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1
SUBJECTIVE & OBJECTIVE METHODS OF CARIES
DETECTION
2CONTENTS
INTRODUCTION DIAGNOSTIC TOOLS
VISUAL EXAMINATION TACTILE BASED ON RADIOGRAPHS
Conventional – IOPAR & BitewingXeroradiographyDigital
FUTURE TRENDS IN RADIOGRAPHIC DIAGNOSIS OF DENTAL CARIES
CO
NTEN
TS
3BASED ON VISIBLE LIGHT
BASED ON ELECTRICAL CURRENT
ULTRASOUND
ENDOSCOPY /VIDEOSCOPE
DYES – Enamel & Dentin
CONCLUSION
REFERENCES
4
In Greek “ Dia” means thoroughly “Giagnoska” means to know
OBJECTIVES
To identify lesions which require surgical treatment
(restoration).
Identify lesions, which require non-surgical treatment.
Identify high-risk group.
INTRODUCTION
5PREREQUISITES:
Accurate Reproducible Sensitive Reliable Specific Cost effective Not transferring infection to other
areas
6Methods of caries detection
In vivo
1. Visual examination
2. Tactile examination
3. Radiographs –conventional , digital and xeroradiography
4. Fiber optic transillumination
5. Optical method – Fluorescence, light scattering
6. Electronic resistance measurements
7. Ultrasonic
8. Dyes
7 In Vitro
Single tooth measurement
1. Chemical analysis
2. Cross sectional microhardness testing
3. Polarized light microscopy
4. Traditional transverse microradiography
5. Microprobe analysis
Method of sequential measurements on tooth slab
6. Iodine absorbitometry
7. Longitudinal microradiography
8. Light scattering
9. Surface microhardness
The visual examination of caries • detection of white spot,• discoloration and •frank cavitation or suspicious pits and fissures.
Visual examination
White spot
Pits and fissures
Discoloration
9 AIDS:
Magnification loupes
Use of temporary elective tooth
separation.
10PROCEDURE:
For detailed examination, the teeth are cleaned & dried with compressed air & illuminated with adequate light source.
DISADVANTAGES:
Discoloration of pits & fissures may be mistaken for cariesNot reliable for detection of secondary caries or occult caries.
11CLINICAL SEVERITY INDEX SCORES
Ekstrand et al, 1998
SCOR
ES
CRITERIA
0No or slight change in enamel translucency after drying
(> 5 sec)
1Opacity or discoloration hardly visible on wet surface,
but distinctly visible after air drying (> 5s)
2Opacity or discoloration distinctly visible without air
drying
3
Localized enamel breakdown in opaque or discolored
enamel &/or grayish discoloration from the underlying
dentine
4Cavitations in opaque or discolored enamel exposing
dentine
12
During the past 10 years the role of explorers in caries detection has become a controversial issue.
PROBING (TACTILE EXAMINATION)
13 AIDS:
-Mouth mirror
For direct illumination
For indirect illumination
Self illuminating
-Explorers
Right angle probe {no.6}
Back action probe {no.17}
Shepherds crook {no23}
Cow horn with curved ends {no.2}
PROCEDURE:
Determining roughness or softness of the tooth with sharp explorer. Both penetration & resistance to removal of an explorer tip i.e. the catch is interpreted as evidence of demineralization.
14REVIEW OF LITERATURE:
•Black et al (1924) gave the concept of passing the explorer into pits & noting whether or not there is softening & whether the instrument catches at any point.
•Simon et al (1956) recognized marginal changes around a previously placed restoration.
•Gilmore et al (1982) showed that a susceptible site can be entered by the use of a small sharp explorer or if enamel is rough , decalcified or directly opens in dentin.
15•Marzouk et al (1985) showed that by pressing a sharp explorer tip into pit &fissure will cause it to penetrate the enamel & or dentinal caries cone making a definitive diagnosis of caries.
•Strudvent et al (1985) were of the view that defects are best detected when an explorer provides tug back or resistance to removal.
16DISADVANTAGES:
•Can produce traumatic defects in lesions arrested by plaque control alone.
•Does not improve accuracy of diagnosis.
•Inter-operative variables.
•May transfer cariogenic bacteria from one site to another.
•Study by Lussi (1991) has found that application of too much pressure on explorer does not increase the accuracy of caries detection.
Use of floss as an adjunct to tactile sensation
Pickard (1961)
the use of floss for detection of caries.
18 VISUAL TACTILE METHOD
EUROPEAN SYSTEM
Visual methodexamination
requires 10 minutes / subject.
