DS125-2019

Caries Detection Methods

Bacteria assessment methods

Peter Rechmann
Peter.Rechmann@ucsf.edu
University of California San Francisco

Caries Detection Methods

course objectives

• To know and understand methods for

early caries detection,
including methods likely to be
available in the near future

Caries Management by Risk

Assessment (CAMBRA):
 Caries Management Step by Step
u Dental/medical history
u Clinicalexam
u Detect caries lesions early enough to
reverse or prevent progression
u Assess caries risk
u Treatment plan including chemical therapy
u Use fluoride and/or antibacterial therapy
based on observations
u Use minimally invasive restorative
procedures to conserve tooth structure
u Recall and review

Tooth-Decay
plaque
fissure

decay

TOO LATE !!

Caries Management by Risk

Assessment
u Early caries detection, especially in
occlusal surfaces is essential as
part of caries management by risk
assessment
 Detecting Dental Caries

visual – white spots lesions & ICDAS

tactile - (explorer)
radiographic
transillumination – (FOTI, NIR, ...)

fluorescence (Diagnodent, Soprolife, ....)

optical coherence tomography

How do we
know what is
inside?

• Sound

Huge cavity - no doubt

 The explorer is inaccurate as a decay detection device
≥ 50% of the time.

Potential damage caused by using a sharp

explorer in pits & fissures – smooth surfaces

Protective Factors

Fissure lesion
section viewed
in polarized
light (in water)
 Effects of probing with dental explorer

Kühnisch et al., Caries Res 2007

Effects of probing with dental explorer

Kühnisch et al., Caries Res 2007

Diagnosis versus Detection

Caries diagnosis:

u Detection of existing lesions,

u Assessment of the bacterial
challenge,
u Assessment of caries risk which
includes pathological factors and
protective factors
u Is the patient caries active?
Which teeth have hidden decay? How can you tell?

Radiographic Pictures

Problems with radiographic pictures

proximal lesions

o o th ?
is is your t
b o u t th
H ow a
 occlusal lesions

Radiograph vs hemi-section

Problems with the Traditional Exam Techniques

detection of carious lesions using visual-tactile exams
with aid of a sharp explorer
resulted in iatrogenic damage

• only advanced lesions were detected

consequently warranting surgical interventions only.

International Caries Detection and

Assessment System (ICDAS)
• ICDAS is a method used in diagnosis and classification of
carious lesions of occlusal, smooth and free proximal
surfaces as well as root surfaces
• Relies primarily on visual assessment of clean teeth
with the aid of good lighting and magnification.

• Permits assessment of both

early and advanced carious
lesions
 Detecting “First” and “Early” Changes
• The first sign of carious change is a
change in translucency and light refraction of enamel
due to enamel microporosity
(easily detected only after surface is dried).

ICDAS - occlusal

Jenson et al., CDA Journal, 2007,35:714-723 (www.cdafoundation.org/journal)

Code 0
no evidence of caries after 5sec air
drying

(if it is “just” stain - then visible

symmetrically in most of all fissures)
• Sound
Code 1

1st changes visible a@er

prolonged drying 5 sec

• Sound

opaque or dark changes confined to

base of pits /fissures

because demineralizaGon areas have

taken up stain – also possible to see
when wet

Code 2
air dried -
decalcification
(seen as opacity) wider
than base

• Sound

Code 3
when wet – opaque or
discolored lesion wider than
base
when dry - localized enamel
loss, no visible denGn
• Sound
 Code 5
cavitaGon due to caries exposing
denGn

involves less than half the tooth

surface

• Sound

Caries detection –
explorer vs fluorescence pinpoint

laser tissue reflection

interaction

transmission
absorption

scattering
 Light/Laser fluorescence
Excitation of an atom (molecule) by incoming light,
with absorption of the light (photons)
and then
emission of a characteristic secondary light at a wavelength
longer than the excitation wavelength

UV IR

Diagnodent

laser fluorescence of bacteria

- porphyrines

Caries Detection by Diagnodent

» wavelength (red visible) – enamel is transparent

» detects bacterial by-products (porphyrins) that have entered
the lesion
» consequently, influenced by microbial plaque ….
» one-dimensional - a number (0-99)
» “semi-quantitative”
» detects subsurface decay, especially in dentin
» “suggested number to drill” – 25 ??
 Spectra Caries Detection Aid
VistaProof
by Air Techniques
Dürr Dental

