L12 Diagnosis of Dental Caries Flashcards
What is the difference between symptoms and signs?
- Symptoms: manifestations of disease apparent to the patient (presenting complaint)
- Signs: manifestations of disease detected by the clinician
What are the main 5 stages of caries detection?
1) Record patient history, PCO, risk factors
2) Extra-oral exam
3) Intra-oral exam
4) Visual-tactile examination of the teeth
5) Special investigation (e.g. radiogrpahs, sensibility testing, percussion test)
What risk factors for caries should be identified?
- Dietary habits
- Social and medical history
- Plaque control
- Saliva flow rate, buffering capacity and composition
- Caries history
- Restorative history
What symptoms may a caries patient present with?
- Symptom free (not uncommon)
- Symptoms of acute pulpitis (reversible or irreversible)
- Tender to percussion (TTP)
What are the symptoms of reversible pulptitis?
- Short, sharp pain
- Stimulated by sweet, cold or hot
- Lasts a few seconds
- Tooth not TTP
- Sensibility tests may have exaggerated response
What are the symptoms of irreversible pulptitis?
- Dull, throbbing pain
- Pain is spontaneous or exacerbated by sweet, cold or hot
- Lasts several minutes to hours after removal of stimulus
- Sensibility tests may have exaggerated or negative response
- Tooth not TTP except at late stages
What can pain on chewing indicate other than caries?
Fractured restoration or cracked cusp syndrome.
What are the requirements for visual assessment of caries?
- Clean teeth
- Good lighting
- Dry teeth
- Round end probe to explore teeth but NOT to probe
- Tooth seperators may be used in children
What should be performed prior to caries assessment?
- Biofilm removal
- Dental prophylaxis if medical history allows, careful not to cavitate potential early lesions beneath soft deposits
What is FOTI?
Fiber-optic transillumination:
- Light used to detect presence of crack or caries
- Should be considered an additional supplemental technique, not commonly available in most practices
Why is it important to dry teeth during caries assessment?
- Enamel is more porous in a carious lesion and pores will fill with water/saliva to disguise the presence of caries
- Drying fills the pores with air which has a different refractive index to saliva in pores, therefore light is scattered and early caries lesion is detectable
mICDAS code 0
- No or slight change in enamel after prolonged drying
- No enamel demineralisation
mICDAS code 1
- Opacity or discolouration (white spot lesion) visible after air drying, no obvious cavitation
- Demineralisation limited to the outer 50% of enamel
mICDAS code 2
- White spot lesion or greyish discolouration visible without air drying, no cavitation
- Demineralisation involving the inner 50% of enamel through to the outer third of dentine
mICDAS code 3
- Localised enamel breakdown in opaque or discoloured enamel +/- greyish shadowing from unelrying dentine
- Demineralisation involving the middle to inner third of dentine
mICDAS code 4
- Gross cavitation in opaque or discoloured enamel exposing the underlying stained dentine
- Demineralisation involving the inner third of dentine towards the pulp
Why are tooth separators sometimes used in paediatric dentistry?
- Small elastic bands placed interproximally exerts a pressure on teeth causing slight separation
- Allows interproximal lesion to be viewed directly
- Requires 2 appointments, can cause discomfort
- Less invasive than radiographs
What are the 2 main uses of the dental probe?
- Use the side to remove biofilm
- Use the tip in gentle stroking motion at 90 degree angle to feel texture of tooth
What should you never use a probe to do?
- Never push a probe into tooth tissue
- Never probe fissures
What does lesion activity refer to?
Whether a lesion is progressing or arrested/reversing.
Key to determine appropriate intervention.
What is lesion activity indicated by?
- Presence of biofilm
- Condition of adjacent gingivae (will be red and swollen)
- Texture, hardness and appearance
What is the difference in texture between healthy/arrested lesions and active lesions?
Healthy: enamel and dentine feel smooth and glassy
Active: pitting of enamel causes rough/gritty texture, carious dentine feels like wet suede, slightly tacky and rough
What terms describe disease activity in caries?
- Active
- Inactive/arrested
- Rampant (can be caused by xerostomia or bottle caries in infants)
What terms describe caries location on tooth?
- Smooth surface caries
- Interproximal caries
- Fissure caries
- Root caries
What terms describe a tooth’s previous experience of caries?
- Primary caries: no previous carious lesion on that site of the tooth
- Secondary (recurrent) caries: associated with an existing restoration
- Residual caries; retained over the pulp in a deep cavity
Describe root caries.