AMERICAN DENTAL
ASSOCIATION CRITERIA (USA)Visual tactile
3 min per subject
19
RECENT ADVANCES(Visual, tactile assessment)
CLINICAL SEVERITY INDEX
- Ekstrand et al, 1998
Scor
e
INTERNATIONAL CARIES
DETECTION & ASSESSMENT
SYSTEM (ICDAS)
- Ismail et al, 2007
No/slight change in enamel translucency
after drying (> 5 sec)0
No/slight change in enamel translucency after drying (> 5 sec)
Opacity/ discoloration hardly visible on
wet surface, but distinctly visible after air
drying (> 5s)
1 1st visual change in enamel
Opacity/discoloration visible without air
drying2 Distinct visual changes in enamel
Localized enamel breakdown in opaque/
discoloured enamel &/or greyish
discoloration from the underlying dentine
3Localized enamel breakdown in opaque/ discolored enamel
Cavitations in opaque or discoloured
enamel exposing dentine4
Underlying dark shadow from dentin
- 5 Distinct cavity with visible dentin
- 6Extensive Distinct cavity with visible dentin (>1/2 surface)
SCORE 1
SCORE 6SCORE 5SCORE 4
SCORE 2 SCORE 3
Description and clinical examples of each score of ICDAS
ADVANTAGES :
ICDAS has presented CONTENT VALIDITY
ICDAS has presented CRITERION VALIDITY
Significant correlation with lesion depth in the histologic examination has been shown.
–Braga et al, 2009
The specificity has been high, even when considering the non-cavitated threshold.
- Novaes et al , 2009
LIMITATIONS :
In primary teeth, ICDAS cannot distinguish accurately between lesions related to the outer or inner half of the enamel.
– Braga et al, 2009
Its sensitivity has been low for proximal caries in vivo
- Novaes et al 2009
ACTIVITY ASSESSMENT OF NONCAVITATED
AND CAVITATED CARIES LESIONS- Nyvad et al, 1998
ADVANTAGES :
This system has presented construct & predictive Validity concerning caries lesion activity status.
Worked well in assessing the depth of lesions on PRIMARY TEETH.
– Braga et al, 2009
SCORE
CATEGORY Description of scores in NYVAD’S SYSTEM
0 Sound Normal enamel translucency and texture
1 Active caries(intact surface)
Enamel surface whitish/yellowish, opaque with loss of luster; feels rough on explorer examination. Intact fissure morphology; lesion extending along the walls of the Fissure
2 Active caries(surface discontinuity)Active caries(cavity)
Same as 1.
Surface of cavity feels soft/ leathery on gentle probing.
4 Inactive caries(intact surface)
Enamel surface whitish/ brownish/black. Lesion extending along the walls of the fissure
5 Inactive caries(surface discontinuity)
Same as 4. Localized surface defect. No undermined enamel or softened floor detectable with the explorer
6 Inactive caries(cavity)
Surface of the cavity feels shiny and feels hard on gentle probing.
7 Filling (sound surface)
-
8 Filling 1 active caries
Cavitated/Non-Cavitated Lesion
9 Filling 1 inactive caries
Cavitated/Non-Cavitated Lesion
26
RADIOGRAPHS
Conventional – IOPAR & Bitewing
Xeroradiography
Digital :
1. Enhancement
2. Subtraction
3. Tuned Aperture Computed Tomography (TACT)
27I. CONVENTIONAL RADIOGRAPHY
IOPA radiographs
Bitewing radiographs
It involves two techniques:
28•Other techniques are:
- Occlusal radiograph - Panoramic radiograph
29
LIMITATIONS:
•Overlapping of approximal contacts.
•False diagnosis due to over estimation of lesion depth due to change in angulations
•Occlusal lesions, at times are imperceptible due to bulk of buccal & lingual cusps.
•Radiolucency can be due to resorption or other defects like wear etc.
30
• It gives 2 dimensional image of a 3 dimensional object.
• Superficial demineralization on buccal & lingual surfaces may be misinterpreted as a proximal lesion
• Fracture of one lingual cusp may also appear as radiolucent proximal caries.
• Tilted maxillary lateral too, gives carious appearance
• Cervical burn out also mimics cervical caries.
31CRITERIA FOR RADIOGRAPHIC ASSESSMENT
- Mejare et al, 1999R0 = no radiolucency
R1 = Radiolucency confined to outer half of enamel
R2 = Radiolucency in inner half of enamel + extending upto but not beyond DEJ.
