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Caries Detection: A Review of Current Fluorescence Tools

Peter Rechmann, DDS, PhD; Beate M.T. Rechmann; and John D.B. Featherstone, MSc, PhD

April 2019 RN - Expires Saturday, April 30th, 2022

Updates in Clinical Dentistry

Abstract

Modern caries treatment concepts like caries management by risk assessment—CAMBRA—entail diagnosing early caries lesions in a precavitated stage to make it possible to reverse the caries process with remineralization and bacteria reduction efforts. Newer, sensitive caries diagnostic tools can serve not only for early detection but also for monitoring of caries lesions to confirm the success of prevention and remineralization efforts. This article describes light-based caries diagnostic tools, with emphasis on fluorescence-based techniques, and compares the most common available fluorescence-based tools with a standardized visual caries inspection system—the International Caries Detection and Assessment System (ICDAS II). Fluorescence tools that provide high-resolution fluorescence pictures are likely to provide more reliable scores than fluorescence devices that assess via a single spot. The better visibility of the high-resolution fluorescence imaging could prevent unnecessary operative interventions.

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With respect to treatment of caries, the tendency is to treat caries lesions therapeutically much earlier than at the cavitated stage. Incorporating caries management by risk assessment (CAMBRA)1-7 into their daily dental office routine enables clinicians to identify a patient’s caries risk by evaluating his or her disease indicators, risk factors, and preventive factors. After careful evaluation, a classification of low, moderate, high, or extremely high caries risk can be made, and preventive chemical measures, as well as any changes in lifestyle, can be suggested. In the case of a patient with moderate or high caries risk, the goal is to reduce the risk level and prevent further caries. Already-cavitated lesions, of course, require traditional invasive restorative treatment. In contrast, precavitated caries lesions—where demineralization of enamel has occurred but an intact mineral surface layer still exists—can be treated with remineralization efforts. Remineralization can be achieved directly by providing various levels of fluoride treatment (prescription fluoride toothpaste, fluoride rinse, fluoride varnishes) or indirectly by enhancing saliva flow (xylitol mints/gums) or through bacteria reduction (chlorhexidine applications, xylitol mints/gums).

In order to easily apply the CAMBRA principles outlined above, it is useful to introduce state-of-the-art, sensitive caries diagnostic tools into the dental office armamentarium. Caries detection has traditionally been performed with a visual examination plus the use of an explorer to provide additional tactile information. European studies have demonstrated that the information thought to come from the explorer was correct in fewer than 50% of cases.8 Radiographs—specifically bitewings—have also been engaged to detect caries lesions, but they work satisfactorily only for approximal lesions. Due to the beam attenuation from healthy enamel and dentin when trying to detect occlusal lesions on radiographs, occlusal lesions can be detected only at a very advanced stage.9

If carious lesions are detected early enough in a precavitated stage, intervention methods such as fluoride application, sealants, preventive resin restorations, laser treatment, and antibacterial therapy can be applied to reverse the caries process.9 Sensitive modern caries diagnostic tools can serve not only for early detection but also for monitoring caries lesions to confirm the success of prevention and remineralization efforts.

This article describes light-based caries diagnostic tools that are either available for the dental office or are still in the laboratory research stage. The most commonly available tools—some of which have been successfully marketed—are compared with a standardized visual caries inspection system. The International Caries Detection and Assessment System (ICDAS II) was designed and adopted to avoid inconsistencies between diagnoses from different dentists.10

Light-Based Caries Detection Methods

Fiber-Optic Transillumination

Novel early caries detection methods include fiber-optic transillumination (FOTI). This technique, which has been available for more than 40 years, uses light transmission through the tooth.11-13 A recently marketed method based upon the same principles is the digitized fiber-optic transillumination (DIFOTI) method. Acquired images can be stored for subsequent retrieval and comparative examination. Only limited research has been performed so far, but the results have indicated that the technique is grossly inadequate at quantitatively determining lesion depth or extent.14-16 The technique essentially measures surface scattering on the outside of the lesion, rather than demineralization in the depth of the enamel.

