Diagnosis of Occlusal Caries: Part I.

Conventional Methods
Dorothy McComb, BDS, MScD, FRCD(C) Laura E. Tam, DDS, M.Sc. Abstract Accurate diagnosis of the presence or absence of disease is a fundamental requirement in health care. The diagnosis of non-overt occlusal decay is challenging and can be highly subjective, and its inherent uncertainties can lead to widely differing treatment decisions. The development of more sensitive, specific and reproducible diagnostic tools for occlusal surfaces would contribute greatly to more precise planning of preventive and operative therapy. The purpose of this 2-part paper is to review current knowledge concerning conventional and new diagnostic methods for occlusal caries. Part I looks at established diagnostic methods for occlusal surfaces. Conventional visual, tactile and radiographic examinations provide less-than-ideal diagnostic sensitivity. Neither fissure discolouration (black or brown) nor the use of an explorer has been shown to improve diagnostic accuracy. However, the combination of careful visual examination with optimal radiographic examination affords better diagnostic performance. The best visual indicators involve precise features associated with the presence of disease, such as opaque fissure demineralization and the presence and extent of localized breakdown of the enamel. For best results, teeth should be clean, thoroughly dry and well illuminated. Part II will examine new and emerging technologies, including the DIAGNOdent laser fluorescence device, which are being developed for the diagnosis of occlusal decay. MeSH Key Words: dental caries/diagnosis; observer variation; sensitivity and specificity
J Can Dent Assoc 2001; 67(8):454-7 This article has been peer reviewed.

Both the overall decline in the prevalence of caries and the greater reduction in the prevalence of smooth-surface caries are well documented.1 Epidemiological surveys since the early 1970s have shown age-specific reductions in the prevalence of caries, particularly in children of all ages, and evidence of a cohort effect into adulthood. A 50% reduction was documented for 17-year-olds over the period 19711985, along with a 36% reduction in the coronal DMF surfaces of people under 34 years old. The reported decline in proximal involvement of decayed and filled posterior teeth has revealed a shift away from smooth-surface caries and has implications for the causal role of fluorides. The greater reduction in smooth-surface caries has resulted in an increase in the proportion of primary caries in susceptible pits and fissures. Decay on

occlusal surfaces currently accounts for the majority of new lesions in the dentition of the younger, post-fluoride generation.2 Although accurate diagnosis of occlusal caries has always been regarded as more difficult than the diagnosis of smooth-surface caries, clinicians have recently suggested that fluoride has slowed the progress of occlusal lesions and strengthened occlusal enamel, such that a sound enamel surface may mask relatively large dentinal caries that is discovered only on bite-wing radiographs.3 The terms occult, hidden and covert caries, as well as fluoride syndrome, have been used to describe such presenting scenarios.3 Whether this is an entirely new phenomenon is a subject of debate,4,5 but the relative significance is greater in populations with lower overall prevalence of caries. Accurate diagnosis of the presence, extent and activity of a disease process is a fundamental requirement in health care. The optimal approach is to attempt to identify high risk of caries before disease occurs, to allow initiation of appropriate preventive services. Fissure sealants are indicated for occlusal surfaces at risk. If sealants have not been used, a secondary approach is to diagnose the caries early, before operative treatment is indicated, which would again allow preventive intervention. Enamel caries, both occlusal and proximal, can generally be managed without operative intervention.6 There is consensus that the minimum stage at which surgical intervention is indicated is the carious disease of dentin.6 Accurate diagnosis of dentinal decay is more challenging on occlusal than on proximal surfaces. The diagnosis of occlusal decay is highly subjective,7 and there is considerable variation in opinion among clinicians as to appropriate diagnosis and treatment of early carious lesions on occlusal surfaces. The inherent diagnostic uncertainties have led to differing treatment decisions by clinicians. Exploratory operative intervention and restoration on the basis of inadequate or poorly understood diagnostic information, undertaken in an effort to avoid the risk of hidden caries, could lead to substantial overtreatment. Conversely, inadequate detection precludes appropriate management. It is generally accepted that, especially in an era of lower disease prevalence, unnecessary restorations are unacceptable. Such restorations increase health care costs for patients and health care systems, and submit patients and their teeth to the ongoing re-restoration cycle over their lifetime, which may compromise long-term tooth survival. As stated by Downer,8 Caries in industrialized countries is a disease of slow progression and it is unlikely that a missed borderline dentinal lesion will pose an early threat to the viability of the tooth. Further, there is increasing expert opinion that early involvement of the dentin should not indicate a need for immediate operative intervention in all circumstances.9 Significant clinical evidence is accumulating that optimum sealing can prevent the progress of dentinal decay.10,11 Operative care is generally required only when dentinal caries cannot be arrested or reversed. Individual factors such as case history, age and probability of

disease activity must be considered in all decisions concerning preventive and restorative care. Visual and Tactile Diagnosis To ensure that maximum information is obtained during a visual examination, the teeth should be clean, completely dry and well illuminated. Even so, in vitro visual examination of macroscopically intact occlusal surfaces in an effort to detect caries generally has limited sensitivity (i.e., the ability to accurately determine the presence of true disease), below 30%.12With experience and specific training, sensitivity greater than 60% (60% accurate detection of true disease) and specificity greater than 80% (80% accurate determination of absence of disease) are possible for diagnosis of borderline dentin caries lesions, those in the zone of diagnostic doubt.8 In a whole population, where larger lesions and sound teeth are included, the sensitivity of visual diagnostic methods is much higher. Use of more precise, specific visual diagnostic criteria leads to more accurate detection of hidden caries and provides substantially better diagnostic sensitivities.13 Such criteria necessitate clean teeth and involve discernment of fissure opacity or changes in translucency, with or without prolonged air drying, plus differentiation of the presence and extent of localized breakdown of the enamel (cavitation). Fissure morphology and discolouration (black or brown) are unreliable for definitive diagnosis of caries. After analyzing the results of different diagnostic methods used by 26 dentists who examined extracted, mounted teeth under standard dental operatory conditions, Lussi12 concluded that using these [discolouration] parameters for diagnosis of dentinal caries, at least 55% of sound teeth would be misclassified (false positive). Again, discernment of enamel opacities at the entrance of the fissures allowed better diagnosis. Other studies have also found that the presence of stain is not necessarily indicative of caries.14,15 The use of an explorer does not appear to greatly improve diagnostic accuracy.12 A sticking probe is not necessarily indicative of decay and may be due entirely to local anatomic features. The advisability of applying pressure with a sharp explorer has been called into question, particularly in Europe and Scandinavia, because of documented damage to surface integrity and possible implantation of organisms, both of which may increase lesion susceptibility.16,17 Although this issue is somewhat contentious, the evidence suggests that an explorer should be used lightly or not at all on occlusal surfaces. The presence of visible cavitation of the enamel surface is, in most cases, synonymous with dentinal involvement. When definite cavitation is present, the question generally becomes not if, but how far, the carious process has penetrated into the dentin. In one study of 60 molars with small visible cavitations, caries had reached the dentino-

