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Techniques of ToothTechniques of Tooth
Surface Assessment-Surface Assessment-Indications forIndications for
Sealant PlacementSealant Placement
Margherita Fontana, DDS, PhDMargherita Fontana, DDS, PhD
Domenick Zero, DDS, MSDomenick Zero, DDS, MSIndiana University School of DentistryIndiana University School of Dentistry
Department of Preventive and CommunityDepartment of Preventive and Community
DentistryDentistry
Caries?
Active? Arrested?
How big?
To Seal or Not To Seal?
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Prevention worksPrevention works
Professional dental care
Community water fluoridation
School-based dental sealantprograms
Role of non-dentists Physicians, NPs, RNs, PAs
Social workers
WIC counselors
HeadStart teachers
and others
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Presentation OutlinePresentation Outline
sOverview of Caries Detection/Diagnosis
sTraditional Caries Detection Methods
sHidden Caries
sNew Methods of Caries Assessment
Visual
Technology-based
sCaries Lesion Activity Status
sDiagnostic Thresholds for Placing Sealants
Sound
Carious
Incipient
Cavitated
http://www.omniipharma.com/inspektor_pro.asp8/14/2019 Margherita Fontana
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s What is the accuracy (sensitivity, specificity) of visual or visual-tactile
techniques with and without the use of other adjunctive diagnostic
techniques, such as radiographs, dyes, and lasers. What degree of
accuracy in assessing caries is necessary before sealants can be placed?
How important are missed diagnoses, e.g. hidden caries?What do we know about hidden caries? What should we
do about hidden caries?
What visual signs (color, opacity, stain, translucency orother physical characteristics structure) determine dental
caries status of the surface and classification into
established categories of disease state (sound/caries-free,
questionable, enamel caries, and dentin caries)?
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Improved caries detection and diagnostic methods
would help determine the appropriate cutpoint or
threshold separating the clinical decisions to donothing or preventively seal, or to therapeutically seal
or surgically treat and restore
Theoretically, laser fluorescence could be useful fordetermining whether a tooth is sound and does not
require intervention, has evidence of a low level of caries
ACTIVITY and is appropriate candidate for a sealant
application, or has a higher degree of disease severity
that requires surgical intervention. Ideally it could
subsequently be used to monitor sealant effectiveness
(Weintraub, 2001)
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At this time the panel senses a paradigm shift in the
management of dental caries toward improved diagnosisdiagnosis
ofearly non-cavitated lesionsearly non-cavitated lesions and treatment forprevention and arrest of such lesions.
NATIONAL INSTITUTES OF HEALTH
CONSENSUS DEVELOPMENT CONFERENCE
Diagnosis and Management of Dental CariesDiagnosis and Management of Dental Caries
Throughout Life (March 26-28, 2001)Throughout Life (March 26-28, 2001)
http://odp.od.nih.gov/consensus/cons/115/115_statement.htm
Restorations repair the tooth structure, do not stop caries,
and have a finite life span. They are themselvessusceptible to disease.
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+clin ically detectabl"cavities" limited to enam
+ clinically detectable enamellesions with intact surface
+lesions detectable only with traditiondiagnostic aids
+ sub-clinical initial lesions in a dynamic stateprogression/ regressio
Mis-labelled"caries
free"atthe Dthreshold
3
+clin ically detectabl
lesions in dentine
lesions into pulp
D4
D3 + enamel=
D3
D1
DHSRU/2002
Diagnosticthreshold
determines whais recorded asdiseased or
sound D3
D2
D1
Nigel Pitts
The iceberg of dental cariesDiagnostic thresholds in
surveys, research & practice
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Progress of Mineral Loss/DetectionProgress of Mineral Loss/Detection
(White Spot)
DiseaseDisease
Treatment?Treatment?DiseaseDisease
TreatmentTreatment
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White Spot
Lesion:
It is a subsurface
lesion
External
(outer)
surface
Internal
loss of
minerals
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To DiagnoseDiagnoseimplies not only
finding a lesion (DetectionDetection), but,
most importantly, to decide if it isactive, progressing rapidly oractive, progressing rapidly or
slowly, or already arrestedslowly, or already arrested..
