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Recent Aids in Diagnosis of Dental Caries

Recent Aids in Diagnosis of Dental Caries RECENT AIDS IN DIAGNOSIS OF DENTAL CARIES Various methods

RECENT AIDS IN DIAGNOSIS OF DENTAL CARIES

Various methods are being used for diagnosis of dental caries 1] Radiographic techniques

  • a) Digital

  • b) Xeroradiography

2] Electronic caries monitor (ECM) 3] Detection systems based on electrical current measurement

4] Optical caries detection techniques

  • a) Optical coherence tomography (OCT)

  • b) Polarized Raman Spectroscopy (PRS)

5] Enhanced visual techniques

  • a) Fiber-Optic TransIllumination (FOTI)

  • b) Digital Imaging Fiber-Optic TransIllumination (DIFOTI)

6] Fluorescent techniques

  • a) Visible light fluorescence - QLF

  • b) Laser fluorescenceDIAGNODent

  • c) Infrared fluorescence.

7] Transillumination with Near-Infrared light. 8] Near-Infrared reflectance imaging. 9] Terahertz Pulse Imaging. 10] Multiphoton Imaging. 11] Time-Correlated Single- Photon counting fluorescence Lifetime Imaging

Recent Aids in Diagnosis of Dental Caries RECENT AIDS IN DIAGNOSIS OF DENTAL CARIES Various methods

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Recent Aids in Diagnosis of Dental Caries Caries diagnosis is the art or act of identifying

Caries diagnosis is the art or act of identifying a disease from its signs and symptoms.

TO DIAGNOSE OR TO DETECT?

The

art

of

diagnosis

rests

on

the

assumption

that

diseases can be identified from their signs and symptoms. Diagnostic reasoning is an extremely complex process that involves elements of simple pattern recognition, probabilistic considerations and hypothetico-deductive thinking. Diagnostic decision making is a balancing act. The clinician must not overlook diseases in need of treatment, and, at the same time, he must not make a diagnosis when it is not warranted. The inherent complexity of the diagnostic process explains why nobody has ever been able to unveil how clinicians think when they examine their patients and seek the right diagnosis. During the diagnostic process the clinician attempts to assign a label to a set of signs and symptoms brought together from various sources (e.g. interview, clinical examination and supplementary tests). This information is used to assess the probability that the patient has a certain condition. In medicine the diagnosis is a pivotal step for making treatment decisions. Therefore, the diagnostic step has sometimes been referred to as ‗a mental resting place on the

way to intervention‘. Figure 8.1 illustrates the classical diagnostic decision process as outlined above. 26

Recent Aids in Diagnosis of Dental Caries Caries diagnosis is the art or act of identifying

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FIG 8.1: THE CLASSICAL DIAGNOSTIC DECISION PROCESS
FIG
8.1:
THE
CLASSICAL
DIAGNOSTIC
DECISION
PROCESS
Recent Aids in Diagnosis of Dental Caries FIG 8.1: THE CLASSICAL DIAGNOSTIC DECISION PROCESS Our understanding

Our understanding of the caries process has continued to advance, with the vast majority of evidence supporting a dynamic process which is affected by numerous modifiers tending to push the mineral equilibrium in one direction or another, i.e. towards remineralisation or demineralisation. With this greater understanding of the disease, comes an

opportunity to promote ‗preventative‘ therapies that

encourage the remineralisation of non-cavitated lesions resulting in inactive lesions and the preservation of tooth structure, function and aesthetics. Central to this vision is the ability to detect caries lesions at an early stage and correctly quantify the degree of mineral loss, ensuring that the correct intervention is instigated. The failure to detect

early caries, leaving those detectable only at the deep enamel, or cavitated stage has resulted in poor results and outcomes for remineralisation therapies. A range of new detection systems have been developed and are either

Recent Aids in Diagnosis of Dental Caries FIG 8.1: THE CLASSICAL DIAGNOSTIC DECISION PROCESS Our understanding

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Recent Aids in Diagnosis of Dental Caries

Recent Aids in Diagnosis of Dental Caries currently available to practitioners or will shortly be made

currently available to practitioners or will shortly be made so. These detection systems are therefore aimed at

augmenting

the

diagnostic

process

by

facilitating

either

earlier detection of the disease or enabling

it

to

be

quantified in an objective manner.

Visual inspection, the most ubiquitous caries detection system, is subjective. Assessment of features such as colour and texture are qualitative in nature. These assessments provide some information on the severity of the disease but fall short of true quantification. They are also limited in their detection threshold and their ability to detect early, non cavitated lesions restricted to enamel is poor. It is this ability to quantify and/or detect lesions earlier that the novel diagnostic systems offer to the clinician.

Novel

diagnostic

systems

are

based

upon

the

measurement of a physical signalthese are surrogate measures of the caries process. Examples of the physical signals that can be used in this way include X-rays, visible light, laser light, electronic current, ultrasound, and possibly surface roughness. For a caries detection device to function, it must be capable of initiating and receiving the signal as well as being able to interpret the strength of the

signal in a meaningful way. Table 2 demonstrates the physical principles and the detection systems that have taken advantage of them. 27

Recent Aids in Diagnosis of Dental Caries currently available to practitioners or will shortly be made

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Recent Aids in Diagnosis of Dental Caries CLINICAL METHODS: Visual detection of caries was described as
Recent Aids in Diagnosis of Dental Caries CLINICAL METHODS: Visual detection of caries was described as

CLINICAL METHODS:

Visual detection of caries was described as early as

1801, in a book entitled ―Skinner: A Treatise of Human

Teeth.‖ One of the most important early contributions to

diagnosis of dental caries came from G.V. Black. Black was among the first to describe, in explicit detail, methods of visual and tactile detection of dental caries as part of an oral examination, including the cleaning and drying of teeth

and the use of explorers, that still are in use 100 years later. For detection of proximal caries, Black described the use of separators to directly visualize areas of concern and the use of ligatures (dental floss) passed through the contact point

to detect surface roughness and breakdown. Black‘s

diagnostic methods laid the groundwork for future criteria for the detection of dental caries. Radike described detailed criteria for the visual and tactile detection of dental caries

that until recently were used widely in epidemiologic and

Recent Aids in Diagnosis of Dental Caries CLINICAL METHODS: Visual detection of caries was described as

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Recent Aids in Diagnosis of Dental Caries clinical research. They relied heavily on an explorer ―catch‖

clinical research. They relied heavily on an explorer ―catch‖ for detection of caries on occlusal surfaces and recorded cavitated lesions, but not noncavitated lesions. Since the days of Black, our diagnostic understandings have been far more advanced than simply diagnosing caries at the level of cavitation. The latest contribution to visual diagnostic criteria for caries is the International Caries Detection and Assessment Criteria (ICDAS), the development of which involved a joint effort of international cariologists. ICDAS was designed to facilitate the standardized diagnosis of caries on all tooth surfaces at all stages of severity. An updated version of ICDAS (ICDAS II) has been well accepted and been used in clinical studies with good intraexaminer and interexaminer agreement, as well as satisfactory sensitivity and specificity 28 .