enamel junction in 25% of the teeth. For the remaining 75%, the caries process extended far into the dentin.18 Accurate diagnosis of the presence or absence of occlusal caries remains challenging for the clinician. Visual and tactile methods alone, in the absence of cavitation, generally have relatively poor diagnostic capability for occlusal surfaces under general practice conditions. Radiographic Diagnosis The sensitivity of visual inspection can be augmented with radiography. Findings on bite-wing radiographs are useful indicators of dentinal decay on occlusal surfaces, and it is well recognized that the prevalence of occlusal caries may be underestimated without such imaging.19 In one study involving young air force recruits, only one-third of occlusal dentinal lesions were diagnosed visually, whereas two-thirds were discovered on bite-wing radiographs.20 Another study reported that bite-wing radiographs revealed obvious lesions into the dentin in 15% of apparently sound occlusal surfaces.21 Of some concern is the significant number of 17- and 20-year-old patients who had received sealants but in whom later radiography revealed underlying radiolucencies; these findings suggest that the sealants were placed without prior diagnostic radiography.22 Of additional concern is the evidence that radiographs considerably underestimate lesion size.23 In vitro experiments have shown that, once an occlusal lesion is clearly visible on radiographs, demineralization has extended to or beyond the middle third of the dentin.24 On the other hand, false positives can occur with radiographic diagnosis, and specificities of 66% to 98% have been recorded in vitro.25,26 Because of the superimposition of buccal and lingual enamel, caries of the occlusal enamel are not generally visible,23 and early dentinal involvement is difficult to ascertain with radiographs. In vitro bite-wing radiography alone resulted in a sensitivity of 58%, higher than that of visual inspection, and a specificity of 87% (i.e., 13% false positives), lower than that of visual inspection, according to histological validation.25 The use of digital contrast enhancement shows promise in improving the early radio graphic diagnosis of lesions. Combined Visual and Radiographic Diagnosis An investigation of the validity of diagnosis by means of optimal bite-wing radiography combined with careful visual clinical examination has shown that the majority of carious lesions and nearly all sound teeth can be correctly identified. 19 The validity of each diagnostic method (visual and radiographic), used separately and together, was investigated for extracted teeth with questionable or borderline caries. Together, these methods had a sensitivity of 75% and a high specificity (90%), fulfilling the current recommendations to provide diagnoses that reduce the risk of

unnecessary operative intervention when diagnostic uncertainties exist. However, the 75% sensitivity indicates that there remains a significant risk of missing early dentinal lesions, in teeth with non-overt disease, when conventional visual and radiographic diagnostic methods are used. Some diagnostic uncertainty is inherent in health care, and optimal patient care decisions should take into account all patient factors, including the probability of disease and the relative risks of delaying treatment versus undertaking unnecessary operative intervention. Conclusions Accurate diagnosis of occlusal dentinal caries is challenging unless cavitation or radiographic evidence is present. As radiographs tend to reveal only significant caries, there is a need for diagnostic methods that can more accurately detect dentinal involvement at an earlier stage. The accurate diagnosis of the presence or absence of disease is paramount for appropriate care. More precise methods for definitive diagnosis of lesion presence, activity and size would significantly improve caries management decisions with respect to operative intervention or preventive care.20 The development of new diagnostic technologies for occlusal surfaces, including the DIAGNOdent laser fluorescence device (KaVo, Biberach, Germany), will be discussed in Part II of this 2-part article.

Dr. McComb is professor and head of restorative dentistry, faculty of dentistry, University of Toronto. Dr. Tam is associate professor of restorative dentistry, faculty of dentistry, University of Toronto. Correspondence to: Dr. Dorothy McComb, Restorative Dentistry, Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto, ON M5G 1G6. E-mail:d.mccomb@utoronto.ca. The authors have no declared financial interest in any company manufacturing the types of products mentioned in this article.

References 1. Brown LJ, Swango PA. Trends in caries experience in US employed adults from 1971-74 to 1985: cross-sectional comparisons. Adv Dent Res 1993; 7(1):52-60. 2. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res 1996; 75(Spec No):631-41. 3. Ricketts D, Kidd E, Weerheijm KL, de Soet H. Hidden caries: what is it? Does it exist? Does it matter? Int Dent J 1997 ; 47(5):259-65. 4. Weerheijm KL, Kidd EA, Groen HJ. The effect of fluoridation on the occurrence of hidden caries in clinically sound occlusal surfaces. Caries Res 1997; 31(1):30-4. 5. Haugejorden O, Tveit AB. The effect of fluoridation on the occurrence of hidden caries in clinically sound occlusal surfaces. [Letter]. Caries Res 1998; 32(4):266.

6. Criteria for placement and replacement of dental restorations: an international consensus report. Int Dent J 1988; 38(3):193-4. 7. Bader JD, Brown JP. Dilemmas in caries diagnosis. J Am Dent Assoc 1993; 124(6):48-50. 8. Downer MC. Validation of methods used in dental caries diagnosis. Int Dent J 1989; 39(4):241-6. 9. Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich,E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999; 33(4):261-6. 10. Basting RT, Serra MC. Occlusal caries: diagnosis and noninvasive treatments. Quintessence Int 1999; 30(3):174-8. 11. Mertz-Fairhurst EJ, Adair SM, Sams DR, Curtis JW, Ergle JW, Hawkins KI, and others. Cariostatic and ultraconservative sealed restorations: nine-year results among children and adults. ASDC J Dent Child 1995; 62(2):97-107. 12. Lussi A. Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 1993; 27(5):40916. 13. Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility and accuracy of three methods for assessment of demineralization depth of the occlusal surface: an in vitro examination. Caries Res 1997; 31(3):224-31. 14. Ferreira Zandon AG, Analoui M, Beiswanger BB, Isaacs RL, Kafrawy AH, Eckert GJ, and other. An in vitro comparison between laser fluorescence and visual examination for detection of demineralization in occlusal pits and fissures. Caries Res 1998; 32(3):210-8. 15. Verdonschot EH, Bronkhorst EM, Burgersdijk RC, Konig KG, Schaeken MJ, Truin GJ. Performance of some diagnostic systems in examinations for small carious lesions. Caries Res 1992; 26(1):59-64. 16. van Dorp CS, Exterkate RA, ten Cate JM. The effect of dental probing on subsequent enamel demineralization. ASDC J Dent Child 1988; 55(5):343-7. 17. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the effect of probing in occlusal surfaces. Caries Res 1987; 21(4):368-74. 18. van Amerongen JP, Penning C, Kidd EA, ten Cate JM. An in vitro assessment of the extent of caries under small occlusal cavities. Caries Res 1992; 26(2):89-93. 19. Ketley CE, Holt RD. Visual and radiographic diagnosis of occlusal caries in first permanent molars and in second primary molars. Br Dent J 1993; 174(10):364-70. 20. Richardson PS, McIntyre IG. The difference between clinical and bitewing detection of approximal and occlusal caries in Royal Air Force recruits. Community Dent Health 1996; 13(2):65-9. 21. Weerheijm KL, Gruythuysen RJ, van Amerongen WE. Prevalence of hidden caries. ASDC J Dent Child 1992; 59(6):408-12. 22. Poorterman JH, Weerheijm KL, Groen HJ, Kalsbeek H. Clinical and radiographic judgement of occlusal caries in adolescents. Eur J Oral Sci 2000; 108(2):93-8. 23. Kidd EA, Ricketts DN, Pitts NB. Occlusal caries diagnosis: a changing challenge for clinicians and epidemiologists. J Dent 1993; 21(6):323-31. 24. Ricketts DN, Kidd EA, Smith BN, Wilson RF. Clinical and radio graphic diagnosis of occlusal caries: a study in vitro. J Oral Rehabil 1995; 22(1):15-20. 25. Ferreira Zandon AG, Analoui M, Schemehorn BR, Eckert GJ, Stookey GK. Laser fluorescence detection of demineralization in artificial occlusal fissures. Caries Res 1998; 32(1):31-40. 26. Huysmans MC, Longbottom C, Pitts N. Electrical methods in occlusal caries diagnosis: An in vitro comparison with visual inspection and bite-wing radiography. Caries Res 1998; 32(5):324-9.