Without this information a logical
decision about treatment is
impossible (Kidd, 2001)
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Visual ExaminationVisual Examinations Most widely used method, in dental offices, in clinical
research and in epidemiological studies.
s Quick, cheap and easy.
s Should be performed on a dry, clean toothdry, clean tooth, with good light,with a mirror.
s Useful on all surfaces and on all types of caries.
s The basis of most other detection, and most oftencompared to new methods.
s Standard on occlusalocclusal, smooth surface and root caries.
s Mostly dichotomous decisions: presence or absence.
s Usually no quantification of lesions and therefore difficult tomonitor lesions.
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Wet
Dry
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Detection of LesionsDetection of Lesions
s Sturdevants (1985) textbook in Operative Dentistry:
Defects are best detected when an explorer placed into a pit or fissure provides tug-back or resistanceto removal.
s Subject of controversy: Use of the explorer does not add anything to the detection yield of the examination.
The use of the explorer may at best be misleading and at worst be potentially damaging.
Use a BLUNT probe, proper lighting, dry, clean teeth and sharp eyes
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Probing with Sharp ExplorerProbing with Sharp Explorer
Ekstrand et al., 1987
Traditional probing with a sharp explorer has come into
question as the ultimate determinant of caries activity. The
exclusive use of a catch by the sharp explorer to diagnose
caries in pit and fissure sites should be discontinued and
clinicians are being called upon to use sharp eyes and a blunt
explorer. Also non-cavitated lesions can become cavitated
simply through pressure from the explorer during the typicalexamination. Thus, penetration by a sharp explorer can actually
cause cavitation in areas that are remineralizing or could be
remineralized.
Treating caries as an
infectious disease. JADA
125 (June): 2-S to 15-S
(1995)
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ValidationValidationmethodmethod
Detection methodDetection method CariesCaries
N=50N=50
No CariesNo Caries
N=950N=950
TotalsTotals
N=1000N=1000
Caries PresentCaries Present
TPTP
True PositiveTrue Positive
N=20N=20
FPFP
False Positive-False Positive-
OvertreatmentOvertreatment
N=57N=57
N=77N=77
Caries Not presentCaries Not present
FNFN
False Negative-False Negative-UndertreatmentUndertreatment
N=30N=30
TNTN
True NegativeTrue NegativeN=893N=893
N=923N=923
Specificity: 94%Specificity: 94%
Sensitivity of Visual ExaminationSensitivity of Visual Examination
Sensitivity: 40%
Alwas-Danowska
et al., 2002
Occlusal surfaces:Occlusal surfaces:
Typically low sensitivity, ~ 0.30, and high specificity
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Appropriate Ways to Use theAppropriate Ways to Use the
Explorer for Sealant PlacementExplorer for Sealant Placement
Clean debris from fissures and interproximal spaces
Confirm and assess cavitations (breaks in the
continuity of the surface)
Feel the texture (roughness) of non-cavitatedlesions, if they extend well beyond the opening of
the fissure (if the program desires to consider
surface activity in their risk decision making
process)
Once sealed, help assess the quality and integrity of
the sealant.