[1] RADIOGRAPHIC METHODS:

Less than six months after W.C. Roentgen‘s discovery

of the x-ray, William J. Morton, a New York physician, was

one of the first to report that x-rays could have dental applications. More recent developments include higher- speed film and digital radiography. Current digital imaging technologies generate images whose diagnostic yield may equal, but not necessarily exceed, that of images obtained by using conventional film 28 .

Recent Aids in Diagnosis of Dental Caries clinical research. They relied heavily on an explorer ―catch‖

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Recent Aids in Diagnosis of Dental Caries

Recent Aids in Diagnosis of Dental Caries A] DIGITAL RADIOGRAPHS Digital radiography has offered the potential

A] DIGITAL RADIOGRAPHS

Digital

radiography

has

offered

the

potential

to

increase the diagnostic yield of dental radiographs and this has manifested itself in subtraction radiography. A digital radiograph (or a traditional radiograph that has been digitised) is comprised of a number of pixels. Each pixe l carries a value between 0 and 255, with 0 being black and 255 being white. The values in between represent shades of grey, and it can be quickly appreciated that a digital radiograph, with a potential of 256 grey levels has significantly lower resolution than a conventional radiograph that contain millions of grey levels. This would suggest that digital radiographs would have a lower diagnostic yield than that of traditional radiographs. Research has confirmed this; with sensitivities and specificities of digital radiographs being significantly lower than those of regular radiographs when assessing small proximal lesions.

However, digital radiographs offer the potential of image enhancement by applying a range of algorithms, some of which enhance the white end of the grey scale (such as Rayleigh and hyperbolic logarithmic probability) and others the black end (hyperbolic cube root function). When these enhanced radiographs are assessed their diagnostic performance is at least as good as conventional radiographs, with reported values of 0.95 (sensitivity) and 0.83 (specificity) for approximal lesions. See Fig. 8.2 for an example of this enhancement. When these findings are

Recent Aids in Diagnosis of Dental Caries A] DIGITAL RADIOGRAPHS Digital radiography has offered the potential

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Recent Aids in Diagnosis of Dental Caries considered, one must remember that digital radiographs offer a

considered, one must remember that digital radiographs offer a decrease in radiographic dose and thus offer additional benefits than diagnostic yield. Digital images can also be archived and replicated with ease. 27

FIG 8.2: COMPARISON OF REGULAR AND ENHANCED DIGITAL RADIOGRAPHS. (A) DIGITAL RADIOGRAPH, (B) ENHANCED RADIOGRAPH WHERE THE INTERPROXIMAL LESIONS BETWEEN FIRST MOLAR AND SECOND PREMOLAR CAN BE SEEN MORE CLEARLY.

Recent Aids in Diagnosis of Dental Caries considered, one must remember that digital radiographs offer a

As described above, using digital radiographs offers a number of opportunities for image enhancement, processing and manipulation. One of the most promising technologies in this regard is that of radiographic subtraction which has been extensively evaluated for both the detection of caries and also the assessment of bone loss in periodontal studies. To perform subtraction radiography the images should be taken using either a geometry stabilising system (i.e. a bitewing holder) or software has been employed to register

Recent Aids in Diagnosis of Dental Caries considered, one must remember that digital radiographs offer a

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Recent Aids in Diagnosis of Dental Caries the images together, then any differences in the pixel

the images together, then any differences in the pixel values must be due to change in the object.

Two radiographs of the same object can be compared using their pixel values.

The value of the pixels from the first object is subtracted from the second image.

The value of the pixels from the first object is subtracted from the second image.

The value of the pixels from the first object is subtracted from the second image.

If there is no change, the resultant pixel will be scored 0; any value that is not 0 must be attributable to either the onset or progression of demineralisation, or regression.

Subtraction images therefore emphasise this change and the sensitivity is increased. It is clear from this description that the radiographs must be perfectly, or as close to perfect as possible, aligned. Any discrepancies in alignment would result in pixels being incorrectly represented as change. Several studies have demonstrated the power of this system, with impressive results for primary and secondary caries. However, uptake of this system has been low, presumably due to the need for well aligned images. Recent advances in software have enabled two images with moderate alignment to be correctly aligned and then subtracted. This may facilitate the introduction of this technology into mainstream practice where such alignment algorithms could be built into practice software currently used for displaying digital radiographs. An example of a subtraction radiograph is shown in Fig. 8.3. 27

Recent Aids in Diagnosis of Dental Caries the images together, then any differences in the pixel

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FIG. 8.3: EXAMPLE OF A SUBTRACTION OF TWO
FIG.
8.3:
EXAMPLE
OF
A
SUBTRACTION
OF
TWO

DIGITAL BITEWING RADIOGRAPHS. (A)

RADIOGRAPH SHOWING PROXIMAL LESION ON MESIAL SURFACE OF FIRST MOLAR, (B) FOLLOW UP

RADIOGRAPH TAKEN 12 MONTHS LATER, (C)

THE

AREAS OF DIFFERENCE BETWEEN THE TWO FILMS ARE SHOWN AS BLACK, I.E. IN THIS CASE THE

PROXIMAL LESION HAS BECOME MORE RADIOLUCENT AND HENCE HAS PROGRESSED

Recent Aids in Diagnosis of Dental Caries FIG. 8.3: EXAMPLE OF A SUBTRACTION OF TWO DIGITAL

B] XERORADIOGRAPHY:

Mechanism: Xeroradiography is an electrostatic process which uses an amorphous selenium photoconductor material, vacuum deposited on an aluminium substrate, to form a plate. The plate, enclosed in light tight cassette, may be likened to films used in halide-based technique. The key functional steps in the process involve the sensitization of the photoconductor plate in the charging station by depositing a uniform positive charge on its surface with a

Recent Aids in Diagnosis of Dental Caries FIG. 8.3: EXAMPLE OF A SUBTRACTION OF TWO DIGITAL

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Recent Aids in Diagnosis of Dental Caries corona-emitting device called scorotron. That is, the uniform electrostatic

corona-emitting device called scorotron. That is, the uniform electrostatic charge placed on a layer of selenium is in electrical contact with a grounded, conductive backing. In the absence of electromagnetic radiation, the photoconductor remains nonconductive and with its uniform electrostatic charge when radiation is passed through an object which will vary the intensity of the radiation, observed Rawls and Owen. The photoconductor will then conduct its electrostatic charge into the grounded base in proportion to the intensity of the exposure. After charging, the cassette is inserted into a thin polyethylene bag to protect the cassette and plate from saliva. The generated latent image is developed through an electrophoretic development process using liquid toner. The process involves the migration to and subsequent deposition of toner particles suspended in a liquid onto an image reception under the influence of electrostatic field forces. That is, by applying negatively charged powder (toner) which is attracted to the residual positive charge pattern on the photoconductor, the latent image is made visible and the image can be transferred to a transparent plastic sheet or to paper. The toner is thereafter fixed to a receiver sheet onto which a permanent record is made. The plate is then cleaned of toner for reuse. 30

