What are the recent advances in diagnosis of dental caries?

Answer 1

1. Summary.In this revision of Literature a description of the used clinical methods of diagnosis for the detection used for the detection of initial injury of decay is realized, of such way to help the odontologist to leave to a side the traditional methods of detection of decay, considering the nature of the initial injury, that is to say, the presence of a relatively intact superficial zone on a subsuperficial zone that has undergone an important demineralization, where these traditional methods, far from to facilitate the diagnosis can turn a reversible injury into a frank cavity.

Key words: Diagnosis, decay, initial injury.

2. Abstract.In this review of the literature, it was performed to description of the clinical diagnostic methods used to detect the initial decay injury in such to way that dentists uses those methods taking into consideration the nature of the initial injury, in the words, the prescence of an almost intact superficial zone to over to subsuperficial zone that there are suffered an important desmineralization, where the traditional methods may become to reversible injury in a cavity.

Key Word: Diagnosis, decay, initial injury.

3. Introduction.The word diagnosis derives from the Greek day, to traverse and gnosis, knowledge. This it implies that a deep knowledge of the disease of the factors responsible for its etiology and pathogenesis entails to the identification of the same through its signs and síntomas1.

In addition, it must be clear that the escogencia of the methods of diagnosis approved and the understanding of the data obtained jointly with the knowledge of the disease are the bases for a right diagnosis and, consequently, for decisions of the treatment apropiadas1.

The diagnosis of the cariosa injury represents a technique that is central pair the clinical practice. The advances happened in relation to the cariología force the clinical one to update themselves and to let to a side the traditional methods detection of injuries of decay to lead itself the new use of métodos2.

There are published evidences that the initial injuries of decay prevail more than the injuries with cavities, this is of great importance since if we detected the injury in its initial stages before forming the cavity, we can interfere in the carioso process and revert using it one or more mechanism known to promote and to allow the remineralization of the tooth. A great interest in the development of valid clinical methods for the early detection of the decay injury exists therefore, that allows to majors advances in the prevention of caries3.

For the clinical ones he has been complicated to reach an agreement in the detection of the initial injury. With the aid of a mirror the new technology allows the diagnosis us of the injury without using tactile techniques that far from to help in the diagnosis can turn a reversible injury into irreversible when fracturing an enamel of the relatively intact superficial zone, therefore, the tactile method (use of the explorer) will be only used in cariosas injuries where there is formation of cavidad3, 4.

To diagnose the initial injury before the presence of a relatively intact superficial zone, is difficult task, it requires of the cognitive support and the use of up-to-date methods in order to evaluate the dynamics of the injury of caries5.

The objective of this article is to describe two present methods of clinical diagnosis used for the detection of the initial injury of decay in order to help the odontologist to leave to a side the traditional methods of decay diagnosis.

4. Clinical methods for the diagnosis of the initial injury of the decay.Visual method.

The clinical inspection depends on the evaluation of the changes in the translucence of the enamel, that is to say, the loss of the brightness, the opaque aspect. (Part I) Also we can evaluate the pigmentations, the location and the presence or not of soft weave or the changes in the texture of the resulting enamel of the demineralization degree. This last one has been indicated like the mostvalid indicator of active decay. It is recommended in addition, to improve the visualization of the injury the use of magnificación5.

Criteria used in the clinical examination of the initial injury of caries4, 6.

Smooth surfaces

1. Injury located by vestibular zone of susceptible decay 1-1,5 mm that goes parallel to the gingival margin.

2. Injury of aspect tizoso or lechozo in the enamel (it stains white).

3. To the drying with air syringe, it increases the visibility, it is observed the surface with loss of brightness.

4. Use of the explorer is not recommended because excessive forces cause penetration of the intact surface.

5. Interproximal zone. Separation of the papilla with blunt instrument or the use of dental separators to facilitate the observation

Points and Fissures

1.

2. Base of the dark fissure and walls of the aspect fissure tizoso or lechozo.

3. After curing, it is observed if the zone presents/displays cavity or no.

4. Use of the explorer is not recommended does not have to be pressed at heart of the fissure.

5.

Tactile method.