Diagnosis of Occlusal Caries: Part II. Recent Diagnostic Technologies

Laura E. Tam, DDS, M.Sc Dorothy McComb, BDS, MScD, FRCD(C) Abstract Accurate diagnosis of the presence or absence of disease is a fundamental requirement in health care. The diagnosis of non-overt occlusal decay is challenging and can be highly subjective, and its inherent uncertainties can lead to widely differing treatment decisions. The purpose of this 2-part paper is to review current knowledge concerning conventional and new diagnostic methods for occlusal caries. Part I looked at established methods for diagnosing occlusal decay. These methods have several limitations, particularly in their ability to diagnose early carious lesions. Part II examines new and emerging technologies that are being developed for the diagnosis of occlusal decay. Electrical conductance measurements and quantitative laser- or light-induced fluorescence represent significant improvements over conventional diagnostic methods, especially for in vitro applications and particularly with regard to sensitivity and reproducibility. Proponents of the DIAGNOdent laser fluorescence system claim that it evaluates the fluorescence that develops when laser light is incident on areas of demineralization. This noninvasive device is simple to use and provides quantitative data. Studies supporting its validity are limited but do suggest good sensitivity and excellent reproducibility. However, the DIAGNOdent system requires more scientific scrutiny. Although it offers a high rate of disease detection, it has little ability to indicate the extent of decay. In all treatment decisions, clinicians must be aware of the limitations of the diagnostic methods that have been used. Clinical judgment based on the patients case history, visual cues, review of radiographs and probability of disease is still the most important aspect of optimum patient care. New technologies may provide supplemental information, but they cannot yet replace established methods for the diagnosis of occlusal caries. MeSH Key Words: dental caries/diagnosis; fluorescence; human lasers/diagnostic use
J Can Dent Assoc 2001; 67(8):459-63 This article has been peer reviewed.

Accurate diagnosis of occlusal caries is difficult. The established diagnostic methods of visual and radio graphic examination were discussed in Part I of this 2-part article. New diagnostic technologies are now emerging to meet the challenge of diagnosing

occlusal decay. Each must be thoroughly investigated and evaluated before clinical use. Such new techniques include measurements of the scattering of light, fibre optic transillumination, ultrasound imaging, measurement of endoscopically viewed fluorescence, electrical conductance measurements and quantitative laser- or lightinduced fluorescence.1 These new technologies quantify changes in the physical characteristics of enamel related to demineralization. Some of the above-mentioned technologies are suitable only for interproximal or smooth-surface lesions, and others are unsuitable for clinical application. Electrical conductance measurements and laser fluorescence methods (including the DIAGNOdent laser fluorescence device [KaVo, Biberach, Germany]) are 2 distinct technologies with applications in the diagnosis of occlusal caries. The reported sensitivity and specificity for electrical conductance measurements and laser fluorescence methods are presented in Tables 1 and 2. Electrical Conductance Measurements (EC) The electrical conductivity of a tooth changes with demineralization, even when the surface remains apparently intact. Electrical conductance measurements make use of the increased conductivity of carious enamel in pits and fissures. The entire occlusal surface is first covered with a conducting medium. Conductivity from the occlusal surface to a ground electrode is then measured with a probe. An increase in conductivity is due to the development of microscopic demineralized cavities within enamel, which are filled with saliva. Two early commercial models of devices for measuring electrical conductance are no longer available, but a new instrument, the Electronic Caries Monitor (Lode Diagnostic, Groningen, The Netherlands), is currently being evaluated. No commercial devices are available in Canada. Generally high sensitivity and specificity have been reported for EC techniques.4,7,9,10 In one in vivo study, the diagnostic performance of 2 different commercial electronic devices was superior to that of bite-wing radiography, but one device outperformed the other.9 In another study, the in vitro sensitivity of EC was generally superior to that of previously reported visual or radiographic techniques, but its specificity was lower.4 Some concern has been expressed about the level of specificity (below 80%) that has been reported for the Electronic Caries Monitor.4 This translates into a false-positive rate of 20% or a 20% risk of unnecessary operative intervention. Laser Fluorescence (LF)

The LF method measures the fluorescence of the tooth that is induced after light irradiation to discriminate between carious and sound enamel. It is accepted that the induced fluorescence of enamel is lower in areas of reduced mineral content, and that there is a relation between mineral loss and the radiance of the fluorescence.11 The term quantitative laser fluorescence (QLF) has been applied to the research method of measuring induced tooth fluorescence after using laser light generally at or near 488 nm range to quantify tooth demineralization and lesion severity. Several studies in which an argon laser light source (488 nm) was used to examine smooth enamel surfaces have shown a strong correlation between a decrease in fluorescence and the degree of enamel demineralization.12-15 QLF is best suited for longitudinal diagnosis of early lesions of the enamel on accessible smooth surfaces, and many investigations have involved the monitoring of white-spot lesions,12-15 such as those observed in orthodontic patients during treatment and after debracketing. Fewer studies have assessed QLF for its ability to detect occlusal pit and fissure caries.2,3,8 In in vitro studies of artificial and natural decay of occlusal fissure enamel, QLF had better sensitivity but poorer specificity than visual examination alone or radiographic examination alone.2,3 QLF can be affected to some extent by the wet or dry state of the fissure, by stains in the fissure and by fissure morphology. The use of air-polishing to remove plaque improved diagnosis by QLF.2 Some reports suggest that QLF may be limited to measurement of enamel lesions of at most several hundred micrometres depth.12,13,16 QLF can only discern enamel demineralization and cannot differentiate between decay, hypoplasia or unusual anatomic features. QLF was not designed to discriminate between lesions restricted to the enamel and those extending into the dentin. Furthermore, Banerjee and Boyde17 showed that the fluorescence from dentin was not related to dentin demineralization, so this method is not suitable for measuring dentin demineralization. DIAGNOdent System A commercial development of LF is the chairside, battery-powered quantitative diode laser fluorescence device (DIAGNOdent). The unit emits light at 655-nm wavelength from a fibre optic bundle directed onto the occlusal surface of a tooth. A second fibre optic bundle receives the reflected fluorescent light beam, and changes caused by demineralization are assigned a numeric value, which is displayed on the monitor. The system is calibrated to a provided standard and to reference (sound) enamel. The instructions for the DIAGNOdent system specify that the occlusal area to be diagnosed be clean, because plaque, tartar and discolouration may give false values. A laser probe is used to scan over the fissure area in a sweeping motion. Two values are displayed, a current value for the probe position (moment) and a maximum value for the whole surface examined (peak). The instructions suggest that, in general, numeric data between 5 and 25 indicate initial lesions in the enamel and that values