POSSIBLE ADVANTAGES OF XERORADIOGRAPHY

ELIMINATION OF ACCIDENTAL FILM EXPOSURE:

the reasons being that large light intensity is required for

photoconduction and even when there is exposure, the

Recent Aids in Diagnosis of Dental Caries corona-emitting device called scorotron. That is, the uniform electrostatic

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Recent Aids in Diagnosis of Dental Caries charged area intrinsically gets erased. As a result, there

charged area intrinsically gets erased. As a result, there is

minimal need processing.

for

storage

for film protection during

HIGH RESOLUTION: Xeroradiography has excellent characteristics of the forces around the electrostatic charges which form the latent image. The strengths of the fields are smaller at the centre of charged ones than at the edge, resulting in a greater number of powder pa rticles collections peripherally than in central charged areas. This greatly enhances local contrast which, in turn, improves resolution and image quality.

SIMULTANEOUS EVALUATION OF MULTIPLE TISSUES EASE OF REVIEWING USE OF REFLECTED OR

TRANSMITTED LIGHT is allowed by xeroradiography. This is because the image can be mounted either in a

transparent plastic sheet or on opaque paper.

HIGHER LATITUDE OF EXPOSURE FACTORS: little image quality change in xeroradiography will require large kilo-voltage variations. The end point is that chances of incorrect exposure and retakes are highly slim.

BETTER EASE

AND SPEED OF PRODUCTION

EECONOMIC BENEFIT REDUCED EXPOSURE TO RADIATION HAZARDS

WIDE APPLICATIONS

Recent Aids in Diagnosis of Dental Caries charged area intrinsically gets erased. As a result, there

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Recent Aids in Diagnosis of Dental Caries POSSIBLE DISADVANTAGES OF XERORADIOGRAPHY: TECHNICAL DIFFICULTIES : Both the

POSSIBLE DISADVANTAGES OF XERORADIOGRAPHY:

TECHNICAL DIFFICULTIES: Both the amount of radiation exposure and the thickness of xeroradiographic plate are linearly proportional. An increased thickness of the plate will increase the speed, because of the greater

likelihood that the x-rays passing through the photo conducting layer will interact.

FRAGILE SELENIUM COAT: the amorphous selenium photoconductor is a highly electrically stable layer. However, the layer is quite easily scratched. Notwithstanding, it has been observed that the surface shows good resistance to scratching, chipping and abrasion. As a result, placement and retention in confined area like the mouth would possibly be difficult.

SLOWER SPEED: comparatively, xeroradiography has a lower speed than halide radiographs. This can be signific ant when dealing with intraoral films. 30

[2] ELECTRONIC CARIES MONITOR (ECM):

MECHANISM: The ECM device employs a single, fixed- frequency alternating current which attempts to measure the ‗bulk resistance‘ of tooth tissue (see Fig. 5). This can be undertaken at either a site or surface level. When measuring the electrical properties of a particular site on a tooth, the ECM probe is directly applied to the site, typically a fissure, and the site measured. During the 5 s measurement

Recent Aids in Diagnosis of Dental Caries POSSIBLE DISADVANTAGES OF XERORADIOGRAPHY: TECHNICAL DIFFICULTIES : Both the

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Recent Aids in Diagnosis of Dental Caries cycle, compressed air is expressed from the tip of

cycle, compressed air is expressed from the tip of the probe and these results in a collection of data over the measurement period, described as a drying profile that can provide useful information for characterising the lesion. An example of this is shown in Fig. 8.4 While it is generally accepted that the increase in porosity associated with caries is responsible for the mechanism of action for ECM, there are some points to consider:

(1) Do electrical measurements of carious lesions measure the volume of the pores, and if so, is it the total pore volume or just a portion, perhaps the superficial portion, that is measured? (2) Do electrical measurements measure pore depth? If this is the case, what happens during remineralisation where the superficial layer ma y remineralise, leaving a pore beneath? (3) Is the morphological complexity of the pores a factor in the measurement of conductivity? There are also a number of physical factors that will affect ECM results. These include such things as the temperature of the tooth, the thickness of the tissue, the hydration of the material (i.e. one should not dry the teeth prior to use) and the surface area. 27

Recent Aids in Diagnosis of Dental Caries cycle, compressed air is expressed from the tip of

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Recent Aids in Diagnosis of Dental Caries FIG. 8.4: A DEMONSTRATION OF AN ECM PROFILE OBTAINED

FIG. 8.4: A DEMONSTRATION OF AN ECM PROFILE OBTAINED FROM A PRIMARY ROOT CARIES LESION IN VITRO DEMONSTRATING THE SITES ASSESSED.

Recent Aids in Diagnosis of Dental Caries FIG. 8.4: A DEMONSTRATION OF AN ECM PROFILE OBTAINED

FIG.8.5 THE ECM DEVICE (VERSION 4) AND ITS CLINICAL APPLICATION. (A) THE ECM MACHINE, (B) THE ECM HANDPIECE, (C) SITE SPECIFIC MEASUREMENT TECHNIQUE, (D) SURFACE SPECIFIC MEASUREMENT TECHNIQUE.

Recent Aids in Diagnosis of Dental Caries FIG. 8.4: A DEMONSTRATION OF AN ECM PROFILE OBTAINED
Recent Aids in Diagnosis of Dental Caries FIG. 8.4: A DEMONSTRATION OF AN ECM PROFILE OBTAINED

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Recent Aids in Diagnosis of Dental Caries The reproducibility of the device has been assessed in

The reproducibility of the device has been assessed in a number of publications and has been rated as good to excellent for both measurement techniques. A clinical trial has been undertaken using the ECM device on root caries, and the successful outcome of this study suggests that dentine may be a more suitable tissue for ECM. The study assessed the effect of 5000 ppm fluoride dentifrice against 1100 ppm on 201 subjects with at least 1 root caries lesion. These were site specific measurements taken using the airflow function of the ECM unit. After 3 and 6 months, there was statistical difference between the two groups, with the higher fluoride group showing a better remineralising capability than the lower fluoride paste users21 (see Fig 8.6). This is good evidence to suggest that ECM is capable of longitudinal monitoring and that clinicians may be able to employ the device to monitor attempts at remineralising, and thus potentially arresting, root caries lesions in their patients. 27

Recent Aids in Diagnosis of Dental Caries The reproducibility of the device has been assessed in

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Recent Aids in Diagnosis of Dental Caries FIG. 8.6: ECM VALUES FROM A ROOT CARIES STUDY

FIG. 8.6: ECM VALUES FROM A ROOT CARIES STUDY USING HIGH AND LOW CONCENTRATIONS OF FLUORIDE DENTIFRICES. THE INCREASING ECM VALUES RELATE TO A REDUCTION IN POROSITY AND INCREASE IN ELECTRICAL RESISTANCE.