Spectra Caries Detection Aid

Excitation wavelength blue LED (405 nm)
Emission - green fluorescence of sound “enamel”
- “red fluorescence” – from caries

on-screen false color & number scale

Rodrigues et al, Caries Res 2008

Jablonski-Momeni et al, Odontology 2011

Quantitative Light Fluorescence - QLF

InspektorPro QLF
by Inspektor Research
Systems
 QLF contrast enhancement
Excitation wavelength peak intensity at 370 nm (UV/blue)

white light QLF

Quantitative Light-induced Fluorescence

Yellow an
d
excited in orange fluorescenc
the blue an e
d green
■ Quantitative
■ Smooth
surfaces,
occlusal
surfaces
■ ~ 500µm depth

Photo by Jan Kühnisch

 InspektorPro QLF
» 370 nm excitation, > 520 nm emission;
tooth auto-fluorescence from dentin
» enamel is transparent at this wavelength
» detection of smooth surfaces demineralization (+ occlusal)
lesion scatters light and produces “shade”
» electronic reposition aid
» quantifies mineral loss ΔF
» not useful in clinical practice

» bacteria fluorescence

SOPRO-Life
by Acteon Imagine
 SOPRO-Life Acteon

blue diodes
Pr Hervé Tassery,* - green
Alain Mazuir, & red*PU-PH.
CarolineSarraquigne. fluorescence
Marseille Dental School, France

4 White LED

4 Blue LED

SOPRO-Life
- background
high resolution & high magnification intraoral camera system
- daylight mode
- blue fluorescence mode

- excitation wavelength LED at 450 nm (blue)

- emission – green fluorescence of the dentin body
- “red” fluorescence of caries lesions in enamel/dentin

Red fluorescence is believed to originate from

and related compounds from oral bacteria.
 § upper second molar, distal

§ daylight mode

§ fluorescence mode 14PK

ICDAS 3
first visible
loss of enamel

■ Sound

SOPROLIFE Blue Fluorescence Codes

§ Code 1 - Sound, no visible change in enamel

 SOPROLIFE Blue Fluorescence Codes

§ Code 2 - In addition to tiny, thin red shimmer in pits and fissures possibly
coming up the slopes darker red spots confined to the fissure are visible

SOPROLIFE Blue Fluorescence Codes

§ Code 4 - Dark red or orange areas wider than fissures;

surface roughness occurs, possibly grey or rough grey zone visible

SOPROLIFE Blue Fluorescence Codes

§ Code 5 - Obvious wide openings with visible dentin

 SOPRO-Life

» 450 nm excitation, tooth green auto-fluorescence

» high resolution - high magnification camera system
» daylight mode / fluorescence mode
» clean surface necessary – in fissures plaque obscures view
» sensitivity: 70% specificity: 73%

in need of more scientific papers

Rechmann, Charland, et al. (2012). "Performance of laser fluorescence devices and visual examination
for the detection of occlusal caries in permanent molars.” Journal of Biomedical Optics 17(3)

What is caries detection?

u Another word for caries diagnosis

u An explorer stick in an occlusal surface
uA method such as fluorescence that
highlights demineralized regions
u None of the above

Optical Coherence Tomography (OCT)

Detection of Early Dental Decay in Enamel
not available for
dentistry
“so far”
 Optical Coherence Tomography (OCT)

» potential new application in dentistry

» 1310 nm – enamel is transparent at this wavelength
» scattering from lesion can be imaged 2 or 3 dimensional
» ideal for detecting very early caries lesions
» consequently followed by laser and/or fluoride
remineralization treatment

Optical Coherence Tomography

- low coherence interferometry
source arm sample arm
1310-nm fiber
laser
interferometer
diode
tooth

near-IR mirror
detector

detection arm reference arm

Depth + lateral resolution ~ 20-30 µm

Interproximal caries

Is
lesion
Intensity
progressing scan
path high low
or arrested ?
Optical Depth (mm)

3 0 -10 -20 -30 -40

dB
2

0
0 2 4 6 8
Lateral Position (mm)
 3D OCT - composite, marginal gap

clinical view

QLF
showing plaque
in gap

Schneider, H et al. (2017). "Dental Applications of Optical Coherence Tomography in Cariology.” Applied Sciences

Fiber-optic transillumination (FOTI)

Digital imaging fiber-optic
transillumination (DIFOTI)
by ?

