Caries diagnosis Presentation Transcript CARIES DIAGNOSIS What is diagnosis? Diagnosis is an art and science that results from the synthesis of scientific knowledge, clinical experience, intuition & common sense Caries diagnosis implies deciding whether a lesion is active, progressing rapidly or slowly or whether is already arrested. ASSESSMENT TOOLS Stepwise progression toward diagnosis & treatment planning depends on thorough assessment of the following Patient History Clinical examination Nutritional analysis Salivary analysis Radiographic assessment HIGH RISK LOW RISK Social History Socially deprived High caries in siblings Low knowledge of caries Middle class Low caries in sibling High dental aspirations Medical History Medically compromised Xerostomia Long-term cariogenic medicine No such problem Dietary habits Sugar intake: frequent Infrequent HIGH RISK LOW RISK Use of fluoride Non-fluoridated area No fluoride supplements Fluoridated area Fluoride supplements used Plaque control Poor oral hygiene maintenance Good oral hygiene maintenance Saliva Low flow rate& buffering capacity S.mutans & lactobacillus counts Normal flow rate& buffering capacity S.mutans & lactobacillus counts HIGH RISK LOW RISK Clinical evidence New lesions Premature extractions Anterior caries restorations Multiple/repeated restorations No fissure sealants Multi-band orthodontics No new lesions No extraction for caries Sound anterior teeth No/few restorations Fissure sealed No appliances CONVENTIONAL METHODS OF CARIES DETECTION VISUAL-TACTILE METHOD RADIOGRAPHY CARIES DETECTING DYES FIBEROPTIC TRANSILLUMINATION ELECTRONIC CARIES MONITOR VISUAL-TACTILE METHODS Visual methods: Detection of white spot, discoloration / frank cavitations Without aids, unreliable Magnification loupes- Head worn prism loupes (X 4.5) or surgical microscopes(X 16) may be used comfort, relatively inexpensive, available in various magnification Use of temporary elective tooth separation Tactile methods: Explorers are widely used for the detection of carious tooth structure - Right angled probe- no.6 - Back action probe- no.17 - Shepherd's crook- no. 23 - Cowhorn with curved ends- no.2 Dental floss Use of explorer is not advocated because; Sharp tips physically damage small lesions with intact surfaces Probing can cause fracture & cavitation of incipient lesion. It may spread the organism in the mouth Mechanical binding may be due to non-carious reasons Shape of fissure Sharpness of explorer Force of application Path of explorer placement Use of explorer Explorer is useful to remove plaque and debris and check the surface characteristics of suspected carious lesions. gentle pressure just required to blanch a fingernail without causing any pain or damage All surfaces of a tooth are cleaned of debris and plaque, using an air syringe and examined visually. Suspicious areas are explored to check for the surface texture. SMOOTH SURFACE CARIES Non- cavitated: No signs of cavitation after visual or tactile examination. Location: where dental plaque accumulates (gingival margin). Surface characteristics: Matted (not glossy) when a tooth is dried. Areas of demineralization not in close proximity to the gingival margin not covered by plaque smooth and glossy are non-cavitated not active non-cavitated carious lesions . Visual enamel opacity under sound marginal ridge indicate undermined enamel due to dental caries non-cavitated carious lesion in dentin Non-cavitated carious lesion ENAMEL DENTIN Cavitated Lesions: Where there is visual breakdown of a tooth surface, it is classified as cavitated carious lesion. An active cavity on a smooth surface has soft walls or floors shown below: Questionable Area: All stained smooth coronal tooth surfaces that do not have the characteristics of non-cavitated or cavitated lesions are classified as questionable shown below Non-Carious Enamel Opacities Opacity not fluorosis Mild Fluorosis Moderate Fluorosis Severe Fluorosis Caries in Pit or Fissure Surfaces All discolored areas should be explored using gentle pressure. There is no need to penetrate a suspected lesion with an explorer. If a discolored and non-cavitated area is soft when explored, it is recorded as non-cavitated carious pit or fissure . A cavity is detected when there is an actual hole in the tooth in which an explorer could easily enter the space. An active cavity has soft walls or floors (detected using gentle exploring). If there is visual enamel opacity under an ostensibly sound or stained pit or fissure, then the enamel is undermined because of dental caries and the tooth surface is classified with a non-cavitated carious lesion in dentin . Pit and Fissure Caries Non-cavitated carious lesion Enamel Enamel Dentin Enamel If a discolored area is hard when gently explored then it should be marked as questionable . Cavitated Carious lesion Root Caries Root surface caries comprises of a continuum of changes ranging from minute discolored areas to cavitation that