greater than this range indicate early dentinal caries. Advanced dentin caries is said to yield values greater than 35. Shi and others6 evaluated the DIAGNOdent system in vitro. Surprisingly, the device showed higher diagnostic accuracy in the detection of dentinal caries than enamel caries. The authors suggested that the DIAGNOdent values were dependent on the volume of the caries rather than on the depth of the lesion. With a cut-off of 18 to 22, the sensitivity for diagnosis of dentinal caries in wet teeth was 0.78 to 0.82 (diagnosis confirmed by microradiography of tooth sections). The investigators concluded that overall correlation between DIAGNOdent and microradiography results was moderate but that the device appeared superior to conventional radiography. They reported that the instrument was very sensitive to the presence of stains, deposits and calculus, all of which led to erroneous readings. Similarly, any changes in the physical structure of the enamel, including disturbed tooth development or mineralization, produced erroneous readings. Second (repeated) sets of DIAGNOdent measurements showed better cor relation with the microradiography standard, which was construed as revealing operator learning and skill development. Clinical experience was, therefore, a fundamental prerequisite to using the device. In a similar in vitro study with histological measures as the gold standard, the DIAGNOdent device was compared with EC methods.4 The laser device had sensitivities of 0.76 to 0.84 and specificities of 0.79 to 0.87 whereas the Electronic Caries Monitor had sensitivity of 0.92 and specificity of 0.78 in the measurement of dentinal decay on occlusal surfaces. However, because the DIAGNOdent device had higher specificity than EC and similar sensitivity to EC for the diagnosis of enamel decay, the authors concluded that the DIAGNOdent device had higher diagnostic validity for the detection of the initial carious process. Reproducibility for the DIAGNOdent device was high in this study, but there was also evidence of different degrees of learning for individual dentists, and for 2 of the clinicians reproducibility was poor. The investigators used low cut-off values (10 to 18) for diagnosis and recommended caution in extrapolating their results to the clinical situation. In the end, Lussi and others4 concluded that, because of its rapidity and very high specificity, visual diagnosis remains the method of first choice and they suggested that this type of examination be carried out before any other technique. The DIAGNOdent device could then be used for sites of clinical uncertainty, as a second opinion or diagnostic adjunct. The results of Shi and others6 and Lussi and others,4 who evaluated the DIAGNOdent device in vitro for the detection of occlusal decay, cannot be directly generalized to clinical practice. The prevalence of caries in those studies was higher than in the typical clinical situation. Furthermore, the extracted posterior teeth were likely cleaner than the true clinical situation because they were stored and/or immersed in a sodium hypochlorite, thymol and/or formalin solution. In clinical practice, therefore, the sensitivity of the DIAGNOdent device will probably be lower.

Lussi and others5 evaluated the DIAGNOdent system in an in vivo study. Air-dried occlusal surfaces of molars and premolars were examined visually (along with bitewing radiographs if available) and with the DIAGNOdent device. The extent of decay was determined by means of an explorer during operative intervention. A high sensitivity (0.92) was reported for the DIAGNOdent device in detecting occlusal dentinal decay. However, the calculated sensitivity was based on a population of teeth with a very high prevalence of caries, since only teeth that appeared clinically to require operative intervention were assessed for the presence of decay. There was a wide range of readings for enamel caries (approximately 7 to 100), superficial dentinal caries (approximately 7 to 100) and deep dentinal caries (approximately 12 to 100), and the ranges for each overlapped considerably. The DIAGNOdent device was not able to distinguish clearly between deep dentinal caries and more superficial dentinal caries. Unanswered Questions The DIAGNOdent system is the only LF-related method available commercially for clinical application. However, the available documentation for its use is limited and involves primarily in vitro studies. Whereas the basic research behind the typical QLF technique, which uses lower wavelength light, is relatively plentiful, little documentation exists for the measurement of enamel fluorescence with the red 655nm diode laser light source used in the DIAGNOdent system. Many concerns regarding the DIAGNOdent system remain. For example, there is no basic research to show the correlation between DIAGNOdent measurements and the degree of tooth demineralization. The typical QLF methods use a 520-nm high-pass filter to receive the 540-nm autofluorescent light from enamel and to exclude the lower-wavelength light scattered by the teeth. In contrast, the DIAGNOdent system uses a 680-nm filter and detects caries by measuring changes in fluorescence intensity rather than by analyzing spectral differences.18 The DIAGNOdent system, therefore, is fundamentally different from typical QLF methods, and the basic research for the typical QLF technique cannot be extrapolated to the DIAGNOdent device. It is of considerable concern that scientific evidence showing a direct correlation between the numeric DIAGNOdent reading and the severity of disease is lacking. The absence of such evidence precludes the use of the DIAGNOdent device for monitoring the progression of decay. Also of concern is how the DIAGNOdent readings relate to the presence of dentinal decay and the need for operative intervention. As stated previously, typical QLF results show a strong correlation with the degree of enamel demineralization only but no correlation with the degree of dentinal decay. Furthermore, correlation with the degree of enamel demineralization is limited in depth.12,13,16 For the DIAGNOdent device, it has been postulated that the diode laser light does not reach deeper dentinal

layers,5 which would explain the reported inability of the device to distinguish between superficial and dentinal decay in vivo. Yet other questions relate to the optimal technique for clinical use of the DIAGNOdent device. At this time, in light of the unanswered questions and given the overall reduction in the prevalence of caries in the population, the clinical value of the device requires further investigation. Conclusions The development of reliable, accurate quantitative methods to diagnose and monitor early carious lesions is critical. EC and LF demonstrate significant improvements over established diagnostic methods, especially for in vitro applications and particularly with regard to sensitivity and reproducibility. Because of their quantitative nature and high reproducibility, these 2 methods can be used to monitor the progression of a suspected carious lesion and for patient education and motivation. In individual cases, they might also contribute to the decision-making process concerning appropriate preventive and operative strategies in caries management. However, one-time measurements made with EC and LF cannot discriminate between active and inactive lesions, which is also the case with other diagnostic methods. The DIAGNOdent device, a commercial variant of LF technology, is noninvasive and simple to use and provides quantitative measurements. However, more scientific scrutiny is required before it can be recommended for the definitive diagnosis of occlusal decay requiring operative intervention. No current diagnostic method fulfils all the criteria for optimal caries management. Verdonschot and others19 conducted a meta-analysis on various diagnostic tests. They determined a Dzvalue, which they considered representative of the probability above chance that the output from a diagnostic test would be correct (true negative or true positive). For diagnosis of occlusal caries, the EC methods demonstrated the highest Dz value relative to visual and radiographic methods; the Dz of QLF was not reported in that paper. However, true QLF correlated best with histological lesion depth or mineral loss of smooth-surface enamel caries. For occlusal surfaces, visual inspection had the highest correlation with histological observations of demineralization. Incorrect diagnoses result in incorrect treatment decisions. In the current age of lower overall prevalence of decay and slow disease progression, the potential risk of unnecessary restorations is greater than the risk of missing early decay. The potential risk of missing early decay is also lower in patients who return regularly for recall dental examinations. In all treatment decisions, clinicians must be aware of the limitations of the diagnostic methods that have been used. Knowledgeable clinical judgment based on the patients case history, visual cues, review of radiographs and probability of disease is a necessity for the provision of optimum care. Ne

October 2008, Volume 29, Issue 8

Published by AEGIS Communications

Technology-Enhanced Caries Detection and Diagnosis

Howard E. Strassler, DMD; Luis Guilherme Sensi, DDS, MS, PhD

Abstract
The prevalence of dental caries in children and adults in the United States has been declining the past 40 years primarily because of increased use of fluoride, improved oral hygiene and better oral hygiene devices, a greater emphasis on disease prevention and control, and better access to dental care made available by the dental profession. Caries diagnosis and detection for pit-and-fissure lesions has changed dramatically in the past 25 years. Research has confirmed that the carious process is bacterially mediated and is accompanied by changes in salivary flow and pH and the intake of refined carbohydrates. In recent years a number of new technologies have become available as adjuncts to traditional methods of diagnosing carious lesions. While using these new technologies, the clinician still needs to understand the concepts of caries risk, diagnosis, detection, and assessment. Working from the evidence, dental practitioners can decide on a sound clinical diagnosis and treatment plan.