- Lesions on tooth roots, tend to be broad, shallow and progress more rapidly
- Often whole exposed root surface is affected but some areas will be worse than others
- Single lesion can contain active, chronic and arrested areas
- More common in elderly patients
What is the appearance of active root caries lesions?
- Usually next to the gingival margin
- Soft and dull, pale or dark
- Covered in biofilm
What is the appearance of inactive root caries lesions?
- Usually distant from the gingival margin
- Clean, no biofilm
- Hard shiny appearance, pale or dark
- Hard on stroking with probe
What are the benefits and drawbacks of bitewing radiographs for caries diagnosis?
- Shows enamel and dentine
- Shows proximity of caries to pulp and pulp morphology
- Allows depth of lesion to be assessed
However;
- Difficult to diagnose early occlusal caries due to superimposition of buccal and lingual/palatal enamel- occlusal caries usually only seen once they reach dentine
- Tend to underestimate extent of lesions
- Overestimation may also occur due to projection errors
- Small lesions may be completely lost by small changes in angulation of X-ray tube head
- Cannot tell us whether a lesion is active/inactive or cavitated/non-cavitated
When are intra-oral periapical radiographs indicated for caries diagnosis?
- Used when suspected that health of pulp is compromised
- Useful to confirm presence of carious lesions in anterior teeth and proximity to pulp- but not used in routine examination
What is a percussion test?
- Using the handle of a mirror or probe to gently tap vertically down the long axis of the tooth
- TTP = tenderness to percussion
- Patient feels tenderness if there is apical inflammation
What is a tooth sleuth?
- Used to detect cracked cusp
- Place rubbery plastic instrument over cusp and ask patient to bite down
What is laser fluorescence?
E.g. Diagnodent
- Laser light of specific wavelength irradiates tooth
- In the presence of a carious lesion, the amount of fluorescence will increase
- A photodiode at the tip of the device, measures the light feedback to give a numerical reading
- Higher level of fluorescence = indicative of caries
Possibility of false readings due to stained fissures, tertairy dentine and plaque.
What is an electrical caries monitor?
E.g. CariesScan Pro
- Enamel has low electrical conductance
• Increased pore volume in demineralised enamel increases electrical conductance as more saliva can fill these pores - High number of false positives
What is QLF?
Quantitative laser fluorescence e.g. Inspektor Pro
- Displays data on a monitor, shows shows fluorescent image of tooth
- Uses a computer to store information including probe location and placement
- Not to be relied on for diagnosis
What is lower, intra-examiner or inter-examiner, reliability?
Inter-examiner agreement (between different clinicians) is typically lower than intra-examiner agreement.
What are the effects of a false positive diagnosis?
May needlessly enter the tooth into a viscous restorative cycle.
Risk of damage to adjacent teeth.
Risk of effects on the pulp.
What are the effects of a false negative diagnosis?
May cause extensive tissue breakdown and pulp involvement in patients at high risk of rapid caries progression and irregular attenders.
Lesion is likely to be detected at a later visit for slow caries progression in reliable attendees, no serious tissue destruction.
What other conditions mimic caries?
- Fluorosis
- Idiopathic enamel opacities common on incisors
- Molar-incisor hypomineralisation
- Dental hypoplasia
What are causes of tooth loss other than caries?
- Attrition (tooth on tooth wear)
- Abrasion (non-tooth on tooth wear e.g. brushing)
- Erosion (tooth plus acidic substance)
How is dental erosion recorded?
Basic Erosive Wear Examination (BEWE)
Per sextant (like BPE)
Score:
0 = no erosive tooth wear
1 = initial loss e.g. loss of brightness, opaque appearance)
2= distinct defect, hard tissue loss, less than 50% surafce area
3 = hard tissue loss in more than 50% of the surface area
How are abrasion and attrition recorded?
Tooth surface loss (TSL) recorded using a tooth wear index (S&K)
Score:
0 = no loss
1 = loss of enamel surface characteristics
2 = loss of enamel exposing dentine for less than 1/3rd of surface
3 = loss of enamel exposing dentine for more than 1/3rd of surface
4 = complete enamel loss, pulp exposure or exposure of secondary dentine
Very time consuming technique.
What system is used to record TSL in the dental hospital?
Modified version of Smith and Knight system.
is used.
It identifies the worst surface per tooth only.
Codes:
0 = no loss of contour
1 = minor enamel wear, no dentine exposed
2 = dentine exposed up to 1/3
3 = >1/3 dentine exposed
4 = tertiary dentine or pulp space exposed