may extend into the pulp For diagnostic purpose; they may be: Active root surface lesion: well-defined area showing yellowish or light brown discoloration covered by visible plaque presence of softening/ leathery consistency on probing with moderate pressure Inactive root surface lesion (arrested): well-defined dark brown/ black discoloration smooth and shiny hard on probing with moderate pressure Active lesion Questionable Arrested Caries Arrested (remineralized) lesions can be observed clinically as intact, but discolored, usually brown or black spots. The change in color is presumably due to trapped organic debris and metallic ions within the enamel. These discolored, remineralized lesions are intact and are highly resistant to subsequent caries . The arrested caries need not be removed. Recurrent caries It is diagnosed whenever there is softness due to caries at a defective margin, and when the tip of a periodontal probe can enter the defect without any resistance. A restoration with a discolored margin or a small marginal ditch ( 10,000 marked Calorimetric Snyder test: Measures the ability of micro organisms to form organic acids in carbohydrate 0.2 ml of patients saliva is pipetted into melted medium at 50 C. Incubated for 72 hrs. medium contains bromocresol green which changes color from green to yellow in the range of pH5.4 3.8 24 hrs 48 hrs 72 hrs If yellow Marked caries activity If yellow Definite caries activity If yellow Limited caries activity If green Observe 48hrs If green Observe 72hrs If green Caries inactive Swab Test: Developed by Grainger in 1965 Based on the principle of Snyder test Swab is taken from the teeth & incubated in medium pH change after 48 hrs is read on a pH meter pH 4.1or less Marked caries activity pH 4.2 4.4 Active pH 4.5 4.6 Slightly active pH 4.6 0r more Caries inactive Salivary buffer capacity: Tests the buffering capacity of bicarbonate ion in saliva 2 ml of stimulated saliva + 4 ml of distilled water Set up is placed under paraffin seal to prevent loss of volatile bicarbonate ion Micro-burette & micro glass electrode are introduced under the seal & the amount of 0.5 N HCl required to bring saliva to pH 5 is measured Samples requiring less than 0.45 ml of HCl indicate low buffering capacity & vice-versa Saliva-Check BUFFER: Checking pH level & salivary buffering capacity of resting & stimulated saliva The kit consists of pH strips 5.0 8.0 & buffering strips Resting salivary analysis is made by asking the patient to expectorate any pooled saliva Stimulated saliva is obtained by asking the patient to chew paraffin wax for 30 sec Samples collected are tested with the strips available in the kit Buffer strips contain 3 rows test pads. Salivary sample is pipetted onto each of these pads. Color change noted after 5 min pH analysis: Results in 10 seconds Buffering capacity analysis: Results 5 min Color change on each of the test pad is noted & points are assigned accordingly Green 4 pts Blue/ Red 1 pt Green/ blue 3 pts Red 0 pt Blue 2 pts Color change pH range Red 5.0 5.8 Yellow 6.0 6.6 Green 6.8 7.8 Interpreting results: Combined total Buffering ability 0 5 Very low 6 9 Low 10 12 Normal/ high Alban test: Simplified substitute of Snyder test Alban test medium 60 g Snyder test agar + 1 liter water Patient to expectorate saliva in test tube containing Alban test medium. Incubated at 37 C upto 4 days Tubes are observed daily for: - change of colour from green to yellow - depth in the medium to which change has occurred Scale for scoring: color change is noted After 72 hrs/ 96 hrs of incubation No color change Beginning of color change = + (from top to bottom) One half color change = ++ color change = +++ Total color change = ++++ Caries Susceptibility Test Enamel solubility test: When glucose is added to saliva containing powdered enamel, organic acids are formed. This will decalcify enamel leading to an increase in soluble Ca ions Amount of Ca obtained gives a direct measure of caries susceptibility Salivary reductase test: Measures the activity of reductase enzyme in salivary bacteria Kit commercially available- Treatex Salivary sample mixed with Diazoresorcinol dye Color changes are tabulated after 15 min Color Caries conduciveness Blue in 15 min Non- Conducive Orchid in15 min Slightly Conducive Red in 15 min Moderately Conducive Red immediately on mixing Highly Conducive Colorless in 15 min Extremely Conducive CARIOGRAM Introduced by Bratthall to assess factors contributing to development of caries Consists of a pie diagram divided into 5 sector - Green estimation of the chance to avoid caries - Dark blue Diet - Red bacteria- amt of plaque & S. mutans - Light Blue Susceptibility- combination of F program Saliva secretion & buffering capacity - Yellow Circumstances- past caries experience & related disease ENGLISH English Franais Espaol Portugus (Brasil) Deutsch English Franais Espaol Portugus (Brasil) Deutsch

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