A further application of electronic monitoring
A
further
application
of
electronic
monitoring

of

caries is that of Electrical Impedance Spectroscopy or EIS. Unlike ECM which uses a fixed frequency (23 Hz), EIS scans a range of electrical frequencies and provides information on capacitance and impendence among others. This process provides the potential for more detailed analysis of the structure of the tooth to be developed, including the presence and extent of caries. 27

Recent Aids in Diagnosis of Dental Caries FIG. 8.6: ECM VALUES FROM A ROOT CARIES STUDY

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Recent Aids in Diagnosis of Dental Caries [3] DETECTION SYSTEMS BASED ON ELECTRICAL CURRENT MEASUREMENT :

[3] DETECTION SYSTEMS BASED ON ELECTRICAL CURRENT MEASUREMENT:

Every material possesses its own electrical signature; i.e. when a current is passed through the substance the properties of the material dictate the degree to which that current is conducted. Conditions in which the material is stored or physical changes to the structure of the material will have an effect on this conductance. Biological materials are no exception and the concentration of fluids and electrolytes contained within such materials largely govern their conductivity 27 .

For example, dentine is more conductive than enamel. In dental systems, there is generally a probe, from which the current is passed, a substrate, typically the tooth, and a contra-electrode, usually a metal bar held in the patient‘s hand. Measurements can be taken either from enamel or exposed dentine surfaces. In its simplest form, caries can be described as a process resulting in an increase in porosity of the tissue, be it enamel or dentine. This increased porosity results in a higher fluid content that sound tissue and this difference can be detected by electrical measurement by decreased electrical resistance or impedance 27 .

[4] OPTICAL CARIES DETECTION TECHNIQUES:

Optical

caries

detection

methods

are

based

on

observation of the interaction of energy which is applied to

the tooth, or the observation of energy which is emitted

Recent Aids in Diagnosis of Dental Caries [3] DETECTION SYSTEMS BASED ON ELECTRICAL CURRENT MEASUREMENT :

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Recent Aids in Diagnosis of Dental Caries from the tooth. Such energy is in the form

from the tooth. Such energy is in the form of a wave in the electromagnetic spectrum. In its simplest form, caries can be described as a process resulting in structural changes to the dental hard tissue. The diffusion of calcium, phosphate, and carbonate out of the tooth, the demineralisation process, will result in loss of mineral content. The r esultant area of demineralised tooth substance is filled mainly by bacteria and water. The porosity of this area is greater than that of the surrounding structure. Increased scattering of incident light due to this structural change appears to the human eye as a so called white spot. Hence, the caries process leads to distinct optical changes that can be measured and quantified with advanced detection methods based on light that shines on and interacts with the tooth 29 .

SCATTERING: Scattering is the process in which the direction of a photon is changed without loss of energy. The incident light is forced to deviate from a straight path when it interacts with small particles or objects in the medium through which the light passes. In physical terms scattering is regarded as a material property. A glass of milk is seen as white because incident light on the milk is scattered in all directions, leaving the milk without absorption. Snow appears white because light incident in the snow is scattered in all directions by the small ice crystals. Light of all visible wavelengths exits snow without suffering absorption. Scattering is highly wavelength sensitive, shorter wavelengths scatter much more than longer ones. Therefore, caries detection methods employing wavelengths

Recent Aids in Diagnosis of Dental Caries from the tooth. Such energy is in the form

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Recent Aids in Diagnosis of Dental Caries in the visible range of the electromagnetic spectra (400

in the visible range of the electromagnetic spectra (400 nm to 700 nm) are highly limited by scattering. An early enamel lesion looks whiter than the surrounding healthy enamel because of strong scattering of light within th e lesion. Methods measuring lesion severity are based on differences in scattering between sound and carious enamel 29 .

ABSORPTION WITH FLUORESCENCE: Absorption is the process in which photons are stopped by an object and the wave energy is taken in by the object. The energy lost is mostly converted into heat or into another wave which has less energy and hence longer wavelengths. In physical terms absorption is also regarded as a material property. The previous analogy of the glass of milk appearing white can be extended to a cup of tea; the tea is seen as

transparent because it

does not scatter

light,

but

it looks

brown because much of the light is absorbed by the tea. Likewise, mud and pollution in white snow can be seen as dark spots because certain wavelengths are absorbed by these polluted spots. Absorption of light in tissue is strongly dependent on the wavelength. Water is an example of a strong absorber in the infrared range. After absorption the energy can be released by emission of light at a long er

wavelength, through the process of fluorescence. Fluorescence occurs as a result of the interaction of the wavelength illuminating the object and the molecule in this object. The energy is absorbed by the molecule with subsequent electronic transition to the next state, to a

Recent Aids in Diagnosis of Dental Caries in the visible range of the electromagnetic spectra (400

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Recent Aids in Diagnosis of Dental Caries higher level state where the electrons remain for a

higher level state where the electrons remain for a short period of time. From here the electrons may fall back to the ground state and release the gained energy in terms of longer wavelength and colour, which is related to the energy given off and fluorescent light can be emitted. Autofluorescence, the natural fluorescence of dental hard tissue without the addition of other luminescent substances has been known for a long time. Demineralisation will result in loss of autofluorescence which can be quantified using caries detection methods based on the differences in fluorescence between sound and carious enamel. 29

[A] OPTICAL COHERENCE TOMOGRAPHY (OCT):

OCT can be defined as optical inferometric technique to create cross sectional images of scattering media. There

are various functional techniques developed in OCT. They are 1) Polarisation sensitive Optical coherence tomography (PSOCT) 2) Doppler OCT 3) Wave length dependent OCT

Among these PS-OCT is popular. Studies of light propagation in dental tissue using PS-OCT revealed strong

birefingence in enamel and anisotropic light propagation

through dentinal tubules. Amaechi et al used the area under the LCI signal as a measure of the degree of refle ctivity of the tissue and showed that this area is related to the amount of mineral loss, and increases with increasing demineralization time. Hence, OCT could possibly be used

Recent Aids in Diagnosis of Dental Caries higher level state where the electrons remain for a

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Recent Aids in Diagnosis of Dental Caries to quantitatively monitor the mineral changes in a caries

to quantitatively monitor the mineral changes in a caries lesion. In the early investigations, birefringence induced artefacts in the enamel OCT image. These were eliminated by measuring the polarization state of the returned light. Birefringence detected by PS-OCT, however, has been shown to be useful as a contrast agent indicating precarious or carious lesions in both enamel and dentin 29 .