New Concepts in Caries Detection of Pit-and-fissure Lesions

The prevalence of dental caries in children and adults in the United States has been declining the past 40 years primarily because of increased use of fluoride, improved oral hygiene and better oral hygiene devices, a greater emphasis on disease prevention and control, and better access to dental care made available by the dental profession.1 In spite of this, dental caries continues to be a prevalent oral disease and a major public health problem, particularly among certain segments of the US population.2,3 Approximately 60% of caries occurs in 20% of the population, and fewer than 5% of adults are caries-free.3 Caries has been identified as the single most common chronic disease of childhood. While caries on interproximal surfaces is decreasing, there has been a continuing increase in occlusal pit-and-fissure caries. In general, caries on occlusal and buccal/lingual surfaces account for almost 90% of caries experiences in children and adolescents.4 With the continuing increase in occlusal pit-and-fissure caries and a concomitant change in its pattern and progression, the correct classification of occlusal lesions has become more difficult. This difficulty has led to an increase in research and development for better diagnostic tools for pit-and-fissure caries detection.5-7 From this research, a consensus has developed that the optimal technique should have good diagnostic performance, be

noninvasive, allow for a quantification of disease progression and objective monitoring, and be easy to manage at reasonable costs.8 While correct recognition of sound and cavitated surfaces is typically not a problem, noncavitated lesions create a significant challenge. Clinical research and observations in the past quarter century have led to changes in the way pit-and-fissure caries are detected, diagnosed, and treated. The traditional concepts of classical cavity preparations following G.V. Blacks principles of extension for prevention have changed with the increased use of adhesive restorative materials. In recent years there has been evidence that what appear to be intact pits and fissures are in fact carious lesions that are difficult to diagnose. This difficulty in establishing a diagnosis of pit-andfissure caries is a result of the increased use of fluoride,9-11 which has changed the traditional characteristics of demineralization and the visual appearance of enamel opacities in the initiating lesion. In some cases the dentin is carious without the appearance of caries in the adjacent pit or fissure; this has been referred to as hidden caries,5 fluoride syndrome,12 covert caries,13 and occult caries.14 In the enamel surface, these lesions tend to be minimal in size, but within the dentin, they spread along the dentinoenamel junction as larger, more invasive lesions. These changes in appearance have led to a different evaluation of pit-and-fissure caries, based on caries risk assessment and combined with new technologies used as aids to traditional clinical methods of caries detection. All carious lesions are in a dynamic state of demineralization and remineralization,15 with fluoride playing an important role in enhancing the remineralization process. 16-18 In recent years, research has demonstrated that amorphous calcium phosphate plays a role in tooth remineralization and buffers plaque acid.19-21 There has been concern that fluoride may be too effective at remineralizing the enamel surrounding the opening of a pit or fissure, trapping caries below.10,11,22 Studies have shown that between 15% to 33% of teeth diagnosed as clinically sound were found to have hidden, trapped decay when evaluated histologically.9,22 In some clinical studies, caries that were evident on bitewing radiographs, but not evident clinically, caused the evaluators to state that bitewing radiographs were of limited value in detecting occlusal pit-and-fissure caries.23,24 From this evidence the recommendation was made that bitewing radiographs appeared to have more value for the determination of interproximal caries or cavitated occlusal carious lesions. 16,24 The clinical evidence of decay is difficult to detect in radiographs unless it is > 2 mm to 3 mm deep in dentin, or one-third the buccolingual distance.19

Risk Assessment
Practitioners typically perform a clinical examination to make a diagnosis of caries, while the assessment of caries risk for any given patient usually is neglected. A caries risk assessment is an important tool that the clinician has to respond to clinical findings to establish a treatment plan that is both preventive and restorative in nature. 16 Using a risk assessment will ensure greater success in treatment, as well as be cost-effective.25 There has been an overwhelming use of fluorides through water fluoridation, fluoride-containing oral care products, and professional fluoride treatments.26,27 Coincident to the use of fluorides, there has been an overall decline in the prevalence of caries in the United

States.28 Also, there is evidence that the progression of the carious process through enamel is slower than previously believed.26,29 With this information, the clinician should assess if a patient is at a high, moderate, or low risk for caries. Patients at high risk for caries exhibit behaviors such as frequent ingestion of foods with high carbohydrate contents, which includes many snack foods and soft drinks or juices; have poor oral hygiene;30 and have a lack of fluoride in their public water system.31 Also, the presence of an active carious lesion has been reported as being an important predictor of high-risk status.15 It is critical to chart not only all pathology, but also the assessment of caries risk to determine treatment interventions and the timing of those interventions. 32 When low caries risk has been determined, it is important not to become complacent and to reevaluate frequently at recall visits to establish that the assessment of caries risk was cor-rect.30 The pits and fissures of the occlusal groove system are still considered to be the most susceptible location for caries,22 so a continuous assessment of these locations in the mouth is essential. Enamel remineralization is possible in a compliant patient who follows the prescriptive preventive regimen of oral hygiene and use of fluorides, but at some point a decision must be made as to whether a potentially susceptible pit and fissure will continue to be reevaluated, be sealed, or be restored.18 It is far better to overtreat incipient lesions with sealants and preventive resin restorations than to not diagnose and leave the lesions progressing.33

Caries Detection
To conserve tooth structure and perform minimally invasive dentistry, carious lesions must be detected at the earliest possible stage. When carious lesions are detected in their earliest stages, the caries progress can be arrested, thus avoiding a more invasive operative intervention.32Accurate diagnosis of noncavitated lesions is extremely valuable because an increased prevalence of difficult-to-diagnose caries can be an indication of high caries activity, a circumstance that must be treated with a more aggressive preventive program.16 The assessment of accuracy of any method of caries detection must be accomplished through clinical and basic science research. Validation of technologies to assist in making an accurate caries diagnosis must be done against a true diagnosis or what is referred to as the gold standard.20 The accuracy of any diagnostic test or evaluation typically is measured according to its sensitivity and specificity. Specificity and sensitivity refer to the capability of a test to diagnose disease correctly when disease is present and to rule out the disease when it is absent. In research terms, specificity and sensitivity often refer to the ability of the diagnostic method to eliminate false positives and negatives. Specificity is the rate of false positives while sensitivity is the rate of false negatives. The traditional tool for pit-and-fissure caries detection has, up until now, been the sharptipped dental explorer. In Volume 1 of G.V. Blacks text Operative Dentistry, published in 1924, it was stated: A sharp explorer should be used with some pressure and if a very

slight pull is required to remove it, the pit should be marked for restoration even if there are no signs of decay.34 Studies have reported the lack of reliability of probing pits and fissures with an explorer.35-37 There has been concern that the use of a sharp explorer tip within a pit or fissure can cavitate the enamel and actually create an opening through which cariogenic bacteria can penetrate.35,38 Also, the cariogenic bacteria on the tip of the probe can be seeded into other pits and fissures so that an uninfected tooth can be infected.35 Surprisingly, research has demonstrated that there is no overall improvement in the accuracy of diagnosis with an explorer when compared with judicious visual examination accomplished with careful drying of the teeth, good light, and the use of supplemental magnification.39,40 Use of an explorer has a low sensitivity and low specificity. This means a sharp explorer used for diagnosis of pit-and-fissure caries will give too many false positives, leading to a higher rate of treatment than is necessary. Because detection of early carious lesions is the prerequisite to an optimal preventive and minimally invasive treatment strategy, an adjunctive aid to caries diagnosis would be useful.1Traditional visual-tactile and radiographic methods of detection of dental caries can detect only lesions that are more advanced, involving at least 300 m to 500 m of the enamel.1 In recent years, a number of new technologies have been introduced to the profession as supplements to traditional methods of caries detection. These technologies can be somewhat low-tech, such as the use of magnification during routine clinical exams and the use of fiber-optic transillumination to visualize any changes in color, shadowing, and craze lines within the enamel and dentin. They also can be high-tech digital technologies, such as digital fiber-optic transillumination and digital radiography, with software programs designed to improve visualization of the carious lesion and analyze digital images to provide a detection algorithm that automatically outlines a potential lesion. Also, intraoral handpieces that provide analysis of laser and light-emitting diode (LED) reflection and refraction provide better accuracy in identifying potential pit-and-fissure caries. As with any clinical technique for diagnosis, a diagnosis should not be made based on only a single parameter, but instead should be based on the propensity of evidence to support the diagnosis.