R3 = Radiolucency in dentin, broken DEJ, but with no obvious spread in dentin
R4 = Radiolucency with obvious spread in outer half of dentin.
R5 = Radiolucency with obvious spread in inner half of dentin (> half way through to the pulp)
32FIVE POINT SCALE FOR OCCLUSAL CARIES BASED ON
VISUAL EXAMINATION + RADIOGRAPHS
-Espelidel et al, 1994
Grade 1: Non cavitated white spot / slightly discolored caries lesion in enamel not detected on the radiograph.
Grade 2: Some superficial cavitation in the fissure entrance, some non cavitated mineral loss in the surface of the enamel. Surrounding the fissure / and a caries lesion in enamel detected on the radiograph.
Grade 3: Moderate mineral loss with limited cavitation in the extreme of fissure / lesion in the outer third of dentin, detected on radiograph.
Grade 4: Considerable mineral loss with cavitation / or lesion into the middle third of the dentin, detected on the radiograph.
Grade 5: Advanced cavitation / or lesion into the inner thirds of dentin, detected on radiograph.
33(II) XERORADIOGRAPHY-Chester Carlson, 1937
•It is also called as EDGE ENHANCEMENT RADIOGRAPHY which means differentiating areas of different densities at the margins or edges.
•This technique simulates a Xerox machine.
•The image is recorded on an aluminium plate coated with a layer of selenium.
•These selenium particles are given a uniform electrostatic charge & are stored in a unit called conditioner.
34ADVANTAGES :
•The characteristic feature of this technique is to capture both
positive & negative prints.
•Better contrast
•It is twice as sensitive than D speed film but comparable to E
speed film.
•Edge Enhancement
•No need of any developer unit
35LIMITATIONS:
•The electric charge over the film causes discomfort to the patient as oral cavity provides humid environment which acts as medium for flow of current.
•Exposure time varies as exact thickness of plate is not
decided.
•Processing has to be completed in 15 minutes.
36(III) DIGITAL IMAGING
A digital imaging is an image formed and represented by a
spatially distributed in rows and columns known as pixels.
37•These are of 2 types:
Direct- the direct image receptor that collects the x-rays directly e.g. RVG
Indirect- E.g. Video camera is used for forming digital images of a radiograph.
38
•Digital image is a simple means where image is recorded in non film receptors.
•There are three types of digital detectors available, namely:
- Charged Couple Device (CCD)
- Complementary metal oxide semi conductor (CMOS)
- Phosphostimulable phosphorous plates
39
SYSTEM MANUFACTURER PROBE SIZE
R V G Trophy, Japan 19 x 28 mm
Flash dent Villa, Italy 20 x 24 mm
Sens-a-Ray Regan, Sweden 17 x 26 mm
Vixa Gendex, Italy 18 x 24 mm
Certain examples of Direct Digital Radiography include:
40
ADVANTAGES: •Dark room is not required•Image is viewed instantly •Image quality is consistent•Radiation dose is reduced•Elimination of the hazards of film development•Contrast can be enhanced 70% by digital mode•Digital method is 50% more sensitive in detecting occlusal caries
DISADVANTAGES :
•High cost of system•Life expectancy of CCD in not certain
41
It was shown that the resolution of digital image is lower than radiographs and the range of grey shades is limited to
256, whereas in a radiographic film, over one million shades of grey appear.
The diagnostic performance of unenhanced digital image does not exceed radiographs. Therefore, the contrast can
be digitally enhanced.
1) DIGITAL IMAGE ENHANCEMENT
422) DIGITAL SUBTRACTION RADIOGRAPHY
•Two standardized radiographs produced with identical exposure geometry are used.
•The first one is called reference image & the next ones are for comparison. The reference image is displayed on screen & the comparison images are super imposed on it.
•The difference between the original & the subsequent images shows dark bright areas.
- B.G.Zeides des Plantes, 1920s
43Nummikoski et al (1992) & Minah et al (1998) have regarded
it as a powerful tool in detecting primary & secondary caries.
ADVANTAGES :
•Detecting progress of re-mineralization & de-mineralization pattern.
•Alveolar bone height in periodontal diseases
•It is 90% accurate & can detect even up to 5% of mineral loss as compared to 30- 60% by conventional radiographs.
44•Minimal thickness - detected is 0.012 mm of bone.
•Overall density & contrast are good.
•By increasing spatial resolution the amount of detail displayed can be increased.
DISADVANTAGES :
•Correct projection geometry is mandatory.