For more than 10 years there have been controversies concerning the use of the explorer in the decay diagnosis. Historically, the explorer considered itself like a tool for the decay diagnosis, however, in the light of the present knowledge in relation to the initial injury, a small force exerted with this instrument of acute end could bring about a damage to the weave of the superficial zone, consequently becomes a white spot a cavitada injury. In conclusion the explorer of acute end, does not have to be used for the diagnosis of smooth initial injuries of surface and points and fissures. In its place,we could use an explorer of cleared end or a periodontal sounding to remove nutritional rest before initiating the clinical examination and then, without realizing no type of pressure, we can check the texture of the surface without penetrarla7.

X-ray method.

The coronales x-rays are a complement for the diagnosis of interproximales decays and allow the progression of the injury. However, when histological the decay injury involves only half of the thickness of the enamel, usually, the injury with the coronal x-ray cannot be detected, because the depth of the injury from the histological point of view is more outpost than the x-ray appearance. By the exposed thing, the coronal x-ray for the diagnosis of the initial injuries is not recommended that less than involve half of the thickness of the enamel, but is a good alternative to determine the progression of the injury after a therapy of remineralization in a stage of reevaluación8, 9, 10.

It is important to emphasize, also, that clinically we could diagnose free surfaces intermaxilares of decay, whereas histological the injury already can be present in numerous interproximales surfaces (subclinical injuries). For this reason the odontologists we needed to make emphasis in the preventive practices to clinically avoid the progress of a nondetectable injury at levels visible8, 9, 10. By the exposed thing, we can conclude that the x-ray examination is not an suitable method to as much identify and to measure the injuries of initial decays in proximales surfaces as in occlusal faces despite is a method of complementary diagnosis that allows to detect interproximales decays of injuries more outposts as well as to evaluate the progression of an injury after treatment of remineralización8.

The explained methods previously are but known by the majority of the odontologists, nevertheless, taking into account the difficulty to diagnose the initial injury, a series of methods has been developed that facilitate their detection, we are going to explain some of them briefly.

Method of transiluminación.

This method is based on the transmission of the light through tooth, this one is affected by the refractive indices and the degree of turbidity within medio11. During many years the odontologists we have used east method by means of the aid of the buccal mirror. Through time equipment for the dental transiluminación has been developed and at present we have some of them, who allow to use this method diagnosis of decay with major precisión12.

The transiluminación by optical fiber is a practical method for the decay diagnosis, the visible light is sent by an optical fiber to the tooth the light propagates from the fiber through dental weave to the opposite surface. The result of the obtained images of the distribution of the light is used for diagnóstico12.

The diagnosis done through visual examination can be subjective due to variables intra and interobserver (the carious enamel is observed dark and healthy it transmits the light), by such reason, equipment has been developed that allows to capture the images, as in the case of the transiluminación by optical fiber of digitized image, where the illumination and the images are controlable and reproducible. This system is comparable to the x-ray image convencional12. However, the diagnostic sensitivity of the transiluminación by optical fiber for injuries that have progressed in the dentine is significantly inferior that the one of the x-ray coronal10.

Method of fluorescent light.

The common principle for this method is the fluorescence of the enamel and the dentine. The teeth when illuminating itself with violet blue light emit yellowish green light and when decay exists, the fluorescence pierde13. They have been developed technical of ultraviolet Photography able to evaluate the formation of test-tube cariosas injuries. However, it was observed that the fluorescence or loss of the same is not sufficiently sensible to detect initial injuries of decay. The difference in the absorption and reflection of the ultraviolet light must particularly to the wavelength and that shortwavelengths are much more sensible for the detection of injuries iniciales13, 14.

When it happens the demineralization of the enamel during the decay formation, the occupied spaces by calcium and phosphate are filled up bymaterial plate and of film derived from the buccal environment. These deposited materials contain substances such as proteins that absorb photons in the ultraviolet portion of the electromagnetic spectrum, but in the initial injury the spaces extended by the demineralization are very small and the visualization of the injury in its initial stages requires major sensitivity of método13, 14.

We can conclude that this method is based on the capacity of the dental surface to absorb and to reflect the ultraviolet radiation and not in the differences in the fluorescence or loss of the same. It is important to notice that the human eye can detect differences due to the fluorescence, but cannot differentiate the absorption and the reflection from the light ultravioleta13, 14.

Initially it compared the detection of injuries under visible light and with ultraviolet light by visual observation. Even though that the results indicated a greater sensitivity of the ultraviolet light to detect decay, it was not sufficient before the effort necessary to protect the examiner and to the patient to long exhibitions of ultraviolet radiation, that was tedious and the results continued being subjetivo13, 14, 15.