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Core ICDAS CriteriaFor use on coronal androot surfaces, as well as caries adjacent to
restorations andsealantsThese unifying, predominantly visual, criteria code a range of thecharacteristics of clean, dry teeth in a consistent way that promotes the
valid comparison of results between studies, settings & locations
ICDAS criteria record both enamel anddentine cariesandexplore themeasurement ofcaries activity in all three of the domains below
Epidemiology
/
Public Health
Clinical
Research
Clinical
Practice
The ICDASDetectioncodes are in use now and are recommendedThe ICDASAssessmentcodes are part of a developing research agendaThe ICDASSystem provides an evidence based framework to validate and
explore the impact of existing and new-technology aids to caries diagnosis
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2 A. VISUAL APPEARANCE
ICDAS-2ICDAS-2
Score
5
DISTINCT
CAVITY
Score
6
EXTENSIVE
CAVITY
SOUND
Score
0
2. ACTIVITY
DETECTION AND SEVERITY OF
THE LESION
SURFACEINTEGRI
TY
LOSS
Score
3
OPACITY
withoutair-
drying:WHITE,
BROWN
Scores2W,2B
Ekstrand et al., modified by ICDAS (Ann Arbor), 2002;further modified by ICDAS (Baltimore) 2005
OPACITY
withair-
drying:WHITE,
BROWN
Scores1W,1B
UNDERLYING GREY
SHADOW
Score
4
Lesion in Dentin Lesion
in
Ename
l
Lesio
n in
Enam
el/Dentin
http://www.dundee.ac.uk/dhsru/news/icdas.htm
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s It must be emphasized that cleaning of the tooth surface and
use of air are essential components in the use of thesecriteria, especially if differentiation between the lowercategories (e.g., 0, 1 and 2) is considered necessary. If cavitation is the threshold for sealant placement, then for surface assessment
teeth can be dried with cotton rolls, gauze, or compressed air
s No magnification is required to make these calls. Magnification may be useful for surface assessment; sealant application; and
retention checks; however, there is limited evidence in the scientific literature tosupport the adoption of magnification for visual assessment of tooth surfaces forsealant placement
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s Lussi (1993) compared unaided VE with that using 2xmagnification, VE with bitewings, bitewings alone, andvisual/tactile with gentle probing, and found thatmagnification did NOT significantly improve sensitivity.
s Forgie et al. (2002) found that using 3.25x loupes forocclusal and interproximal assessment sensitivity wassignificantly higher than unaided vision. Specificity andPPV were similar to unaided vision .
s However, although magnification is not necessary to detectlesions using the ICDAS-2 criteria, its use may affect theinterpretation of the histological findings in relation to the
criteria developed to correlate with it. -For example, a category 2
tooth could be viewed as a category 3 under magnification, and this would result inmore teeth being eliminated from consideration of sealants.
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Role of Magnification in DeterminingRole of Magnification in Determining
CavitationCavitation
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Hidden Caries or Mis-Diagnosis?Hidden Caries or Mis-Diagnosis? When no lesion is detected by visual examination, but
radiographic methods reveal a lesion into the dentin. Noted in several reports in the 1980s and 90s (changes in
histopathology of disease, slower progression, increased use of
fluoride). Most studies at that time (that report a criteria) use
cavitation as a threshold for caries.
Prevalence: Ranges from 3% to
50% of lesions only detected on
radiographs, usually 8-15% in
adolescent population (Rickettset al, 1997)
Hidden caries does not seem to be a major problem when the
clinical caries diagnostic criteria include non-cavitated
diagnoses (Machiulskiene et al., Caries Res 1999)
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Hidden Caries:Hidden Caries:
Of the clinically sound surfaces, between 26%-50% in 14-
20 year olds showed a radiolucency in the radiograph(Weerheijm et al., 1992)
Should we use other methods to aid in the visual detection?
Note: Sound teethincluded everything except
those with dentine caries
clearly present-cavitation
decalcification at theentrance of a discolored
fissure or a dim white
aspect in enamel: Sound
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Radiographic ExaminationRadiographic Examination
Radiographs show that demineralization is present, but when looked
at in one period of time they cannot determine ACTIVITY
Sealants can arrest active lesions and prevent further
demineralization. However, the radiolucency will remain.