Baumgartner et al showed that PS-OCT can provide additional information related to the mineralization status and/or the scattering properties of the dental materials. The studies demonstrated that PS-OCT is well suited for the imaging of interproximal and occlusal caries, early root caries, and for imaging decay under composite fillings. Longitudinal measurements of the reflected light intensity in the orthogonal polarization state from the area of simulated caries lesions linearly correlated with the square root of time of demineralization indicating that PS-OCT is well suited for monitoring changes in enamel mineralization over time. OCT provides high resolution morphological depth imaging of incipient caries. With OCT, early lesions can be readily identified as regions of high light backscattering with depth into the enamel as compared to healthy sound enamel. From the OCT images, the lesion depth can be approximated to provide clinically useful information to guide treatment decisions. In addition, there is a derived parameter known as the optical attenuation coefficient in order to distinguish sound from carious enamel non-subjectively. OCT is being combined with

Recent Aids in Diagnosis of Dental Caries to quantitatively monitor the mineral changes in a caries

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Recent Aids in Diagnosis of Dental Caries Polarized Raman Spectroscopy (PRS) since regions of high light

Polarized Raman Spectroscopy (PRS) since regions of high light backscattering not related to caries development can lead to false-positive results. PRS provides biochemical specificity along with molecular structural/orientational information. With PRS, the Raman depolarization ratio calculated from the main phosphate vibration at ~959 cm-1 from parallel- and crosspolarized Raman spectra allows discrimination between sound and early developing caries. In combination, OCT and PRS have potential for detecting and monitoring early lesions with high sensitivity and high specificity. 29

[B] POLARIZED RAMAN SPECTROSCOPY (PRS):

OCT imaging in regions of hypocalcification can sometimes show increased light back-scattering at the surface, which could be misinterpreted as signs of early caries. To help rule out such false-positive readings and increase the specificity of this method, OCT and PRS have been coupled to obtain biochemical information for confirmation of caries. PRS provides details on the molecular composition (e.g., collagen in dentin vs. predominantly inorganic apatite in enamel) and molecular structure of cells and tissues. Like OCT, PRS measures light scattering. Although most scattered photons have the same energy and wavelength as the incoming excitation light, about 1 in 107 photons scatter at energy different from that of the incoming light. This energy difference is proportional to the vibrational energy of the scattered molecules within the sample and is known as the Raman

Recent Aids in Diagnosis of Dental Caries Polarized Raman Spectroscopy (PRS) since regions of high light

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Recent Aids in Diagnosis of Dental Caries Effect. As with other emerging optical methods, the properties

Effect. As with other emerging optical methods, the properties of the scattered light within sound or porous carious regions are being explored to determine their use in caries detection. In fluorescence-based techniques, there are a limited number of intrinsic fluorophores that can provide diagnostic information without the addition of external dyes. In contrast, PRS can provide information not only about bacterial porphyrins leached into carious regions, but also about the primary mineral matrix and, thus, the state of demineralization or remineralisation of the tooth. This information is gathered without the need to add extrinsic dyes or agents. PRS provides information on the composition, crystallinity and orientation of the mineral matrix, all of which are affected in caries formation or remineralization. 4

[5] ENHANCED VISUAL TECHNIQUES [A] FIBRE OPTIC TRANSILLUMINATION (FOTI):

The basis of visual inspection of caries is based upon the phenomenon of light scattering. Sound enamel is comprised of modified hydroxyapatite crystals that are densely packed, producing an almost transparent structure. The colour of teeth, for example, is strongly influenced by the underlying dentin shade. When enamel is disrupted, for

example in the presence of demineralisation, the penetrating photons of light are scattered (i.e. they change direction, although do not loose energy) which results in an optical disruption. In normal, visible light, this appears as a ‗whiter‘ area—the so called white spot. This appearance is

Recent Aids in Diagnosis of Dental Caries Effect. As with other emerging optical methods, the properties

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Recent Aids in Diagnosis of Dental Caries enhanced if the lesion is dried; the water is

enhanced if the lesion is dried; the water is removed from the porous lesion. Water has a similar refractive index (RI)

to enamel, but when it is removed, and replaced by air, which has a much lower RI than enamel, the lesion is shown more clearly. This demonstrates the importance of ensuring the clinical caries examinations are undertaken on clean, dry teeth. Fibre optic transillumination takes advantage of these optical properties of enamel and enhances them by using a high intensity white light that is presented through a small aperture in the form of a dental hand piece. Light is shone through the tooth and the scattering effect can be

seen as shadows in enamel and dentine, with the device‘s

strength the ability to help discriminate between early enamel and early dentine lesions (see Fig. 7). A further benefit of FOTI is that it can be used for the detection of

caries on all surfaces; and is particularly useful at proximal lesions 27 .

The diagnosis of approximal carious lesions has been primarily through visual clinical examination. However, in situations where the teeth are normally in anatomical contact with others, it is a very difficult task for the dentist to detect caries in posterior teeth by that exam, re sulting in a high proportion of false negative decisions. Conventional bitewing radiography remains the most common diagnostic aid because it has been shown to enhance the detection of approximal lesions. However, there are some problems associated with this technique, for example, if the horizontal angulation is incorrect, overlapping of

Recent Aids in Diagnosis of Dental Caries enhanced if the lesion is dried; the water is

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Recent Aids in Diagnosis of Dental Caries approximal surfaces will occur on the radiograph. Other problem

approximal surfaces will occur on the radiograph. Other problem is the incapacity of method to distinguish noncavitated from cavitated lesions. Fibre -optic transillumination (FOTI) has been investigated as an alternative method for the detection of approximal carious lesions. In this method, a white light from a cold -light source is passed through a fibre to an intraoral fibre-optic light probe that is placed on the buccal or lingual side of the tooth and the surfaces are examined through transmitted light, which is viewed from the occlusal surface. A carious lesion has a lowered index of light transmission and so appears as a darkened shadow when transilluminated. FOTI is a simple, non-invasive, and painless procedure that can be used repeatedly with no risk to the patient. In the literature, the validity of diagnoses made with FOTI has usually been assessed by comparison with the radiographic diagnosis of the same surface, although it is well known that radiography itself is not an accurate method 29 .

Fibre optic consists of a halogen lamp and a rheostat to produce a light of variable intensity. Two attachments are used; a plane mouth mirror mounted on a steel cuff and a fibre optic probe of 0.5 mm diameter so that it can be placed in embrasure region. It produces a narrow beam of light for transillumination. The rheostat is set to give a light of maximum intensity. For examination the tip of the probe is placed in the embrasure immediately beneath the contact point of the proximal surface to be examined either on the buccal or lingual surface depending on the tooth. The

Recent Aids in Diagnosis of Dental Caries approximal surfaces will occur on the radiograph. Other problem

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Recent Aids in Diagnosis of Dental Caries marginal ridge is viewed from the occlusal surface. A

marginal ridge is viewed from the occlusal surface. A shadow extending to the dentinoenamel junction beneat h the marginal ridge may be evident if there is a break in the integrity of the enamel of marginal ridge. 4

 

One

would

expect

that

FOTI

would

enable

discrimination of occlusal lesions to be improved

(particularly dentine

lesions),

as

well

as

detection

of

proximal lesions (in

the

absence

of

radiographs)

to

be

higher. As a technique FOTI is an obvious choice for

translation

into

general

practice;

the

equipment

is

economical, the learning curve is short and the procedure is

not time consuming. However

with

the

simplicity

of

the

FOTI

system

come

limitations;

the

system

is

subjective

rather than objective, there is no continuous data outputted

and

it is not possible to record

what is

seen in the

form of

an image.