Fiber-optic Transillumination and Magnification

Magnification, increasing the size of the object being used, improves caries diagnosis. 41-43 In comparison with clinicians using unaided and magnified vision for caries detection, where the specimens had a true diagnosis obtained by histological sectioning, there was a significant improvement in diagnosis of caries using magnification.41 Use of an operating microscope also improved pit-and-fissure caries detection.42 Fiber-optic transillumination (FOTI) has been an important adjunctive tool for caries diagnosis. The relative translucence of a tooth allows a clinician to shine a bright light through it, and visualize any discolorations and penetrations of these discolorations from tooth surface to the inner zone of dentin44 (Figure 1A and Figure 1B). Also, transillumination with a bright light source and the use of magnification may reveal a suspicious fissure or the presence of enamel cracks.45 In cases where there is a chief complaint of pain on biting and

release indicative of cracked tooth syndrome, the use of FOTI can reveal a fractured cusp (Figure 2A and Figure 2B). Most enamel displays varying forms of enamel cracks or crazing caused by constant temperature variations. Of concern are cracks that are stained, which must be considered permeable or permeated. Cracks that show shadowing require treatment, usually with a proximal box preparation and restoration. A recent innovation to fiber-optic transillumination was the introduction of digital imaging fiber-optic transillumination (DIFOTI, Electro-Optical Sciences, Irvington, NY). The DIFOTI was developed as a diagnostic tool for early detection of caries without the need to use ionizing radiation. The light from the DIFOTI probe is positioned on the tooth to be assessed, the tooth is illuminated, and the image on the opposite nonilluminated surface is captured by a digital electronic charged-coupled device (CCD) camera. The data collected then is analyzed by computer software. The DIFOTI appears to have the potential to both detect early carious lesions and assess their progression.46In a study comparing DIFOTI to F-speed radiographic film in estimating the depth of approximal le-sions, it was found that DIFOTI was not able to measure the depth of a lesion but was able to show surface changes associated with early demineralization. F-speed film was more accurate in the depth of approximating carious lesions. The conclusion was that a clinical decision to prepare a class II or III preparation should be made based on cavitation rather than histologic depth.1When comparing FOTI with DIFOTI for enamel caries detection, although both methods showed similar percentages of sites and caries, there was a fairly high level of disagreement regarding which sites were carious.47

Digital Radiographic Assessment

While the diagnostic accuracy of radiographs has come into question for initial pit-andfissure lesions, radiographs are a valuable tool in making a diagnosis of caries. 20 When using radiographs to diagnose caries, it is important that the images are of higher density (darker). Also radiographs are better at providing diagnostic information for dentinal lesions rather than enamel lesions.48,49 The combination of careful visual assessment, patient factors (such as caries risk), and the appearance of a possible lesion on radiographs is the next level of caries diagnosis, especially that of heavy caries infection.44 Also, using digital radiography, many manufacturers provide software enhancements to change contrast and density of the image. These changes allow for improved diagnostic decisions50,51 (Figure 3a and Figure 3b). Many different studies have evaluated the diagnostic quality of film vs filmless images (digital radiographic images) and, also, film images vs scanned films. In the diagnosis and evaluation of periodontal bone defects, digital images have been shown to be equivalent.52 One benefit of digital radiographs is the ability to use the software program to process the image (make digital adjustments to contrast, lightness and darkness, and use other tools) to better see conditions to make a more accurate diagnosis. Also, all digital radiographic software programs offer a magnification tool to enlarge the image for an improved evaluation.53 A comparison in the diagnosis of caries using digital radiography and film radiographs is equivalent.54,55 Of interest, not all digital radiography systems perform the same. When comparing high-resolution and standard-resolution digital radiographic

systems, it was found that caries diagnosis did not improve when using high-resolution. Also, the probability of caries detection was different for the sensor systems of different manufacturers.56 Digital radiography, through the use of digital panoramic units, has improved diagnosis and, with the latest three-dimensional cone-beam technologies, allows for the use of extraoral imaging with excellent diagnostic potential. 57,58 One important advance with digital radiology was the introduction of a caries detection software, Logicon Caries Detector Software (Kodak Dental Systems, Atlanta, GA). Logicon is a software enhancement that is US Food and Drug Administration (FDA) approved for assisting in the diagnosis of interproximal caries. Logicon software extracts image features of the digital radiographic image and correlates them with a database of known and identified caries problems. The software, through an algorithm, automatically highlights possible abnormalities so that the clinician can investigate the clinical condition further. This software has the ability to locate and classify proximal caries, indicating depth of caries penetration.59 This image is displayed using the digital radiograph with an overlay of the potential carious lesion, changes in density, and lesion probability. The Logicon program had an increased sensitivity, especially in lesions with caries extending into the dentin.60

Enhanced Caries Detection with Light-emitting Devices

The early detection of pit-and-fissure caries has continued to be the most subjective of all diagnostic methods used in clinical dentistry.61 The introduction of light- and laser-based technologies for supplemental caries detection has changed this view. These new technologies are noninvasive and include quantified light-induced fluorescence (QLF), laser fluorescence, and LED light reflectance and refraction.

Quantified Light-induced Fluorescence

If the goal for diagnosis is early caries detection, then clinicians must be able to detect demineralized areas of the enamel in the white spot stage or earlier before the early lesion becomes cavitated. If detected at or before this stage, the lesion can be remineralized with fluoride and calcium phosphate application. One property of enamel is its ability to fluoresce. Through the use of quantitative laser or light-induced fluorescence, an image of the physical condition of the tooth can be created by a xenon microdischarge arc lamp that is passed through an optical band pass filter with a peak intensity of 370 nm to produce blue light. The fluorescent, filtered images of the enamel of the tooth then are filtered by a green pass filter and captured digitally by a CCD camera. These images then can be captured, stored, and analyzed by specialized software that can quantify mineral changes in enamel. Inspektor Pro (Inspektor Dental Care, Amsterdam, The Netherlands) (Figure 4) is the commercial device that uses this technology.62 Used clinically, quantitative light-induced fluorescence (QLF, Inspektor Dental Care) will show demineralization or incipient lesions as, typically, a dark spot. Caries and plaque appear red, indicating a bacterial presence. For the patient, the differences in color can be motivational because the invasion of bacteria is obvious and dramatic. For the

clinician, it is a viable tool not only to detect decay, but also to monitor the progression of demineralization.63 When comparing QLF to a laser fluorescence device (DIAGNOdent, KaVo, Lake Zurich, IL), the QLF detected very small lesions significantly better than the laser fluorescence device.64 In other studies, this technology quantified white spot lesions and their progression for orthodontic patients,65 quantified progression of occlusal lesions,66,67 and compared different treatment regimens in reversing white spot lesions.68 Unfortunately, Inspektor Pro is a costly device that generally is purchased by universities and research centers to evaluate and collect longitudinal data on tooth demineralization.