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s Fluorescence methods
QLF
Infra-red Fluorescences Transillumination
FOTI
DiFOTI
s Electrical Conductance ECM
s Digital Radiography
DDR
A New Way to Look at DentalA New Way to Look at Dental
CariesCaries
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Why new methodsWhy new methods
Goals:
Detect lesions early More reliably than
before
Quantification
Lesion Progression: Occlusal surface at 0, 4, 8, 12 months (QLF)
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Fluorescence Example
White Spot
Reflections obscuring image
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QLFQLF in Vivoin Vivo SystemSystem
Light
CCD camera
with FilterDental mirror
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QLF; scattering, absorption andQLF; scattering, absorption and
fluorescence in sound and carious enamelfluorescence in sound and carious enamel
with sound dentin underneathwith sound dentin underneath
Van der Veen and de Josselin de Jong00Van der Veen and de Josselin de Jong00
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QLF ExaminationQLF Examination
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At a follow-up visit a second image it taken with an innovativeAt a follow-up visit a second image it taken with an innovative
repositioning software, specifically made for this technique.repositioning software, specifically made for this technique.
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Images can be taken and analyzedImages can be taken and analyzed
over time to monitor non-cavitatedover time to monitor non-cavitated
lesionslesions
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QLF, summary of studiesQLF, summary of studies
Studies of natural caries on extracted
teeth:Sensitivity Specificity
Smooth Surfaces 0.94 0.80Occlusal 0.77 0.74
Root caries 0.59 0.84 0.77 0.88
Secondary Caries 0.87 0.21
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Infra-RedInfra-Red
Fluorescence:Fluorescence:DiagnodentDiagnodent
Values Interpretation Recommendation
0-13 Sound no treatment
14-20 Enamel lesion preventive treatment
>20 Dentin Lesion preventive or restorative treatment
depending upon risk
>30 Dentin Lesion restorative treatment
Lussi et al, 2001Note: As you lower the threshold, you increase Sens. and decrease Spec.
(more false positives-more overtreatment)
S i i i f D i S
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ValidationValidationmethodmethod
Detection methodDetection method CariesCaries
N=50N=50
No CariesNo Caries
N=950N=950
TotalsTotals
N=1000N=1000
Caries PresentCaries Present
TPTP
True PositiveTrue Positive
N=46N=46
FPFP
False Positive-False Positive-OvertreatmentOvertreatment
N=133N=133
N=179N=179
Caries Not presentCaries Not present
FNFN
False Negative-False Negative-UndertreatmentUndertreatment
N=4N=4
TNTN
True NegativeTrue NegativeN=817N=817
N=821N=821
Specificity: 86%Specificity: 86%
LussiLussi et al.,et al., 20012001
Sensitivity of a Detection System-Sensitivity of a Detection System-
Low Caries Prevalence PopulationLow Caries Prevalence Population
Sensitivity: 92%
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Limitations Stain in fissures (e.g., tea)
Calculus and plaque
Some dental materials, e.g. some sealants
Adjacent to fillings, some resin materials give signal
Not a good correlation between high score and depth of lesion
Irresponsible to let a machine do the diagnosis (It is not a stand alonediagnostic tool http://www.kavousa.com/download/diagnodent.pdf)
Bader and Shugars (2004): Systematic review conclusions for
dentinal caries:Sensitivity is almost always higher than traditional visual methods (range
0.19-1)Specificity is almost always lower (range 0.52-1).The increased likelihood of false positives compared with visual methods
limits is usefulness as a principal diagnostic tool
Performance of Infra-Red Fluorescence
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ACTIVITY: How to assess over time?ACTIVITY: How to assess over time?Increase in number of lesions in a certain time period (incidence, increment)Increase or change in certain lesions (size, etc)
How to assess the caries lesion activity inHow to assess the caries lesion activity in
one appointment?one appointment?Relate to appearance of lesion (chalky white, rough,
dull, high surface porosity)Relate to other patient factors (e.g., presence of
plaque, closeness to gingival margin, presence of other
lesions)(Ekstrand et al., 1998; Nyvad et al., 1999)
We do not have yet a way/tool to do this reliably in real-timeWe do not have yet a way/tool to do this reliably in real-time
Thylstrup and Fejerskov, 1994
WATCHWATCH
Yes
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Caries Detected?
Caries Active Lesion?
Initial
Diagnosis(Based on physical
appearance and location)
Changes Present?