In order to correct this problem the selection of the light source and the filters have been developed to special equipment in relation to. Quartz or fiber glasses are used for the propagation of the ultraviolet light. The images are caught by a camera and soon computerized, this allows to quantify the amount of emitted light and to compare it with a healthy weave reference of the same image. The developed equipment brings devices (quartz or fiber glasses) in the form of ring to be used in smooth surfaces and in the form of end for occlusal faces (graves and fissures) 3.

The fluorescent laser is a new method for the diagnosis of the injury of decay, based on the fluorescence of the dental structure, which happens when the tooth is illuminated with a device that emits a green-blue light with a wavelength of 488 nm. This wavelength allows to detect the initial injuries more easily that x-rays could not be detected with it coronales16. Also the fluorescent laser has been used successful to quantify the degree of remineralization of incipient enamel injuries in therapies with fluoruros17.

Method of electrical conductance.

This method is based on which the enamel is an electrical conductive poor man. As it explained previously (Part 1), size of pores is very small in order of 1 to 6 nm., but when to produce demineralization of enamel during process carioso originates increase as large as the same, if to this we added the filling to him of the spaces enlarged with fluids that contain minerals and ions of the saliva, gives rise to a change in the electrical behavior of the enamel. Therefore the carious enamel has a high compared electrical conductance with the healthy enamel. The conductance of the dentine heals is much greater than the one of the healthy enamel due to its high content of agua18.

The new equipment of electrical conductance brings built-in the test end I supplement of integral air, this air flow is essential to remove the superficial humidity and to prevent the electrical conduction with the dental surface towards the marginal gum, allowing to a conductance reading more estable19.

5. Exactitude of the diagnosis methods.The term exactitude talks about the capacity of the method to provide a diagnosis that corresponds to the true state and requires that the diagnoses are compared with the truth, generally the diagnostic decisions can be:

True positives (VP), cases with disease in that the test that has been positive.

True negative (VN), cases without the disease in that the test that has been negative.

False positive (FP), cases without disease in that the test resultses are positive.

False negative (FN), cases with disease with results negativos1.

When realizing a statistic analysis of the data collected with the different methods we are going to obtain the sensitivity and the specificity of the used method. Sensitivity is the capacity of the method of used diagnosis to correctly identify the cases with the disease or the state of disease that interests to us. It includes the fraction of the true positives. The specificity is the measurement of capacity of the diagnosis method to identify the cases without disease correctly. It includes the true fraction of negativos1.

One has described to a world-wide diminution in the prevalence of the dental decay in children and adolescent. This can require that in the future the criteria of diagnosis for the decay registries they are stricter. During the past few years a change in many countries has taken place towards the use of strict criteria, for example, when it is to decide if to make or not a reconstruction based on the degree of advance the cariosa injury. This can be attributed to the diminution in the prevalence of the decay and to an increase in the use of preventive measures that give to less gravity to the disease not tratada1.

It is important that one knows sensitivity and specificity the method of used diagnosis, so that the consequences in the correct and incorrect decisions are evaluated. In relation to the explained methods of diagnosis previously it has been described that the electrical compared healthy enamel conductance with carious enamel, shows to a 92% of sensitivity and a 87% of specificity to detect dentine decay underneath fissures, which do not have visible signs of cavity formation, to obtain these levels of sensitivity and specificity it is necessary to maintain a air flow, as it were explained previously, in the end of instrumento20.

When comparing visual, x-ray examination and electrical conductance in dentine decay underneath the fissures, the visual examination and the electrical conductance, gave to discharges correlations with respect to the presence of the cariosas injuries, however, the x-rays did not detect initial injuries of enamel decay and dentine, their better S-values in injuries but avanzadas20.

On the other hand, the image analyzes of injuries of decays obtained by transiluminación by optical fiber and digital camera show that this technology has high sensitivy, compared with the x-ray for smooth proximales surfaces and decay oclusal20.

Finally, a great potential of the use of the fluorescent laser in the detection of initial injuries of decay has been indicated, however, more studies to respecto2 are required.

We can conclude that great clinical difficulties exist to diagnose the initial injuries of decay by the conventional methods. Nevertheless, concerted efforts are being realized in this field and every time we approached more gransensibilidad methods and specificity for detects east type of injuries.