In order to address

some

of these concerns, an

imaging version of FOTI has been developed; digital

imaging FOIT (DiFOTI). 27

[B]

DIGITAL

IMAGING

FIBER OPTIC

TRANSILLUMINATION (DIFOTI)

This is a relatively new methodology that was adopted in an attempt to reduce the perceived shortcomings of FOTI

by combining FOTI and a digital charge-coupled device (CCD) camera. Digital Imaging Fiber-Optic TransIllumination (DIFOTI) has been introduced to improve early detection of carious surfaces. DIFOTI uses fiber-optic transillumination of safe visible light to image the tooth.

Recent Aids in Diagnosis of Dental Caries marginal ridge is viewed from the occlusal surface. A

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Recent Aids in Diagnosis of Dental Caries DIFOTI uses visible light and not the ionising radiation

DIFOTI uses visible light and not the ionising radiation and is approved by US food and drug administration for caries detection on approximal smooth and occlusal surface as well as recurrent caries. DIFOTI uses scattering of light by carious tissue as a method of distinguishing it from healthy enamel the carious part of the tooth appears to be dark against the light background of healthy tooth. 29

Light delivered by a fiber-optic is collected on the other side of the tooth by a mirror system and fed to a digital electronic CCD.

Recent Aids in Diagnosis of Dental Caries DIFOTI uses visible light and not the ionising radiation

Then the acquired data are sent to a computer for analysis with dedicated algorithms, which produce digital images that can be viewed by the clinician and patient in real time or stored for later use.

Schneiderman et al.24 found that DIFOTI technique has superior sensitivity over conventional radiographic methods for detection of approximal, occlusal, and smooth surface caries, and specificity was slightly less in general. It has all the advantages of FOTI and also it has overcome the disadvantage of FOTI as images in this technique can be stored for future reference. 29

Recent Aids in Diagnosis of Dental Caries DIFOTI uses visible light and not the ionising radiation

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Recent Aids in Diagnosis of Dental Caries FIG. 8.7: FOTI EQUIPMENT FIG. 8.8: EXAMPLE OF FOTI

FIG. 8.7: FOTI EQUIPMENT

Recent Aids in Diagnosis of Dental Caries FIG. 8.7: FOTI EQUIPMENT FIG. 8.8: EXAMPLE OF FOTI
FIG. 8.8: EXAMPLE OF FOTI ON A TOOTH. (A) NORMAL CLINICAL VISION, (B) WITH FOTI. [6]
FIG. 8.8:
EXAMPLE
OF
FOTI
ON
A
TOOTH.
(A)
NORMAL CLINICAL VISION, (B) WITH FOTI.
[6] FLUORESCENT TECHNIQUES
[A] VISIBLE LIGHT FLUORESCENCE—QLF:
Quantitative
light-induced
fluorescence
(QLF)
is
a

visible light system that offers the opportunity to detect early caries and then longitudinally monitor their progression or regression. Using two forms of fluorescent detection (green and red) it may also be able to determine if

a lesion is active or not, and predict the likely progression of any given lesion. Fluorescence is a phenomenon by which an object is excited by a particular wavelength of light and the fluorescent (reflected) light is of a larger wavelength. When the excitation light is in the visible

Recent Aids in Diagnosis of Dental Caries FIG. 8.7: FOTI EQUIPMENT FIG. 8.8: EXAMPLE OF FOTI

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Recent Aids in Diagnosis of Dental Caries spectrum, the fluorescence will be of a different colour.

spectrum, the fluorescence will be of a different colour. In the case of the QLF the visible light has a wavelength (l) of 370 nm, which is in the blue region of the spectrum. The resultant auto-fluorescence of human enamel is then detected by filtering out the excitation light using a band

pass

filter at

l

>

540

nm by a small intra -oral camera.

This

produces an image that is comprised of only green and red

channels (the blue having been filtered out) and the predominate colour of the enamel is green. Demineralisation of enamel results in a reduction of this auto-fluorescence. This loss can be quantified using

proprietary software and has been shown to correlate well with actual mineral loss. The source of the auto- fluorescence is thought to be the enamel dentinal junctionthe excitation light passes through the transparent enamel and excites fluorophores contained within the EDJ. Studies have shown that when underlying dentine is removed from

the

enamel,

fluorescence

is

lost,

although

only

a

small

amount of dentine is required to produce the fluorescence seen. Decreasing the thickness of enamel results in a higher

intensity of fluorescence. The presence of an area of

demineralised enamel reduced

the fluorescence for two

main reasons. The first `is that the scattering effect of the lesion results in less excitation light reaching the EDJ in this area, and the second is that any fluorescence from the EDJ is back scattered as it attempts to pass through the lesion. 27

Recent Aids in Diagnosis of Dental Caries spectrum, the fluorescence will be of a different colour.

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The QLF is comprised of a light box containing a equipment xenon bulb an intraoral and
The
QLF
is
comprised
of
a
light
box
containing
a
equipment
xenon bulb
an intraoral
and
a
hand
piece,
similar
in
appearance to
camera, [see
Fig.
8].
Light is

passed to the hand piece via a liquid light guide and the

hand piece contains the band

pass filter. Live images are

displayed via a computer and accompanying software

enables

patient‘s

details

to

be

entered

and

individual

images of the teeth

of interest to be captured

and stored.

QLF can image all tooth surfaces except inter- proximally. [See Fig.8.9] for an example of QLF images that have been merged to create a montage on the anterior teeth

demonstrating resolution of buccal caries over a 1 month period following supervised brushing. Once an image of a

tooth has

been

captured, the next stage is

to analyse

any

lesions and produce a quantitative assessment of the

demineralisation

status

of

the

tooth.

This

is

undertaken

using proprietary software and involves using a patch to

define areas of sound enamel around the lesion of interest.

Following

this

the

software

uses

the

pixel

values

of

the

sound enamel to reconstruct the surface of the tooth

and

then subtracts those pixels which are considered to be

lesion.

This

is

controlled

by

a

threshold

of

fluorescence

loss, and

is generally set to

5%.

This

means that all pixels

with a loss of fluorescence greater than 5% of the average

sound value will be considered to be part of the lesion.

