1. Evolution of diagnostic approaches in cariology:
1.1. Traditional diagnostic methods:
Most often, the diagnosis of carious lesions comes from a clinical assessment (visual and tactile) supplemented or not by a radiological examination (panoramic and/or retro-veolar radiographs and/or bite-wings). Some practitioners also use a trans illumination technique to detect interdental caries.
1.1.1. Visual examination:
- Its aim is to highlight:
- Enamel opacities (diagnosis of subsurface lesions).
- The cracks and colorations of the furrows.
- The presence of a bluish (or grayish) coloration at the level of a marginal ridge (suspicion of advanced caries at the level of the proximal surface).
- The presence of cavitations visible to the naked eye.
- This visual examination has certain diagnostic limitations:
- It can only be carried out correctly if the dental surfaces examined are perfectly clean and dry.
- It can lead to misdiagnosis. Indeed, the morphology (crevices) and discoloration of an occlusal groove do not necessarily indicate underlying carious demineralization. Conversely, apparently healthy enamel can hide significant dentin decay.
- Visual examination is very unreliable at the level of the proximal faces (very difficult visibility) as well as at the level of the posterior teeth (difficulty in having good lighting) (Pitts, 1991).
1.1.2. Tactile examination:
Probing remains a very reliable diagnostic tool for detecting advanced lesions:
when forced unintentionally into the enamel crevices, the probe is used to test tissue resistance and highlight carious cavities.
On the contrary, probing initial lesions that are still non-cavitated (i.e., lesions where the external surface of the enamel is macroscopically intact) does not appear to be a good diagnostic tool.
The pressure of the probe on the surface of the intact enamel has the effect of collapsing the weakened enamel panels. Consequently, the non-cavitated lesion becomes a cavitated lesion that can no longer be treated in a strictly non-invasive manner (medicinal remineralization using fluoride products).
1.1.3. The intraoral camera:
are part of the instruments necessary for practitioners wishing to precisely verify their actions.
1.1.4. The surgical microscope:
aims to improve the therapeutic benefit of oral and dental treatments by integrating new diagnostic tools, care and new clinical techniques that are more efficient with less risk for patients.
1.1.5. Dental floss
Separating elastics
1.1.6. Dyes:
Caries revealing dyes appeared in the 1970s. The main dye used was basic fuchsin.
1.1.7. Diagnosis by radiological examination:
- Bitewing: The first dental X-ray was taken in 1895 by Otto WALKHOFF
- Radio Visio Graphie (called RVG)
- Retro alveolar
- Occlusal
- Cone Beam
1.2. Fiber Optic Transillumination (FOTI):
- Their use has now extended into other fields, such as periodontology , for the detection of subgingival tartar; endodontics , to help determine the position of canal entrances; surgery , to detect fragments after a difficult extraction; or to detect
- micro fractures not detectable on X-rays.
1.3. Optical fiber transillumination with digital imaging (DIFOT.I.):
- Like the FOTI, the DIFOTI emits a white light. This light is emitted through the tooth and then captured by the camera. The images of the tooth acquired by the camera are sent to the computer, which analyzes them using a specific algorithm. The system instantly creates a high-definition digital image of the analyzed surface.
- DIFOTI has the same advantages as FOTI. Displaying images on a computer screen is a good tool for communicating with the patient.
- However, as with FOTI devices, DIFOTI requires training on the part of the practitioner on its use.
- Manipulation is more difficult for the mouths of younger patients (a major drawback in pediatric dentistry).
1.4. Near-infrared transillumination and infrared reflectance:
- Near infrared transillumination: numerous clinical trials have been carried out and compared to radiography.
- Infrared reflectance makes it possible to differentiate healthy enamel from damaged enamel and to obtain better contrast compared to other light devices.
- Reflectance is the quantity of light reflected by a surface and expressed as a percentage of the incident light.
- New diagnostic aids:
In preventive dentistry, the diagnosis must be made as early as possible and should be established even before the lesion becomes “visible”.
2.1. Quality of a diagnostic tool:
- Reproducibility: This is the ability of a diagnostic tool or test to be used in different circumstances and obtain identical results.
- Sensitivity: this is the ability to detect a lesion when it really exists.
- Specificity: this is the ability to affirm the absence of a carious lesion when the lesion is truly absent.
2.2. DIAGNOdent (Kavo):
This is a portable device based on measuring the loss of fluorescence of square tissues compared to the natural fluorescence of the mineralized tissues of the tooth.