Use of a Laser Fluorescent Device as an Adjunct for Caries Detection

It has been proposed that a device could be made that uses the enamels fluorescence to detect caries.69 Research demonstrated that sound and carious enamel had differences in fluorescence.70 Fluorescence results from changes in incident light wavelength after reflection from the surface of a material. It has been suggested that fluorescence of tooth structure is caused by the presence of chromophores within the enamel, and sound and carious enamel have differences in fluorescence because of the loss of chromophores during the carious process. During the carious process, some of the mineral content of enamel is lost and replaced by water, which results in increased light scattering, and subsequently, less observed fluorescence.71Based on these findings, the original DIAGNOdent and more recently the handheld, portable DIAGNOdent Pen (KaVo) were developed72 (Figure 5). The DIAGNOdent is a device that emits a red laser light (wavelength, 665 nm) that is absorbed by inorganic and organic parts of the tooth. The tooth then fluoresces under this red light and this fluorescence is captured by a probe that sends the light back to a photocell, providing an analog scale of reflectance and fluorescence combined with an acoustic cue (Figure 6). The sound volume can be adjusted. The numeric readout of the device indicates the amount of fluorescence. The manufacturer provides a correlation of values to recommend possible courses of treatment, and these values have been verified in a number of studies.73-75 When using the digital readout, keep in mind that teeth have a natural fluorescence of 5 to10 (on the devices scale). When evaluating the reading, it is worthwhile to deduct a value of 5 to use the table that the manufacturer provides for restorative decision-making. Also, measurements from the DIAGNOdent are correlated strongly with the depth and volume of cavity preparations that resulted from carious lesions in the pits and fissures of posterior teeth.76 When the DIAGNOdent Pen was compared with the classic DIAGNOdent, it was found that both devices performed similarly, with the Pen producing slightly higher readings, leading to a slightly lower sensitivity.77 To use the DIAGNOdent, the tooth being evaluated must be both clean and dry. It is recommended that pits and fissures be debrided. The use of airpolishing devices is the most effective means for debriding a pit and fissure of calculus, plaque, and other organic plugs and debris present. DIAGNOdent cannot be used reliably to diagnose recurrent caries adjacent to restorative materials, and it has not been shown to be effective in diagnosing proximal caries.

Research has demonstrated that the laser fluorescence technique showed higher sensitivities than bitewing radiographs, but lower specificities.78 A comparison between visual techniques and disclosing dyes in diagnosing pit-and-fissure caries on extracted teeth was made so that the teeth could be evaluated histologically for the true diagnosis of caries. Visual techniques were correct only 53% of the time and caries disclosing dyes were correct only 43% of the time.79 In a comparison of four different techniquesradiographs, sharp explorer, caries disclosing dyes, and DIAGNOdentthere was variation in accuracy.80 When using radiographs, there were false positives 25% of the time. A sharp explorer missed 25% of the caries and when the use of the explorer indicated caries present, the diagnosis was wrong 12% of the time (false positives). It was found that disclosing dyes were the least accurate, missing 40% of the caries present and having 20% false positives. Laser fluorescence was the most accurate. While 90% of the carious lesions were accurately diagnosed, there were no false positives. Also, QLF can be used to assess caries on smooth surfaces.80 One aspect of laser fluorescence that needs further investigation is that it cannot detect the difference between an active or inactive lesion.81 Also, the device is sensitive to the presence of stains, deposits, and calculus, which may be registered falsely as a change in enamel or dentin.82

LED Technology
The technology of LED reflectance and refraction (Midwest Caries I.D., DENTSPLY Professional, York, PA) (Figure 7) has been shown to be an effective tool for both occlusal and proximal caries diagnosis, and has been approved by the FDA for both occlusal pitand-fissure and interproximal evaluation of caries.83 Because healthy tooth structure is generally more translucent than decalcified enamel, there is a different optical signature between healthy and demineralized tooth structure. The device analyzes the reflectance and refraction of the LED, which is captured by the built-in fiber-optics and converted into an electrical signal which is analyzed. The microprocessor within the handle of the device contains a computer-based algorithm that differentiates the presence or absence of changes in optical translucency and opacity. The presence of demineralization activates a change in the LED from green to red with a concurrent audible signal, confirming the presence of caries. This LED device has been shown to be able to diagnose 92% of occlusal lesions and 80% of proximal lesions when the device is used correctly on a wet occlusal tooth surface.84 This compares with 39% accuracy for occlusal lesions and 50% accuracy for interproximal lesions with conventional methods of diagnosis. 61 The Midwest Caries I.D. is easy to use. Unlike the DIAGNOdent, which must be calibrated using a graphic user interface menu on the handle, the Midwest Caries I.D. is activated with a simple-to-use power-on button. The tip of the unit is pointed in the air when the unit is turned on. A self-diagnostic provides the user with information that the optical tip of the probe is in good condition by measuring a baseline optical response. After the unit is ready to be calibrated, the clinician wets with water the tip of the probe and the calibration target. With the tip placed in the center of and perpendicular to the ceramic calibration target for 1 second, the probe tip LED turns from a red light to a green light with an audible tone. With the probe and device calibrated, the unit is ready to be used.

For interproximal caries, the probe must be directed along the long axis of the tooth at the marginal ridge area, and not between the teeth. Clinical examination of carious pits and fissures or interproximal caries being evaluated from the marginal ridge area will cause the green LED light to change to red, with an increase in the audible beeps in the presence of demineralization below the enamel surface (Figure 8A; Figure 8B; Figure 8C). If there is a high level of decalcification, the audible signal will be more rapid than for moderate and slight levels of decalcification.

Comparison of Clinical Usage of Midwest Caries I.D. and Diagnodent

Clinical use of the Midwest Caries I.D. is different than the DIAGNOdent. For both diagnostic devices, the teeth being examined must be clean of all plaque, calculus, and residue of prophylaxis or polishing pastes. The DIAGNOdent recommends debridement of pits and fissures and a dry tooth for examination. The Midwest Caries I.D. requires that the tooth surfaces being evaluated are wet. In both cases, the devices require the scanning of the end of the probe on the tooth surface with contact on the tooth surface, but there is no need for pressure to be applied. With both units, the tip should be pivoted upon a positive audible tone that caries is present to determine the size and direction of the caries. False positives with Midwest Caries I.D. and DIAGNOdent can be caused by:

atypical morphology of the enamel presence of restorations or sealants presence of calculus or plaque presence of thick, dark brown stains presence of food on the tooth presence of contaminants on the tip of the probe the probe not being in contact with tooth surface if tooth is dry (Midwest Caries I.D.) or if tooth is wet (DIAGNOdent)

