today ADX Sydney 2014

science & practice12 ADX14 Sydney Dentalcariesisstilloneofthemost prevalent but preventable diseases in the world. There is increasing evi- dence that those with poor oral health have poorer general health outcomes as well. Whether this is a causative relationship or an associa- tion with other co-factors is yet to be determined. Eventhoughalargeproportionof the population in developed coun- trieshaveseenimprovementintheir oralhealthoverthepastthreeorfour decades, individuals from certain groups, such as lower socio-eco- nomicgroupsandthemedicallycom- promised, are still at high risk of de- veloping dental caries. There has been a change in the philosophy aroundwhatisconsideredappropri- ate treatment, with a move away from the surgical model to a disease management model, often termed minimum intervention dentistry. As a result of the decline in caries expe- rience, the sensitivity of caries diag- nosishasbeenreduced.Earlydiagno- sisisvital,asitallowsinterventionto remineralise or heal the carious le- sion, whilst also addressing the caries risk factors and undertaking preventive actions, such as fissure sealing (Figs. 1a & b). Dentalcariesisconfusingtomany due to the profession using the same termforboththediseaseprocessand its outcome. A distinction should be made between three separate but in- terlinkedprocesses: the diagnosis of dental caries, the detection of a cari- ouslesion,andtheassessmentofthat lesion. While caries diagnosis in- volvestheassessmentofthewholein- dividual, considering all caries risk factors, such as personal and social factors, oral environmental factors and daily factors directly contribut- ingtothecariesriskoftheindividual and of the specific tooth surface, cariesdetectioninvolvestheuseofan objectiveinstrumenttodetectthedis- ease in the form of carious lesions, with assessment characterising and quantifying the extent and status of disease. The development of the Interna- tional Caries Detection and Assess- mentSystem(ICDAS)forthequantifi- cationofcariouslesionshasrecently providedavalidmethodforassessing and quantifying lesions, and the re- cent addition of an associated man- agement system, the International Caries Classification and Manage- ment System (ICCMS), provides evi- dence-basedmanagementoptionsfor the various stages of the carious le- sion, allowing for individual circum- stances. ICDAS rates lesions from a scoreof1,theearlieststagewherethe tooth needs to be dried to identify a white spot lesion, to 6, which repre- sents an advanced lesion. Educa- tional software is available (www.ic- das.org) and recently software to aid in the use of ICDAS in epidemiologi- cal surveys has been released (www.icdas.org/software-tools). Using a probe or explorer as a caries detection method persists in bothclinicalpracticeandundergrad- uatedentaleducationbutitmaydam- age the surface layer of deminer- alised enamel, increasing the likeli- hoodoftheneedforrestorativeinter- vention. Probing provides no advantageoverotherdetectionmeth- ods, even when interpreted in con- junction with them, so it is recom- mended that only a ball-ended probe be used, especially to check enamel surfaceintegrity/roughness. The sensitivity of a detection method relates to its ability to detect thediseasewhenitispresent,andthe specificity relates to the ability to de- tect the absence of the disease when itisnotpresent.Occlusalcariesdetec- tion is complicated clinically by sur- face morphology, past fluoride expo- sure, anatomical fissure topography, and the presence of plaque and stains. Commonly used methods for thistypearevisualandtactileinspec- tion, radiography, transillumination and laser fluorescence. This method, namely DIAGNOdent (KaVo), is pro- motedforuseforbothocclusalandin- terproximal lesion detection, with the technology based on the fluores- cence of porphyrins excited by laser lightatawavelengthof655nm(Figs. 2a&b).Thesensitivityandspecificity of laser fluorescence in detecting in- tra-dentinal lesions varies greatly, with false positives, the major limit- ing factor of the technology. In order to achieve the best results, the angu- lation of the tip should be consistent, andtheresultsshouldbeseenincon- junction with other detection meth- ods, not as a stand-alone gold stan- dard. Recently developed quantitative light-induced fluorescence systems (including QLF, Inspektor Research Systems, and SOPROLIFE, Acteon) utilise differences in auto-fluores- cence between sound and deminer- alised enamel and dentine (Fig. 3). Demineralised enamel appears darkerthantheadjacentsoundtooth structure, and