Optical Coherence Tomography

Optical coherence tomography (OCT) is a non-ionizing imaging technique that can produce cross-section images of biologic tissues.17-20 When a tooth with a carious lesion is illuminated with infrared light at 1,310 nm, OCT technology can produce 2- or 3-dimensional images as well as a quantitative image of the subsurface lesion to the full depth of the enamel.21,22 Polarized sensitive OCT (PS-OCT) can be correlated with the degree of demineralization and lesion severity.21,23 Potential future use for OCT could be monitoring in-vivo caries lesion changes as well as detecting demineralization beyond sealants.24

Fluorescence Caries Diagnostic Tools

The following diagnostic tools are based on the phenomenon of fluorescence. Fluorescence is a property of natural and some man-made materials that absorb energy at certain wavelengths and then emit light at longer wavelengths. Several caries detection methods engage the use of fluorescence.

DIAGNOdent—Enamel is essentially transparent under red light. When a caries lesion is illuminated with, for instance, red laser light (655 nm), organic molecules that have penetrated porous regions of the tooth—especially metabolites from oral bacteria—will create an infrared (IR) fluorescence. The IR fluorescence is believed to originate from porphyrins and related compounds from oral bacteria.25-28

In the case of the DIAGNOdent tool (KaVo Dental, www.kavousa.com), the emitted light is channeled through the handpiece to a detector, and a digital number (1-99) and a sound is presented to the operator. A higher number indicates more fluorescence and a more extensive lesion below the surface; a value of 5 to 10 indicates initial caries in enamel, 10 to 20 denotes initial caries in dentin, and > 20 signifies caries in dentin. The system has shown good performance and reproducibility for detection and quantification of occlusal and smooth-surface carious lesions in in-vitro studies.25,29 In vivo, the results are more contradictory, both in the primary and permanent dentition.30-36 DIAGNOdent has also been tried for longitudinal monitoring of the caries process and for assessing the outcome of preventive interventions.37 As reported in various papers, the sensitivity of the system ranges between 19% and 100%, with a specificity between 52% and 100%.38 (Note: Sensitivity means that the test correctly indicates when a person, in fact, has the disease; while specificity means that the test indicates that a person without the disease is, in fact, disease-free.)

Quantitative Light-Induced Fluorescence—It has been suggested that tooth autofluorescence and its attenuation is useful for the detection of dental caries.39 The reasoning behind this theory is that increased porosity due to a subsurface enamel lesion, which is occupied by water, scatters the light either as it enters the tooth or as the fluorescence is emitted. This scattering results in a loss of its natural fluorescence. As a result, on a digital image the demineralized area appears opaque and darker than sound enamel. Inspektor™ Pro (Inspektor Dental Care, www.inspektordentalcare.com), a QLF method on the market in several countries, can detect lesions to a depth of approximately 500 µm on smooth enamel surfaces. QLF uses a 370-nm excitation wavelength, resulting in a green autofluorescence of the tooth. The QLF method has been tested in several in-vitro,40-42 in-situ,43 and in-vivo44-49 studies for smooth-surface caries lesions. Adapting the QLF method for occlusal caries diagnosis is under investigation.50 The sensitivity of the system is reported to be 80% to 96%, with a specificity of 11% to 80%.51,52

Spectra® Caries Detection Aid System—This system (Air Techniques, Inc., www.airtechniques.com) aids in the detection of caries using fluorescence technology light-emitting diodes (LEDs), which project high-energy light at an excitation wavelength of 405 nm onto the tooth surface. Cariogenic bacteria fluoresce red, and healthy enamel fluoresces green. The on-screen picture of the tooth includes false coloring and a number scale predicting the caries depth, with 1.0 to 1.5 as early enamel caries, 1.5 to 2.0 as deep enamel caries, 2.0 to 2.5 as dentin caries, and 2.5 or above as deep dentin caries. The sensitivity of the system is reported to be 71% to 86%, with a specificity of 32% to 76%.53,54  Figure 1 shows on-screen false colors and numbers for a tooth clinically presenting obvious caries lesions (ICDAS II code 5), while the tooth in Figure 2 clinically shows some beginning demineralization of the fissure system (ICDAS II code 1).