DIFOTI - digital imaging fiber-optic transillumination

visible light
 FOTI- fiber-optic transillumination
“courtesy of your dental unit”

visible light transillumination from the turbine connector

Near Infrared Imaging (NIR)

…

Near Infrared Imaging (NIR)

» potential new application in dentistry

» uses 1310 nm – enamel is transparent at this wavelength
» scattering from lesion can be visualized in the same way as
radiographs
» works for detecting early decay in occlusal and approximal
surfaces
» provides a 2 dimensional image optically
 NIR NIR

Courtesy of Dan Fried, UCSF

CariVu

by Dexis

CariVu

788 nm laser transillumination

 CariVu

approximal and occlusal lesions

become visible

CariVu

first commercially available red/infrared

transillumination systems

approximal and occlusal lesions

become visible

- potentially replacing x-rays for detection of approximal caries lesions

- also potential to provide information about occlusal lesions

Caries Detection by Optical Methods
- Ideal Device -
» wavelength where enamel is transparent
» method to detect demineralization – scattering of light -
occlusal
» two or 3-dimensional images
» quantitative measure of mineral loss

Caries Detection Methods

course objectives

• To know and understand methods for

early caries detection,
including methods likely to be
available in the near future

Course objective:

To know the current methods for

cariogenic bacterial assessment
Caries Management by Risk
Assessment
u Early caries detection, especially in
occlusal surfaces is essential as part
of caries management by risk
assessment
u Biological risk assessment measures
can be used to guide clinical
decision making

Cariogenic Bacteria Detection

and Quantification
u Cariogenic bacteria: mutans streptococci
(S. mutans and S. sobrinus) and
lactobacillus species and others –
bifidobacteria, scardovia, actinomyces
u Traditional detection and assay by plating
on selective media where other species
are suppressed. e.g. mutans streptococci
on MSB (mitis salivarius bacitracin)
u Molecular biology methods: DNA, RNA,
surface antigens

Caries Risk Assessment form:

6 years - adult (covered in a later session)
•High risk or extreme risk indicates
- bacterial test needed for MS and LB *
• Extreme risk is high risk plus salivary dysfunction

*- Yes – True in an ideal world … !

 Cariogenic Bacteria Assessment
Why Do We Need to Do It?
u A patient with cavities has high levels of cariogenic
bacteria so why bother with a bacterial test?
u We need to know the starting levels of MS and LB (or
the overall level of cariogenic bacteria) so that when
we do antibacterial treatments we can monitor
progress, compliance and success
u We need to continue to monitor after antibacterial
treatment is stopped to know whether recolonization
occurs
u TRUE in an Ideal World

CRT – Caries Risk Test

bacteria test

Ivoclar Vivadent

Mixed saliva is added to

the two sided selective
media slide (mutans
streptococci and
lactobacilli)

Incubate for 72
hours and read
versus density
scale
Mutans
streptococci

Low High

Lactobacilli

Vivadent Test Strips - Used to measure mutans

streptococci and lactobacilli bacterial challenge level.

CRT – Caries
Ivoclar RiskCRT
Vivadent Test
bacteria test

u 72 hours incubation - “time consuming”

u “a little nasty …”

CariScreen Testing Meter

by CariFree

u uses ATP bioluminescence to identify

oral bacterial load
u chair-side in minutes
 CariScreenTM ATP Test
Real time (15 second )
screening test for
quantitative measure of
bacterial activity

>1,500 high caries risk

<1,500 low caries risk

CariScreen score had a positive correlation

in lab studies at OHSRU.

Efficacy of an adenosine triphosphate

meter for evaluating caries risk in clinical
dental practice

Journal of American Dental Association, October 2019

CariScreen scores at different caries risk

Rechmann et al., IADR 2017
levels – PBRN data JADA 2019

Claim:
“… differentiates between low risk (reading 0-1,500)
and at risk (reading 1,501-9.999) for caries …”
Course objective:

To know the current methods for

cariogenic bacterial assessment