Once the pixels have been assigned ‗‗sound‘‘ or ‗‗lesion‘‘

the software then calculates the average fluorescence loss

in the lesion, known as

%DF, and

then

the total

area of the

lesion in mm2, a the multiplication of these two variables

Recent Aids in Diagnosis of Dental Caries The QLF is comprised of a light box containing

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Recent Aids in Diagnosis of Dental Caries results in a third metric output, DQ. See Fig.

results in a third metric output, DQ. See Fig. 8.10 for an example of the analysis and the resultant lesion. When examining lesions longitudinally, the QLF device employs a video repositioning system that enables the precise geometry of the original image to be replicated on subsequent visits. QLF has been employed to detect a range of lesion types. Smooth surfaces, secondary caries and demineralisation adjacent to orthodontic brackets have all been examined. The reliability of both stages of the QLF process; i.e. the image capture and the analysis; have been examined and has been shown to be substantial. The QLF system offers additional benefits beyond those of very early lesion detection and quantification. The images acquired can be stored and transmitted, perhaps for referral purposes, and the images themselves can be used as patient motivators in preventative practice.

FIG. 8.8: QLF EQUIPMENT. (A) THE QLF UNIT LIGHT BOX, DEMONSTRATING THE HANDPIECE AND LIQUID LIGHT GUIDE; (B) A CLOSE-UP OF THE INTRA-ORAL CAMERA FEATURING A DISPOSABLE MIRROR TIP THAT ALSO ACTS AS AN AMBIENT LIGHT SHIELD.

Recent Aids in Diagnosis of Dental Caries results in a third metric output, DQ. See Fig.
Recent Aids in Diagnosis of Dental Caries results in a third metric output, DQ. See Fig.

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Recent Aids in Diagnosis of Dental Caries For clinical research use, the ability to remotely analyse

For

clinical

research

use,

the

ability

to

remotely

analyse

lesions

enables

increased

legitimacy

in

trials;

permitting,

for

example,

a

repeat

of

the

analyses

to

be

conducted by a third-party. QLF is one of the most

promising

technologies

in

the

caries

detec tion

stable

at

present, although further research

is

required

to

demonstrate its ability to correctly monitor lesion changes

over

time.

There

is

also

a

great

deal

of

interest

in

red

fluorescence, and whether or not this can be a predictor of

lesion

activity

and

again,

research

is

currently

being

undertaken in this area. 27

FIG.8.9: EXAMPLE OF QLF IMAGES. (A) WHITE LIGHT IMAGE OF EARLY BUCCAL CARIES EFFECTING THE MAXILLARY TEETH, (B) QLF IMAGE TAKEN AT THE SAME TIME AS (A), NOTE THE IMPROVED DETECTION OF LESIONS AS A RESULT OF THE INCREASED CONTRAST BETWEEN SOUND AND DEMINERALISED ENAMEL, (C) 6 MONTHS AFTER THE INSTITUTION OF AN ORAL HYGIENE PROGRAMME, THE LESIONS HAVE RESOLVED. 27

Recent Aids in Diagnosis of Dental Caries For clinical research use, the ability to remotely analyse

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Recent Aids in Diagnosis of Dental Caries FIG. 8.10: AN EXAMPLE OF LESION ANALYSIS USING QLF.
Recent Aids in Diagnosis of Dental Caries FIG. 8.10: AN EXAMPLE OF LESION ANALYSIS USING QLF.

FIG. 8.10: AN EXAMPLE OF LESION ANALYSIS USING QLF. (A) LESION ON THE OCCLUSAL SURFACE OF A PREMOLAR IS IDENTIFIED AND THE ANALYSIS PATCH PLACED ON SOUND ENAMEL, (B) THE RECONSTRUCTION DEMONSTRATES CORRECT PATCH PLACEMENT AS THE SURFACE NOW LOOKS

HOMOGENOUS, (C) THE ‗SUBTRACTED‘ LESION IS DEMONSTRATED IN FALSE COLOUR INDICATING THE SEVERITY OF THE DEMINERALISATION, (D) THE QUANTITATIVE OUTPUT FROM THIS ANALYSIS AT A VARIETY OF FLUORESCENT THRESHOLD LEVELS. 27

Recent Aids in Diagnosis of Dental Caries FIG. 8.10: AN EXAMPLE OF LESION ANALYSIS USING QLF.

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Recent Aids in Diagnosis of Dental Caries [B] LASER FLUORESCENCE — DIAGNODENT: The DIAGNODent (DD) instrument
Recent Aids in Diagnosis of Dental Caries [B] LASER FLUORESCENCE — DIAGNODENT: The DIAGNODent (DD) instrument

[B] LASER FLUORESCENCEDIAGNODENT:

The DIAGNODent (DD) instrument (KaVo, Germany) is another device employing fluorescence to detect the presence of caries. Using a small laser the system produces an excitation wavelength of 655 nm which produces a red light. This is carried to one of two intra -oral tips; one designed for pits and fissures, and the other for smooth surfaces. The tip both emits the excitation light and collects the resultant fluorescence. Unlike the QLF system, the DD does not produce an image of the tooth; instead it displays a numerical value on two LED displays. The first displays the current reading while the second displays the peak reading for that examination. A small twist of the top of the tip

Recent Aids in Diagnosis of Dental Caries [B] LASER FLUORESCENCE — DIAGNODENT: The DIAGNODent (DD) instrument

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Recent Aids in Diagnosis of Dental Caries enables the machine to be reset and ready for

enables the machine to be reset and ready for another site examination and a calibration device is supplied wit h the system. There has been some debate over what exactly the DD is measuring; it is not employing the intrinsic changes within the enamel structure in the same way as QLF; this has been demonstrated by the inability of DD to detect artificial lesions in in-vitro settings. Instead the system is thought to measure the degree of bacterial activity; and this is supported by the fact that the excitation wavelength is suitable for inducing fluorescence from bacterial porphyrins; a by product of metabolism (Fig 8.11). Initial evaluations of the device suggest that it may be a promising tool for clinical use. However, the device is not without its confounders, and, like many novel caries detection devices, requires teeth to be clean and dry. The presence of stain, calculus, plaque and, when used in the laboratory, the storage medium, have all be shown to have an adverse effect on the DD readings. Most confounders tend to cause an increase in the DD reading, leading to false -positives. The literature surrounding the DD device was recently assessed in a systematic review. The authors found that, for dentinal caries, the DD device performed well, although there was a great deal of heterogeneity in the studies and they were all undertaken in vitro. The authors stated th at these results could not be extrapolated into the clinical setting and then detected a worrying trend for the device to produce more false-positives than traditional diagnostic systems. Their conclusion was therefore that there was insufficient evidence to support the use of the device as a

Recent Aids in Diagnosis of Dental Caries enables the machine to be reset and ready for

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Recent Aids in Diagnosis of Dental Caries principle means of caries diagnosis in clinical practice. It

principle means of caries diagnosis in clinical practice. It should be noted that the DD device has not been employed in a clinical trial, so there are no data indicating that the system can detect a dose response. 27

FIG 8.11: THE DIAGNODENT DEVICE.