Conclusion
The variation among clinicians in diagnosing (small) caries lesions and in treatment decision-making is significant. These differences can be explained not only by the limitations of caries decision-making investigations, but also by incorrect decisions caused by the clinicians wrong or incomplete understanding of the diagnostic devices parameters. Using a dental mirror and explorer during a clinical examination, a clinician makes the observation that there are pits, fissures, and grooves on the surfaces of teeth. The decisionmaking for the diagnosis of carious pits and fissures has changed because of better understanding of the caries process and improved diag-nostic techniques.85 Clinicians need to demand to be better educated not only on the use of adjunctive aids for caries detection, but also on the cost-effectiveness and cost-utility of these caries diagnostic tools. Rather than accept the utility and finality of these tools, clinicians need to continue to review the performances of these diagnostic tests and the experiences of the general practitioners who are using these tests. From this information, clinicians can continue to assemble evidence-

based clinical guidelines on the relationship between diagnosis and treatment decsions, and to evaluate the effect of diagnostic and treatment decisions using conventional and technologic adjunctive caries detection and diagnosis aids on the outcome of care. Even with newer technologies for caries diagnosis, it is still difficult to chart the progression of the disease.86-88
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2. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon GeneralExecutive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. 3. Diagnosis and Management of Dental Caries Throughout Life. NIH Consensus Statement. 2001;18(1):1-24. 4. Ripa LW, Leske GS, Sposato A. The surface-specific caries pattern of participants in a school-based fluoride mouthrinsing program with implications for the use of sealants. J Public Health Dent. 1985;45(2):90-95. 5. Wenzel A, Larsen MJ, Ferjerskov O. Detection of occlusal caries without cavitation by visual inspection, film radiographs, xeroradiographs, and digitized radiographs. Caries Res.1991;25(5):365-371. 6. Verdonschot EH, Wenzel A, Bronkhorst EM. Assessment of diagnostic accuracy in caries detection: an analysis of two methods. Community Dent Oral Epidemiol. 1993;21(4):203-208. 7. Pitts NB. Clinical diagnosis of dental caries: a European perspective. J Dent Educ. 2001;65(10): 972-978. 8. Khnisch J, Heinrich-Weltzien R, Tabatabaie M, et al. An in vitro comparison between two methods of electrical resistance measurement for occlusal caries detection. Caries Res.2006;40(2):104-111. 9. Weerheijm KL, Gruythuysen RJ, van Amerongen WE. Prevalence of hidden caries. ASDC J Dent Child. 1992;59(6): 408-412. 10. Haugejorden O, Tveit AB. The effect of fluoridation on the occurrence of hidden caries in clinically sound occlusal surfaces. Caries Res. 1998;32(4):266. 11. Ricketts D, Kidd E, Weerheijm K, et al. Hidden caries: what is it? Does it exist? Does it matter?Int Dent J.1997;47(5):259-265. 12. Millman CK. Fluoride syndrome. Br Dent J. 1984;157(10): 341-344. 13. Lavin AJ. Covert caries detection. Br Dent J. 1983;155(4): 111-115. 14. Ball IA. The fluoride syndrome: occult caries? Br Dent J. 1986:160(3):75-76. 15. Suddick RP, Dodds MW. Caries activity estimates and implications: insights into risk versus activity. J Dent Ed. 1997;61(11): 876-884. 16. Anusavice KJ. Management of dental caries as a chronic infectious disease. J Dent Ed. 1998;62(10):791-801. 17. Emilson CG, Ravald N, Birkhed D. Effects of a 12-month prophylactic programme on selected oral bacterial populations on root surfaces with active and inactive carious lesions. Caries Res. 1993;27(3):195-200. 18. Meskin LH, ed. Caries diagnosis and risk assessment: a review of preventive strategies and management. J Am Dent Assoc. 1995;126(Suppl):1S-24S. 19. Rock WP, Kidd EA. The electronic detection of demineralization in occlusal fissures. Br Dent J.1988;164(8):243-247. 20. Yang J, Dutra V. Utility of radiology, laser fluorescence, and transillumination. Dent Clin North Am. 2005;49(4): 739-752. 21. Charig A, Winston A, Flickinger M. Enamel mineralization by calcium-containing bicarbonate toothpastes: assessment by various techniques. Compend Contin Educ Dent. 2004;25(9 Suppl 1):14-24. 22. Aoba T. Solubility properties of human tooth mineral and pathogenesis of dental caries. Oral Dis. 2004;10(5):249-257. 23. Machiulskiene V, Nyvad B, Baelum V. A comparison of clinical and radiographic caries diagnoses in posterior teeth of 12-yearold Lithuanian children. Caries Res. 1999;33(5):340-348.

24. Bader JD, Shugars DA. What do we know about how dentists make caries-related treatment decisions? Community Dent Oral Epidemiol. 1997;25(1): 97-103. 25. Anusavice K. Clinical decision-making for coronal caries management in the permanent dentition. J Dent Educ. 2001;65(10): 1143-1146. 26. Schwartz M, Grndahl HG, Pliskin JS, et al. A longitudinal analysis from bite-wing radiographs of the rate of progression of approximal carious lesions through human dental enamel. Arch Oral Biol. 1984;29(7): 529-536. 27. Pitts NB. Monitoring of caries progression in permanent and primary posterior approximal enamel by bitewing radiography. Community Dent Oral Epidemiol. 1983;11(4):228-235. 28. Ekanayake LS, Sheiham A. Reducing rates of progression of dental caries in British schoolchildren. A study using bitewing radiographs. Br Dent J. 1987; 163(8):265-269. 29. Berkey CS, Douglass CW, Valachovic RW, et al. Longitudinal radiographic analysis of carious lesion progression. Community Dent Oral Epidemiol. 1988;16(2):83-90. 30. Anusavice KJ. Treatment regimens in preventive restorative dentistry. J Am Dent Assoc. 1995;126:740-3. 31. Kobayashi S, Kishi H, Yoshihara A, et al. Treatment and posttreatment effects of fluoride mouthrinsing after 17 years. J Public Health Dent. 1995;55(4):229-233. 32. Angmar-Mnnson BE, al-Khateeb S, Tranaeus S. Caries diagnosis. J Dent Educ. 1998;62(10):771-779. 33. Hudson P. Conservative treatment of the class I lesion: a new paradigm for dentistry. J Am Dent Assoc. 2004;135(6):760-764. 34. Black GV. Operative Dentistry. Vol. I. 7th ed. London: Henry Kimpton; 1924:32

LED battery-powered fiber-optic transilluminator (Orascoptic DK, Orascoptic, a Kerr Company, Middleton, WI) being used to transilluminate the proximal surface of the maxillary lateral incisor.

Clinical evidence of caries penetrating past the dentinoenamel junction viewed with transillumination.

Fiber-optic cable (Orascoptic Ti2200, Orascoptic, a Kerr Company) connected to light system (Zeon LumenArc, Orascoptic, a Kerr Company)

Fiber-optic cable (Orascoptic Ti2200, Orascoptic, a Kerr Company) connected to light system (Zeon LumenArc, Orascoptic, a Kerr Company) being used to transilluminate fracture in cusp.

Digital bite-wing radiograph after software processing, revealing an improved view for diagnosis of distal and mesial caries in the maxillary right second premolar

Qlf

Handheld, battery-powered laser-fluorescence diagnostic device (DIAGNOdent Pen), being used to diagnose occlusal caries.

Battery-powered, chairside laser-fluorescence diagnostic device (DIAGNOdent) being used to evaluate the occlusal pits and fissures in a mandibular molar.

Handheld, battery-powered LED caries-tooth demineralization diagnostic device (Midwest Caries I.D.) being used to evaluate pits, fissures, and interproximal surfaces for the presence of demineralization (photo courtesy of DENTSPLY Professional).

The LED probes green color and no audible cue is indicative of normal, healthy tooth structure on the mesial of the mandibular molar.

The Midwest Caries I.D.s LED is red with an accompanying audible cue, indicative of tooth demineralization and caries on the distal central fossa area.