– The DIAGNOdent consists of a LASER diode (625 nm/mW) transmitting a pulsed light that will be absorbed to a depth of approximately 2 mm by the tested surface.
– Insert A with a conical and thin tip allows the exploration of interproximal contact areas and occlusal grooves/putts; Insert B with a flat and wide tip is only used to test vestibular, lingual and palatal surfaces.
– The light probe with its insert (A/B) is applied to a healthy dental surface. This then emits a fluorescence corresponding to the natural fluorescence of the patient’s healthy dental tissues. This natural fluorescence is then quantified by the device, which gives a reference X value.
2.2.1. The DIAGNOdent has many advantages:
– It is a very precise and efficient diagnostic tool.
– It is a valuable tool for monitoring lesions because it allows the activity of a carious lesion to be assessed over time.
– It has proven effective in detecting carious recurrences under composite restorations.
– Unlike probing, the DIAGNOdent is a non-invasive diagnostic technique (no risk of collapse of the enamel prisms which are no longer supported).
– It is easy and quick to handle.
– Its cost is relatively attractive (around 1000 Euros).
2.2.2. The limitations of DIAGNOdent: lie in the fact that it can only be used properly if the surfaces tested have been thoroughly cleaned beforehand (which considerably lengthens the appointment).
2.3. QLF (Quantitative Light-induced Fluorescence):
– QLF (Quantitative Light-induced Fluorescence) quantifies the loss of fluorescence of square tissues (compared to the natural fluorescence of healthy dental tissues) but detection is done by light fluorescence (and not by LASER fluorescence).
2.3.1. Advantages of QLF:
– It is a very weak diagnostic tool for the detection of initial lesions strictly localized to the enamel as well as for the monitoring of these lesions treated medically.
New diagnostic approaches Page 2
2.3.2. The limits of the QLF:
- It is not reliable on dominal lesions.
- It is more difficult to use.
- It is significantly more expensive than DIAGNOdent.
- The QLF can only be a diagnostic tool for very early enamel lesions.
2.4. The ECM (Electronic Caries Monitor):
- Teeth have low electrical conductivity (i.e., high electrical resistance) when they are free of caries. Any increase in this conductivity would reflect a loss of minerals and thus indicate the presence of a carious lesion.
- The ECM measurement must be carried out on a perfectly clean tooth and must be isolated from saliva:
- The tested surface is covered with a conductive liquid.
- The probe is pronounced on the tested site and a gentle jet of air (located around the probe) is blown on the tooth surface until a stable measurement is obtained.
2.4.1. Advantages of ECM:
- It is a more accurate early diagnostic tool than clinical examination (visual and tactile).
- It allows the severity of the carious lesion to be quantified.
- It provides reproducible results over time and from one operator to another.
- ECM is an excellent diagnostic tool for the detection of secondary caries located under composite resin fillings.
2.4.2. Diagnostic limits of ECM:
- ECM proves ineffective through highly mineralized enamel on the surface (“fluoride syndrome”) which can give rise to false negatives (phantom caries).
- ECM does not differentiate between immature (hypomenorrhea) and dominant enamel, which results in false positives in 30% of cases.
- The ECM remains a less reliable diagnostic tool and more difficult to handle than the DIAGNOdent.
2.5. Wet abrasion air:
- Wet air abrasion is primarily a therapeutic technique developed to provide ultra-conservative care. However, when faced with a cracked and colored groove, wet air abrasion can be used advantageously for diagnostic purposes: under the jet of aluminum oxide (driven by kinetic energy), only the prisms of demineralized enamel collapse.
- So, if a tiny cavitation appears after the passage of the abrasive powder, it means that the groove is the site of demineralization.
- On the other hand, if it remains intact, it is healthy.
2.6. Ultrasound:
The main advantage of this device is its ability to analyze the proximal faces and to be able to deply the presence of demineralization.
2.7. Photoplethysmography: diagnostic aid in conservative dentistry – endodontics
We use a light generator placed on one side of the tooth and a photosensitive sensor located on the opposite side. Their positions will be determined so that the light beam will pass through all the tissues of the tooth, including the pulp, before being collected by the photosensitive sensor.
3. Conclusions:
- The ideal diagnostic tool should be easy and quick to use and should allow:
- detect all carious lesions, including initial lesions, in a non-invasive manner,
- make a differential diagnosis between healthy tissue and decayed tissue,
- quantify the severity of the caries,
- reproducibly measure the development of carious damage ,
- identify carious recurrences (secondary caries).
- There is no perfect diagnostic tool, each with advantages and disadvantages.
New diagnostic approaches
Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.