Margherita Fontana

8/14/2019 Margherita Fontana

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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.asp


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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
http://www.omniipharma.com/inspektor_pro.asp


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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

Margherita Fontana

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