Low Risk
Yes
No
No
At Risk No
Yes
Yes
High Risk Moderate Risk
Transmission
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Once a pit andfissure surface is assessed
and determined to be sound, questionable or
carious (Incipient/enamel to frank/dentin
caries), which categories are indicated for
sealants?
What are the potential benefits and risks
of sealing or not sealing sound, questionable
or carious surfaces??
Does it really matter?Does it really matter?
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Clearly, since our diagnostic methods for
assessing pit and fissure caries have been up tothis time basically an educated guess, we must be
placing sealants almost routinely over undetected
incipient lesions (Simonsen, 2002)
When we view the low sensitivity of current
methods, we have always misdiagnosed a
significant number of fissures calling them soundwhen they are carious (Fiegal, 2002).
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Indications for Occlusal SealantsIndications for Occlusal Sealants
(Siegel, 1995)
On sound, at risk surfaces
To arrest enamel lesions
Should the threshold be
questionable or non-cavitated
(incipient) caries lesions?
Di d t d t fi d l i d th l t
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32
Diagnodent score used to find lesions underneath sealants:
Takamori et al.,
2001: Diagnodentcould find 53.5% of
lesions under white
sealants). False
positives?
Is that lesion active or not?
Was it there to begin with?Do not use
it to
diagnose
secondary
carieshttp://www.kavousa.com/download/di
agnodent.pdf
Handelman 1991 review of radiographic and bacteriologic studies
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Handelman, 1991 review of radiographic and bacteriologic studies
(several years of follow up) on the therapeutic use of sealants
Concluded that caries is inhibited and may in fact regress under
intact sealants. (Handelman et al. 1976; Handelman 1982; Mertz-Fairhurst et al., 1986, 1995).
Even with partially lost sealants no radiographic evidence of
caries progression after 2 years (Handelman et al., 1986;
Messer et al., 1997)
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Heller et al. (1995) found in a fluoridated community that
initially sound surfaces were unlikely to become carious in 5years and did not benefit greatly from the application of
sealants (caries rate: 13% if not sealed vs. 8% if sealed).
There were, however, clear benefits in sealing incipient
caries (52% if not sealed vs. 11% if sealed):
Incipient if dark staining; chalky appearance, or if explorer
sticks, but no frank caries (cavitation). When in doubt used
this classification.
Is it ethical to allow disease to occur before instituting a proven,
effective preventive procedure?
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Professional leadership has advocated that any fissure lesionjudged to be limited to enamel is a candidate for sealant
therapy (Siegal, 1995, 2002)
Can we judge when caries is in enamel?
Is it necessary that it be limited to enamel, or is the
question whether it is cavitated or not and in need of
operative intervention?
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The concern with sealing more advanced
lesions is that it is believed that the potential
for caries to advance when sealants are lost isgreater than with incipient lesions
(Dentistry for the Child and Adolescent, 2004)
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A 10-year clinical study evaluated bonded and
sealed composite restorations placed directly
over frank cavitated lesions extending intodentin vs. sealed conservative amalgam
restorations and conventional unsealed amalgam
restorations (Mertz-Fairhurst et al., 1998).
Time
Susceptibl
e Host
Carbohydrat
e-rich diet
Cariogenic
Microflora
Caries
X
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s How do we assess cavitated vs. non-cavitated lesions?How do we assess cavitated vs. non-cavitated lesions?
Visual assessment is appropriate
Teeth can be dried with cotton rolls, gauze, or compressed
air Explorer may be used to clean the fissures and gently
confirm cavitations (i.e., breaks in the continuity of thesurface); do not use sharp explorer under force
Magnification (2x-4x) can be used, but is not required due
to insufficient evidence on its effect in assessing cavitation Radiographs are unnecessary, especially in programs
targeting children in grades 2 3
Insufficient evidence to recommend other technologies todetermine presence or absence of cavitation
SummarySummary
J Pub Health Dent, 1995
* * *Non-Cavitated Cavitated
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Thank youThank you