SOPROLIFE System—This system (Acteon Imaging, www.acteongroup.com) is said to combine the advantages of a visual inspection method (high specificity) with a high-magnification oral camera and a laser fluorescence device (high reproducibility and discrimination). This technique is based on the light-induced fluorescence evaluator for diagnosis and treatment (LIFEDT) concept.55,56 In the “daylight mode,” white LEDs illuminate the tooth, while in the “fluorescence mode,” the excitation is managed by four blue LEDs at a 450-nm wavelength. The intense blue light shines through the enamel and induces a green fluorescence from the dentin core, which, on its way back through dentin/enamel, consequently initiates a red fluorescence due to porphyrins and related compounds from oral bacteria remaining at a caries lesion site.57

In order to classify caries lesions in early stages using the SOPROLIFE tool, the authors have introduced a new scale. SOPROLIFE daylight and SOPROLIFE fluorescence pictures for occlusal fissure areas were each categorized into six different groups—code 0 to code 5.57 The categorization followed appearance criteria of the lesion and was performed independently from a parallel registered ICDAS II code. The categorization was based on the idea that the width of a lesion was related to the confines of fissures, difference in color and intensity of the registered color expressions, as well as the roughness of the enamel structure and the break in enamel with first enamel loss, and, finally, that visible dentin would coincide with the progression of a caries lesion. Thus, precavitated and cavitated lesions and their development levels were categorized.

Daylight mode codes for coronal caries using SOPROLIFE, along with observed tooth changes, are depicted and summarized in Figure 3 through Figure 8. When evaluating occlusal fissure areas with SOPROLIFE, daylight mode code 0 is given for sound enamel with no changes in the fissure area (Figure 3). Code 1 is applied if the center of the fissure shows whitish or slightly yellowish change in the enamel. In code 1, change is limited to part or all of the base of the pit and fissure system (Figure 4). In code 2, the whitish change is wider and extends to the base of the pit and fissure system and comes up the slopes (walls) of the fissure system in the direction of the cusps. The whitish change can be seen in part or all of the pit and fissure system, but no enamel breakdown is visible (Figure 5). In code 3, fissure areas are rough and slightly open, depicting a beginning slight enamel breakdown. Changes are confined to the fissure and do not need to come up the slopes. There are no visual signs of dentin involvement (Figure 6). In code 4, the caries process is no longer confined to the fissure width and presents itself as much wider than the fissure; the changed areas have a “mother-of-pearl” glossy appearance (Figure 7). If there is obvious enamel breakdown with visible dentin, code 5 is given (Figure 8).

Blue fluorescence mode codes for coronal caries using SOPROLIFE, along with observed tooth changes, are depicted and summarized in Figure 9 through Figure 14. SOPROLIFE blue fluorescence mode code 0 is given when the fissure appears shiny green and the enamel appears sound with no visible changes (Figure 9); rarely, a graphite pencil-colored thin shine/line can be observed. Code 1 is selected if a tiny, thin red shimmer in the pit and fissure system is observed, which can slightly come up the slopes of the fissure system. No red dots are visible (Figure 10). At code 2, in addition to the tiny, thin red shimmer in pits and fissures possibly coming up the slopes, darker red spots confined to the fissure are visible (Figure 11). For code 3, dark red spots extend as lines into the fissure areas, but are still confined to the fissures. A slight beginning roughness of the deepened red-lined areas might be observed (Figure 12). If the dark red (or red-orange) extends wider than the confines of the fissures, a code 4 is given (Figure 13). Surface roughness occurs, and possibly grey and/or rough grey zones are visible. Code 5 is selected if obvious openings of enamel are seen with visible dentin (Figure 14).