Recent Aids in Diagnosis of Dental Caries principle means of caries diagnosis in clinical practice. It

[C] INFRARED FLUORESCENCE:

In

theory, the

tooth is

exposed

to light (irradiation)

with a wavelength of between 700 and 15,000 nm. Barrier filters are used to observe any resulting fluorescence. Studies by Alfano et al. mention exposure of teeth to

wavelengths exceeding 700 nm, but the results were not presented. Unpublished reports commented upon by Longbottom suggest that the technique is able to discriminate between sound and carious enamel and dentin. Further work is required to determine if the fluorescence signal from exposure to infrared irradiation is greater than that from other wavelengths. Additionally, any heating

Recent Aids in Diagnosis of Dental Caries principle means of caries diagnosis in clinical practice. It

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Recent Aids in Diagnosis of Dental Caries effects from absorption of infrared irradiation may have potentially

effects from absorption of infrared irradiation may have potentially damaging effects on the dental pulp, given the increased penetration and decreased scattering of the longer wavelength. Specific coherent sources of such irradiation have been relatively difficult to acquire, and detection involves the use of infrared-sensitive detectors as CCDs or film 29 .

[7] TRANSILLUMINATION WITH NEAR-INFRARED LIGHT:

The caries lesion may also be examined by shining white light through the tooth. Wavelengths in the visible range (400700 nm) are limited by strong light scattering, making it difficult to image through more than 1 mm or 2 mm of tooth structure. Therefore, methods employing wavelengths in the visible range of the electromagnetic spectra (400–700 nm) such as QLF (λ > 520 nm), LF (λ = 655 nm), and Digital Imaging Fibre-Optic Transillumination (DIFOTI) which uses high intensity white light, are highly limited by scattering. Methods that use longer wavelengths, such as in the NIR spectra (780-1550 nm), can penetrate the tissue more deeply. This deeper penetration is crucial for the transillumination (TI) method. Research has shown that enamel is highly transpar ent in the

NIR range (750 nm-1500 nm) due to the weak scattering and absorption in dental hard tissue at this wavelengths. 29

Recent Aids in Diagnosis of Dental Caries effects from absorption of infrared irradiation may have potentially

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Recent Aids in Diagnosis of Dental Caries FIG 8.12: TRANSILLUMINATION (TI) WITH NEAR- INFRARED (NIR) LIGHT.

FIG 8.12: TRANSILLUMINATION (TI) WITH NEAR- INFRARED (NIR) LIGHT. EXPERIMENTAL SET-UP OF THE TI SYSTEM. THE TOOTH IS ILLUMINATED WITH NIR LIGHT. POLARIZERS ARE USED TO EXPERIMENTALLY BLOCK OUT THE AMBIENT LIGHT FROM SATURATING THE DETECTOR, A CHARGE COUPLE DEVICE (CCD). 30

Recent Aids in Diagnosis of Dental Caries FIG 8.12: TRANSILLUMINATION (TI) WITH NEAR- INFRARED (NIR) LIGHT.

[8] NEAR-INFRARED REFLECTANCE IMAGING:

In

this

technique,

the

tooth

is

exposed

to

light

(irradiation) with a wave length of between 700 and 1500 nm. Light scattering in sound dental enamel decreases markedly in the NIR region and studies have shown that enamel has the highest transparency near 1310 nm. At this

wavelength, the attenuation coefficient is only 2 to 3 cm−1,

which is a factor of 20 to 30 times lower than in the visible region. At longer wavelengths, water absorption increases

significantly and reduces the penetration of the NIR light. Even though the light scattering for sound enamel is at a minimum in the NIR, the light scattering coefficient of enamel increases by 2-3 order of magnitudes upon demineralization due to the formation of pores on a similar size scale to the wavelength of the light that act as Mie scatterers. Therefore, caries lesions can be imaged with optimal contrast at 1310 nm. And detection is done by

Recent Aids in Diagnosis of Dental Caries FIG 8.12: TRANSILLUMINATION (TI) WITH NEAR- INFRARED (NIR) LIGHT.

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Recent Aids in Diagnosis of Dental Caries infrared sensitive detectors as CCD or film. According to

infrared sensitive detectors as CCD or film. According to Christian Zakian et al a sensitivity of > 99% and a specificity of 87.5% for enamel lesions and a sensitivity of 80% and a specificity > 99% for dentine lesions. The nature of the technique offers significant advantages, including the ability to map the lesion distribution rather than obtaining single point measurements, it is also non-invasive, noncontact, and stain insensitive. These results suggest that NIR spectral imaging is a potential clinical technique for quantitative caries diagnosis and can determine the presence of occlusal enamel and dentin lesions. 29

[9] TERAHERTZ PULSE IMAGING:

This method uses waves with tetrahertz frequency

(=1012 Hz or a wavelength of approximately 30μm) for an

image to be obtained by tetrahertz irradiation, the object is placed in the path of the beam. It is possible to record tetrahertz images using CCD detector. It has no adverse thermal effects, it is non ionising low signal to noise ratio, but the cost of equipment is high, and careful interpretation

is required. Dental Applications for this technique have been limited but promising. Longitudinal sections through three teeth have demonsrated increased terahertz absorption by early occlusal caries and an apparent ability to discriminate dental caries from idiopathic enamel hypomineralisation. Work in progress to image intact te eth with early carious lesion. 29

Recent Aids in Diagnosis of Dental Caries infrared sensitive detectors as CCD or film. According to

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Recent Aids in Diagnosis of Dental Caries [10] MULTIPHOTON IMAGING: Infra red light of 850 nm

[10] MULTIPHOTON IMAGING:

Infra

red

light

of

850

nm has been used for

multiphoton imaging of teeth. In conventional fluorescence imaging (QLF), a single blue photon is used to excite a fluorescent compound in the tooth. In the multiphoton technique two infrared photons (with half the energy of blue photon) are absorbed simultaneously. With this technique, sound tooth tissue fluoresces strongly, whereas carious tooth tissue fluoresces to a much lesser extent. In practice, by using motors with micron accuracy, one can move the plane of focus through the tissue and record the sectional images from the tooth to form a 3D image. Caries will appear as a dark form with in a brightly fluorescing tooth. To highlight the diseased tissue, the image may be displayed in its negative form so that caries appear bright with in dark tooth. 29

[11] TIME-CORRELATED SINGLE-PHOTON COUNTING FLUORESCENCE: LIFETIME IMAGING:

It has also been demonstrated that fluorescence lifetime imaging microscopy (FLIM) has the ability to distinguish the carious region from sound dental tissue. Optical band pass interference filters were then applied to this broad-bandwidth source to select the 488 nm excitation wavelength required to perform TCSPC FLIM of dental structures. The white-light generation source provides a flexible method of producing variable-bandwidth visible and ps-pulsed light for TCSPC FLIM. The results from the dental tissue indicate a potential method of discriminating

Recent Aids in Diagnosis of Dental Caries [10] MULTIPHOTON IMAGING: Infra red light of 850 nm

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Recent Aids in Diagnosis of Dental Caries diseased tissue from sound, but stained tissue, which could

diseased tissue from sound, but stained tissue, which could be of crucial importance in limiting tissue resection during preparation for clinical restorations. 29

Recent Aids in Diagnosis of Dental Caries diseased tissue from sound, but stained tissue, which could

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