45
This method contracts radiographic section through teeth.
The slices can be viewed for presence of radiolucencies.
Slices can be brought together in 3-D computer model called a psedohologram.
TACT slices and pseudohologram adequately detect primary and secondary caries.
3) TUNED APERTURE COMPUTED TOMOGRAPHY (TACT)
46
Significant differences between film, digital radiography, TACT slices in the
detection of caries.
FILM DIGITAL TACT
47FUTURE TRENDS IN RADIOGRAPHIC
DIAGNOSIS OF DENTAL CARIES
(A) Terahertz Imaging
(B) Multi-photon Imaging
(C) Optical coherence tomography
48(A) TERAHERTZ IMAGING
- Arnone et al (1980)
It uses waves with terahertz frequency (15 µm to 1 mm). This wavelength forms short enough to provide a reasonable resolution.
SOURCE OF TERAHERTZ RADIATION Photoconductive emitters of certain crystals (Zinc telluride) exposed to short pulses (<10-12) seconds of visible infra red light would emit electromagnetic waves with the frequency in the terahertz range.
49 ADVANTAGES:
- Low power used for imaging.
- Use of Non-ionizing radiation.
DISADVANTAGES :
1) Low spatial resolution due to long wave length of the
source.
2) Alterations in image interpretation since terahertz
waves are strongly absorbed by water, a potential
complication in the mouth.
50(B) MULTIPHOTON IMAGING
- Vinerot et al, 2010
ADVANTAGES :
• Non invasive method.
• Low average level of laser power. Therefore lower risk of
photo toxicity to the pulp.
• Longer incident wave
length results in increased
penetration.
• Can collect information
from caries lesion up to 500 µm.
51
DISADVANTAGES :
- The Micron assay involves movements required to produce
serial tomographic images over a period of 1 min or so is
well beyond the capabilities of most dentists.
- Currently the technique is performed only on extracted
teeth and large laser equipment is required.
52 (C) OPTICAL COHERENCE TOMOGRAPHY
(OCT) Developed for transparent
and semi transparent
structures.
Wave length of light 840-1310
nm with a depth of 0.6-2 mm
is used
53 PRINCIPLE:
Based on interference of light.
OCT uses Super Luminescent Diodes (SLD) as light
source. Which produces light with the broad range of
wave length.
ADVANTAGES:
Non-invasive diagnosis of secondary caries.
Development of prototype hand pieces for intra-oral OCT.
54BASED ON VISIBLE LIGHT
Optical caries monitor (OCM) FOTI and DIFOTI (Electro-Optical Sciences,
Irvington, N.Y.) QLF (Inspektor Pro, OMNII Oral Pharmaceuticals,
West Palm Beach, Fla.) DIAGNOdent (KaVo, Lake Zurich, Ill.; Midwest
Caries I.D., Dentsply, York, Penn), DELF(DYE-ENHANCED LASER FLUORESCENCE) Ultraviolet
55(I) OPTICAL CARIES MONITOR (OCM)
This comprises of
light source
measuring and reference units
a detection part.
The light is transported through a fiber bundle to the tip of
hand piece.
The tip is placed against the tooth surface and the
reflected light is collected by different fibers of the same
tip.
56 (II) FIBER OPTIC TRANSILLUMINATION
( FOTI )
-Friedman & Marcus (1970) PRINCIPLE:
There is different index of light transmission for decayed and
sound tooth. Tooth decay has a lower index of light
transmission than the sound tooth structure, an area of decay
shows up as a darkened
57METHOD:
A 150 watt halogen lamp and rheostat is used to produce a light of variable intensity. A fiber optic probe of 0.5 mm diameter is used to place in embrasure area. The marginal ridge is viewed from occlusal surface.
58ADVANTAGE :
No hazards , lesion not easily diagnosed by radiographs
can be diagnosed.
Initial results indicate that both specificity and sensitivity
are high.
DISADVANTAGE :
Subject to inter and intra observer variation. The major
problem remains low sensitivity.
59Digital imaging fiber-optic transillumination
(DIFOTI) Schneidermanalt et
al 1997 Visible light fiber-optic transillumination and digital CCD
camera.
60
Mini D cariesD-Carie Mini is a new caries detection portable device which is based on Fiber-optic principle.
It is easy to use and requires no calibration.
61(III) QUANTITATIVE LASER OR LIGHT INDUCED FLUORESCENCE
Sundstrom et al. (1981)•Normal Teeth fluoresce under UV light
-Benedict et al (1929)
•There is a difference in the Fluorescence of sound and caries
teeth.