the carious dentine fluoresces red depending on the fil- ters used. The use of QLF (wave- length 405nm) enables the early de- tection of enamel demineralisation, anditmaybeusedtodiscriminatebe- tween affected and infected dentine. LikeDIAGNOdent,QLFtechnologyis reliant on standardised techniques, especially control of ambient light, and the results must be seen in conjunction with other methods. SOPROLIFE uses a longer wave- lengthof450nm,andhassettingsfor the diagnosis of carious dentine, as well as a treatment mode, which as- sists in determining which dentine should be removed. A new system recently released uses laser-based photothermal ra- diometry (The CanarySystem, Quan- tum Dental Technologies), detecting luminescence and change in temper- ature to quantify mineralisation changes (Fig. 4). Further research is requiredonthistechnology. The method of fibre-optic transil- lumination is based on the principle that sound tooth structure has a higher index of light transmission than a carious tooth does. Units such astheSDIdiagnostictipforSDI’slight curingunitortheNSKtransillumina- tionhandpiecearesimpletouse.The lightsourceisplacedonthebuccalor lingualsideofthetoothasinFigure5 illustrating the head of the SDI unit. Transillumination is primarily used for the detection of proximal carious lesions, although studies have indi- cateditcanalsoimprovevisualdetec- tion of occlusal lesions. Carious le- sionslimitedtotheenamelappearas grey shadows, and those in the den- tine appear as orange-brown or bluishshadows. Theuseofdigitalradiographyhas become commonplace among many practitioners. The detection capabili- ties of digital radiography are re- ported to be similar to that of film- based methods, and have the benefit of reduced radiation exposure and the ability to readily transfer the im- ages. The recent development of multi- tonedisclosinggels(TriPlaqueIDGel, GCCorporation)mayaidcariesdetec- tion,asoldandcariogenicplaquecan be identified relatively easily—and whitespotstendtooccurunderolder plaque,sothiscantargettheareasto be investigated after gel removal. These products are potentially good for patient education, as the area of risk can be easily pointed out to the patient. Obtaining diagnostic repro- ducibilitybetweenexaminersisdiffi- cult,asclinicianstendtodevelopindi- vidualconceptsbasedonexperience regarding caries detection and the subsequentpreventiveorrestorative treatment options. Length of experi- ence also contributes, with experi- enced examiners having higher sen- sitivity,higherspecificityandgreater reproducibility than those less ex- perienced. Owing to the lack of a single detection method that pro- vides both high sensitivity and high specificity, combining a number of methodsisrecommendedtoincrease the accuracy of detection. For exam- ple, this may mean combining DIAGNOdentorSOPROLIFEfindings with direct visual and radiographic images. Several factors, such as fluo- rescentlighting,canupsettheresults of fluorescent-based detection meth- ods, so care in control of ambient lighting and standardisation of methodology are imperative when usingthesenewdetectionmethods. Thedevelopmentofnewtechnolo- giestoassistinthedetectionanddiag- nosis of caries can provide increased reliability; however, they must be used in the context of traditional vi- sual and radiographic assessment still being the gold standards of care at present. The current development ofICCMSbyaworldwidegroupofcar- iologists will use ICDAS and the cur- rent evidence base to provide infor- mation that will allow clinicians to use information such as lesion char- acteristics and caries risk to formu- latevalidtreatmentdecisions. Prof. David Manton currently heads the Growth and Development Unit (paediatric dentistry and orthodon- tics) at the University of Melbourne’s dentalschool. A list of references is available from thepublisher. Detecting dental caries:Is there anything new? An overview of the latest technologies and their clinical potential By Prof.David J.Manton,Melbourne Figs. 1a & b: Detection of occlusal caries can be difficult. (DTI/Photo courtesy of Prof. David Manton) Figs. 2a & b: The Diagnodent from KaVo works with laser fluorescence. (DTI/Photos courtesy by KaVo, Germany) Fig. 3: SOPROLIFE, a quan- titative light-induced fluorescence system, is available from Acteon. (DTI/Photo Acteon Group, France) Fig. 4: The Canary System. (DTI/Photo courtesy of Quantum Dental Technologies Inc, Canada) Fig. 5: Transillumination with SDI diagnos- tic light and collimator. (DTI/Photo courtesy of Dr Narisha Chawla, Australia) 1a 1b 2a 2b 3 4 5