Diagnostic Capabilities of Fluorescence Tools

 

Conclusion

When comparing spot-measuring fluorescence tools with those providing high-resolution fluorescence pictures, the better visibility provided by the high-resolution tools might help prevent unnecessary operative interventions that are based solely on high fluorescence scores. A fluorescence camera system can produce a visible depiction of the source of the fluorescence signal as well as help determine the reason for an unexpected high fluorescence value. Having better “visibility” of the lesion makes it easier to interpret the higher fluorescence. The observation capacity of such a system can guide clinicians towards a more preventive and minimally invasive treatment strategy in the course of monitoring lesion progression or remineralization over time, and it should deter them from restoratively over-treating a lesion.68

Disclosure

The authors declare that there is no conflict of interest regarding this manuscript.

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About the Authors

Peter Rechmann, DDS, PhD
Department of Preventive and Restorative Dental Sciences
School of Dentistry
University of California at San Francisco
San Francisco, California

Beate M.T. Rechmann
Department of Preventive and Restorative Dental Sciences
School of Dentistry
University of California at San Francisco
San Francisco, California

John D.B. Featherstone, MSc, PhD
Department of Preventive and Restorative Dental Sciences
School of Dentistry
University of California at San Francisco
San Francisco, California

Figure 1  Spectra Visix fluorescence pictures with on-screen false colors and numbers: tooth clinically presenting obvious caries lesions deep into dentin (ICDAS II code 5) (Fig 13); tooth clinically presenting only beginning demineralization (ICDAS II code 1).

Figure 1

Figure 2  Spectra Visix fluorescence pictures with on-screen false colors and numbers: tooth clinically presenting obvious caries lesions deep into dentin (ICDAS II code 5) (Fig 13); tooth clinically presenting only beginning demineralization (ICDAS II code 1).

Figure 2

Figure 3  Daylight code 0: sound; no visible change in the fissure.

Figure 3

Figure 4  Daylight code 1: center of the fissure showing whitish, slightly yellowish change in enamel, limited to part or all of the base of the pit and fissure system. (See arrows.)

Figure 4

Figure 5  Daylight code 2: whitish change comes up the slopes (walls) towards the cusps; the change is wider than the confines of the fissure and can be seen in part or all of the pit and fissure system; no enamel breakdown is visible. (Arrows mark the changes coming up the slopes.)

Figure 5

Figure 6  Daylight code 3: fissure enamel is rough and slightly open with beginning slight enamel breakdown; changes are confined to the fissure and do not need to come up the slopes; there are no visual signs of dentinal involvement. (Arrows mark slight enamel loss.)

Figure 6

Figure 7  Daylight code 4: caries process is not confined to the fissure width; presents itself much wider than the fissure; changed area has a “mother-of-pearl” glossy appearance.

Figure 7

Figure 9  Blue fluorescence code 0: sound; no visible change in enamel fissure; shiny green fissure. (Note: Rarely, a graphite pencil-colored thin shine/line can be observed.)

Figure 9

Figure 10  Blue fluorescence code 1: tiny, thin red shimmer in the pit and fissure system can come up the slopes; no red dots visible. (Arrows mark tiny, thin red shimmer.)

Figure 10

Figure 11: Blue fluorescence code 2: in addition to tiny, thin red shimmer in pits and fissures possibly coming up the slopes, darker red spots confined to the fissure are visible; there is no surface roughness. (Arrows mark dark red spots.)

Figure 11

Figure 12  Blue fluorescence code 3: dark red extended areas confined to the fissures; slight beginning roughness possible.

Figure 12

Figure 13  Blue fluorescence code 4: dark red or orange areas wider than fissures; surface roughness occurs; possibly grey or rough grey zone visible. (Arrows mark surface roughness.)

Figure 13

Figure 14  Blue fluorescence code 5: obvious wide openings with visible dentin. (See arrows.)

Figure 14

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SOURCE: Inside Dental Hygiene | December 2012

Learning Objectives:

  • Explain the CAMBRA principle
  • Describe advances in caries detection technology
  • Review light-based caries detection methods

Author Qualifications:

Peter Rechmann, DDS, PhD Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California at San Francisco, San Francisco, California Beate M.T. Rechmann Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California at San Francisco, San Francisco, California John D.B. Featherstone, MSc, PhD Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California at San Francisco, San Francisco, California

Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to justin.romano@broadcastmed.com.