•Loss of fluorescence is due to:
i. Light scattered and thus the absorption per unit volume is small.
ii. Light scattering in the lesion that prevents the light from reaching the
fluorescing dentin.
iii. Protenic chromophores are removed by caries process.
METHOD:
Blue-green visible light emitted from a argon ion laser of
wavelength 488 nm is used.
Demineralization appears as dark spots.
Clinical example of a lesion on the mesial surface of the canine associated with partial denture wear.
The QLF image showing enhanced contrast between sound and demineralized enamel.
63ADVANTAGES
Diagnosis of early lesion of enamel
High diagnostic validity
Detection of carious lesions in deciduous is more accurate than in permanent teeth.
DISADVANTAGES Cannot
differentiate between decay and hypoplasia
Poorer specificity
than the visual examination alone or radiographic examination alone.
Cannot discriminate between lesions restricted to the enamel and those extending into the dentine.
64(IV) DIAGNOdent Lucci et al (1998)
•A variant of QLF system, a DIAGNOdent was based on
research by Hibst and Gal.
•Light source – diode laser red light 655 nm.
65METHOD:
Comprises a pen like device with detachable tips of different diameter.
A reading is provided on a digital display accompanied by an audible tone.
The DIAGNOdent unit (KaVo)
Close-up of the tip and the knob for turning it around. LF device (DIAGNOdentpen) with
the tip for fluorescence measurements on approximal surfaces
Light direction of the tip of DIAGNOdent pen for approximal caries detection.
Guidelines for the clinical use of DIAGNOdent
Values Guidelines
0 to 13 No active care is advised (NCA)
14 to 20 Preventive care is advised (PCA )
21 to 30 (approx) Preventive or operative care is advised, depending on the patient's caries risk, the recall interval, etc (PCA or OCA)
Over 30 (approx) Operative (and preventive) care is advised . (OCA and PCA)
69Bader and ShugarS (2004) recently reviewed the literature
concerning studies of DIAGNOdent and concluded that
DIAGNOdent is more sensitive than conventional methods of
caries detection but that the risk of over diagnosis or false
positive raises concern that detection might imply diagnosis.
Attrill & Ashley (2001) compared the accuracy and repeatability of
three diagnostic systems (DIAGNOdent, visual and radiographic) for
occlusal caries diagnosis in primary molars. The DIAGNOdent was
the most accurate system tested for the detection of occlusal
dentine caries in primary molars.
.
70
DISADVANTAGES:
• It cannot differentiate between decay, hypoplasia, or
unusual anatomic features.
• It can’t differentiate between enamel & dentine caries.
• It can’t differentiate between active & inactive lesions.
• It can give false results due to stain, deposits or
calculus
71(V) DYE-ENHANCED LASER
LUORESCENCE•It had higher sensitivity than laser auto Fluorescence alone.
ADVANTAGES:
•It is convenient & fast method.
•Carious lesion can be detected with less than 1mm diameter
& depth of 5-10μ.
DYES USED ARE:
- Pyro methane 556
- Sodium Fluorescin
72 (VI) ULTRAVIOLET
UV light is used to increase the optical contrast between caries
region and surrounding sound teeth.
ADVANTAGE :
Sensitive than visual tactile method
DISADVANTAGE:
Specificity is a problem as it cannot detect between caries
lesion and developmental defect.
73 BASED ON ELECTRIC CURRENT
-Magitot et al (1878)
PRINCIPLE: It is based on the principle of electric conductance which is
measuring the electrical conductivity through the pores.
The electric conductance & tooth resistance are inversely
proportional.
The increased conductance &/or decreased resistance are
indicative of hypo- or demineralized surface.
74•Two techniques have been devised:
1. Electroconductivity measurements
(Electronic Caries Monitor, Lode Diagnostics,
Groningen, The Netherlands)
2. Impedance spectroscopy (CarieScan,
IDMoS, Dundee, Scotland)
75ELECTRONIC CARIES DETECTOR
•It is the instrument used to measure electric conductivity of
tooth.
•When potential of less than 1 volt is applied, the resistance
above 600,000 ohms -caries free tooth surface,
below 250,000 ohms - caries involving dentin are present.
• 0-9 scale indicating from sound to degree of
demineralization.
76ADVANTAGES:
•It is site & surface specific measurement.
•It is useful in detecting caries at pre-cavitation stage.
•Useful in monitoring progress of caries during caries control
program.
DISADVANTAGES:
•It can only recognize demineralization & not caries
specifically.
