

The result was a fissure sealant

Photo courtesy A Brostek


Stained pits and fissures l.jpg

Stained Pits and Fissures

Non-probeable pits and fissures (32yr old)

6

21


What happened here l.jpg

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


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Stained enamel does not always give positive DIAGNOdent readings

The dilemma of stained fissures.

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.


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Laser Caries Diagnosis

Cautious, minimally invasive techniques like the step-down technique are required at marginal DIAGNOdent readings

Under 30 because…


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Laser Caries Diagnosis

..you might be scanning very shallow, intensely demineralized enamel, or it might be deep caries developing under 2mm of sound enamel


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Laser Caries Diagnosis

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.


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Laser Caries Diagnosis

Most reliably confirms theabsenceof disease


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It is NOT a traffic light for when to treat a tooth!


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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

Quality radiography

Laser caries diagnosis

CDD to guide caries removal


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Accurate caries diagnosis requires….

...the consistent use of ALL the modern diagnostic modalities because caries can have varied presentations in

a mouth


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Fissure

Sealants


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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


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Caries initiation factors

Studies have shown that due to the chemical immaturity of the newly erupted enamel

-almostall molar occlusal cariesis 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


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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)


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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


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Slow eruption phase

This is when most fissure caries becomes established


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Slow eruption phase

Combine this with some developmental fissure morphology defects

Instant caries


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36

Caries initiation factors

Morphology and slow eruption phase

DIAGNOdent

What if the defects are in the depths of a fissure?

Enamel defects

Deep fissures retain plaque and food


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48

36

Caries initiation factors

Morphology and slow eruption phase

DIAGNOdent

Sealing these teeth without diagnosis would lead to failure of the sealant


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Fissure Sealants

  • Most often, sealants have been placed without a detailed caries diagnosis

  • Consequently, inadvertent attempts are made to resin bond to hypocalcific enamel or carious enamel

  • This leads to debonding and staining at the margins which the DIAGNOdent will react to


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Fissure Sealants

  • Opaque sealants cannot be scanned through

  • Transparent sealants may allow leakage and caries to be detected

  • Test the resin response by scanning an obviously sound area of resin

  • If there is no response from the resin, it is safe to “scan” through the resin


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DIAGNOdent 65

12 Yr Old Fissure Sealant


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Sealant removed, stained with CDD and opened


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DIAGNOdent 55

Suspect clear fissure sealant in a 14yr old


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Fissure sealant removed and stained with CDD


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Was not on the X-rays!


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Sealant placed on undiagnosed caries

Caries Detection Dye can be used to check for leakage. Here it is penetrating through the porous, carious enamel underneath the partially retained sealant


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Sealant placed on undiagnosed caries

Microleakage indicated by CDD diffusing under the sealant


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Sealant placed on undiagnosed caries

Microleakage indicated by CDD diffusing under the sealant


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5 year old opaque sealant stained with Caries Detection Dye


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A very seriously failed fissure sealant!!


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Reliability

  • The DIAGNOdent is not reliable in detecting leaking sealants, however, it will give you some assistance when assessing the seal on clear sealants.

  • 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.


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Diagnose prior to any treatment

  • All fissures should be scanned with the DIAGNOdent before placing fissure sealants

  • This will alert you to the presence of damaged enamel that could prevent successful resin bonding, which can lead to failure of the sealant

  • Removal of diagnosed carious or hypocalcific enamel with Air-abrasion will improve the success rate of sealants


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KaVo DIAGNOdent

YES

DO YOU NEED A DIAGNOdent ?


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Micro-Dentistry requires a conscious effort to adopt diagnostic, re-mineralization, preparation and restorative techniques that allow for conservation of sound tooth structure


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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.


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KaVo RONDOflex

A simple Air-abrasion unit that connects directly to a multiflex coupling


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For more information on Microdentistry techniques go to the website link below.

There are further CDRoms available covering

Patient Microdentistry Education

Micro restorative techniques

Glass Ionomer-Composite Co-cure technique

E-mail: [email protected]

Website: www.advancedental-ltd.com

Postal: G W Milicich,

72 Braid Rd, Hamilton 2001, New Zealand


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