•Developmental defects also give similar effect.
•Enamel cracks may give false positive result.
77
(i)Van Guard Electronic Caries
Detector
•Massachusetts Manufacturing Corp. in 1980.
•The measure scale ranges from 0-9.
•The tooth is dried to prevent conductance.
78(ii) Caries Meter L
•It was given by GE International Corp., Belgium.
•It gives indication by glowing lights.
•There are 4 light sequences denoting caries:
Green - No caries
Yellow - Enamel caries
Orange - Dentine caries
Red - Pulp involvement
79BASED ON ULTRASOUND
MEASUREMENTS
•Ultrasound makes use of sound waves (by application of an
alternating voltage applied to a piezoelectric crystal) with a
frequency ranging from 1.6 to 10 MHz.
•Ultrasound interacts differently with different tissues.
80
METHOD:
To reach the target tissue, a coupling agent namely water/
glycerin is used. A flexible probe tip is fit into wedge shaped
inter proximal contours to conform to the shape of the
tooth.
DISADVANTAGE :
Useful only for superficial enamel lesions.
81 ENDOSCOPE/ VIDEOSCOPE A blue light (400-500 nm) is used to excite fluorescence within
the tooth.
ADVANTAGE: 5-10 fold magnification possible.
DISADVANTAGES:
- Requires meticulous drying and isolation.
- Takes 5-10 minutes compared to 3-5 minutes for conventional
technique.
Additionally a camera can be used to store the image.
82 DYE-PENENTRATION METHODS
Dyes can help visualize a subject from its routine
background or from objects that appears similar.
It gives qualitative as well as quantitative values.
For caries detection qualitative examination is done.
83 FOR ENAMEL CARIES:
- Procion: disadvantage - irreversible as dye reacts with nitrogen
and hydroxyl groups of enamel.
- Calcein : Complexes with calcium
- Fluorescent Dye: i) Brilliant blue ii) Zyglo ZX – 22
FOR DENTINAL CARIES:
- 0.5% basic fuschin in propylene glycol
- 1% acid red in propylene glycol
MODIFIED DYE PENETRATION METHOD – Iodine penetration
method for measuring enamel porosity of incipient carious region was
developed by Balnos et al (1977).
According to Fusayama et al. (1979), basic fuschin
stains the outer layer of carious dentine but not the inner.
This outer layer is infected, highly degraded and
unremineralizable and therefore must be removed prior to
restoration. In contrast the inner layer is not infected and
has been invaded only by bacterial products.
85
Fusayama & Terachima (1972) also separated lesions
into acute and chronic in terms of stainability. They
postulated that in an acute lesion, heavier staining
occurred because of the lower dentine hardness,
whereas in a chronic lesion, lighter staining is observed
because of the harder dentine in the level below.
86SUMMARY & CONCLUSION
“Inspite of all new discoveries there is a truth in the
past which is not and cannot be ignored or brushed aside”-Dr R.A.Millikan.
87Tandon S . Text Book Of Pedodontics. ; 2nd edition , Paras Medical Pub : 2008
Vimal K Sikri. Textbook of Operative dentistry .2nd ed Delhi, CBS publishers and distributors :2008.
Fejerskov . Dental caries disease & management ; 2nd edition, blackwell publication:2005
Soben Peter. Essentials of Preventive & Community Dentistry. 3nd edition, Arya Publishing house :2005
Pinkham . Pediatric Dentistry ; 4th Edition, 2005 .Mc Donald . Dentistry for Child & Adolescent ; 8th
Edition, Mosby pub. : 2005.Stewart R E . Pediatric Dentistry; 1st Edition, 1985.
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Newborn E. Cariology. 3rd ed. Chicago: Quintessence publishing co, Inc, 1989 Axelsson . Diagnosis of Caries .Quintessence Pub. Co., 2000.Nikiforuk G .Understanding Dental caries: Vol 1 , 1985.Hidden and incipient carious lesions : DCNA 2005 ; 49.Bo Krasse. Caries risk ;Quintessence publication: 1982.Ricketts DN, Kidd EA, Wilson RF. A re-evaluation of electrical resistance measurements for the diagnosis of occlusal caries. Br Dent J 1995; 178(1):11-17. Thomas CC. Caries detector dye is useful and in diagnosis of dental caries. Dental abstract 2000 vol 45(5) D C Attrill & P F Ashley .Occlusal caries detection in primary teeth: a comparison of DIAGNOdent with conventional methods British Dental Journal 2001; 190: 440 – 443.
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