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Clinical examination of dental caries(conservative)

Caries 1. Investigation : radiography ✅✅ 2. Visual ✅ 3. Aids 4. Instrument ❌

Preparation for Clinical Examination

  • The clinical examination is performed systematically in a clean, dry, well illuminated mouth.
  • Proper instruments, including a mouth mirror, an explorer, and a periodontal probe, and the ability to air-dry the surfaces of the teeth, are required.
  • A cotton roll is placed in the vestibular space and another under the tongue to maintain dryness and improve visualization of the teeth and adjacent gingiva (Fig. 3.1).
  • Every accessible surface of each tooth must be inspected for localized changes in colour, texture, and translucency.
  • A routine for charting should be established, such as starting in the upper right quadrant with the most posterior tooth and progressing around the maxillary and mandibular arches.
  • Dental floss is useful in identifying overhanging restorations, improper proximal contours, and open contacts.
  • Heavy biofilm accumulation may require flossing and a toothbrush prophylaxis to aid in the examination process. Occasionally a gross debridement must be scheduled before final clinical examination of the teeth.

Clinical Examination for Caries

Caries lesions may be detected by: I.Visual changes in tooth surface texture or colour. II. instrument tactile sensation, when an explorer is used judiciously to detect surface roughness by gently stroking across the tooth surface. III. Radiographs, which show changes in tooth density from normal. IV. Adjunctive tests that use various technologies to aid in caries lesion detection and caries activity (discussed in later sections).

I.Visual Assessment

• The occlusal surface is diagnosed as diseased if external chalkiness (enamel caries) or subsurface opacity (dentine caries) or cavitation of tooth structure, forming the fissure or pit, is seen.

• At times a brown-gray discolouration, radiating peripherally from the fissure or pit, is present (see Fig. 3.2A, enamel area adjacent to the central pit/lingual fissure) indicating caries progression in dentine below the translucent enamel. In contrast, it is common to observe non-diseased occlusal surfaces with narrow grooves or fossae which exhibit superficial staining, but no visual changes in light reflection through the enamel immediately adjacent (see Fig. 3.2A, distal aspect of central groove and distal fossa area) and with no radiographic evidence of caries. The superficial staining is extrinsic and occurs over several years of oral exposure in a person with low caries risk.

• Carious lesions occasionally develop on cusp tips (see Fig. 3.2B). Typically, these are the result of developmental enamel defects or following loss of enamel (exposure of dentine) due to erosion, abrasion, or para-function

Use ICDAS()

ii.instrument tactile sensation

The recommended instrument for assessment of surface roughness is the Community Periodontal Index of Treatment Needs (CPITN) probe having a 0.5 mm sphere at the tip (Fig. 3.4). • Sharp explorers previously have been used to evaluate fissures and pits in an attempt to diagnose fissure/pit caries. However, numerous studies have found that the use of a sharp explorer for this purpose did not increase diagnostic validity compared with visual inspection alone. • The use of the sharp dental explorer for this purpose was found to fracture enamel and serve as a source for transferring pathogenic bacteria among various teeth.9,10 It cannot be overemphasized that the explorer must not be used to determine a ‘stick’ (i.e. a resistance to withdrawal from a fissure or pit). Forcing an explorer into pits and fissures also theoretically risks cross-contamination from one probing site to another. In contrast, for assessment of root caries, an explorer is valuable for detecting root surface softness.

iii.Radiographs

Interpretation of radiographs When interpreting the radiographic presentation of proximal tooth surfaces, it is necessary to know the normal anatomic picture presented in a radiograph before any abnormalities may be diagnosed. In a radiograph, a proximal caries lesion usually appears as a dark area or a radiolucency in the enamel slightly apical to the contact (see Fig. 3.5A). This radiolucency is typically triangular and has its apex towards the DEJ. • Some defective aspects of restorations, including improper contour, overhangs (see Fig. 3.6), and recurrent caries lesions gingival to restorations (see Fig. 3.5D), may also be identified radiographically. 92 • The height and integrity of the marginal periodontium may be evaluated using bitewing radiographs. • Pulpal abnormalities such as pulp stones and internal resorption may be identified in various radiographs. • Periapical radiographs are helpful in diagnosing changes in the periapical periodontium such as periapical abscesses, dental granulomas, or cysts. • Impacted third molars, supernumerary teeth, and other congenital or acquired abnormalities also may be discovered on periapical radiographic examination. • Radiographs aid in determining the relationship between the margins of existing or proposed restorations and bone.

iv.Adjunctive aids and tests

  • Magnification in operative dentistry
  • Photography in operative dentistry
  • Diagnostic study models
  • Transillumination
  • Newer caries detection technologies

The technologies currently approved by the FDA include laser-induced fluorescence, light-induced fluorescence,and alternating current (AC) impedance spectroscopy (ACIST).

Types

Clinical Examination of Proximal Surface Caries

• Early proximal surface caries: This form of smooth-surface caries is usually diagnosed radiographically (Fig. 3.5A and B). It also may be detected by careful visual examination after tooth separation or through fibre-optic transillumination.19 • Cavitated Proximal surface caries: When the caries lesion has progressed through the proximal surface enamel and has demineralized dentine, a white opaque appearance or a shadow under the marginal ridge may become evident (see Fig. 3.2C). Careful probing with an explorer on the proximal surface may detect cavitation, which is defined as a break in the surface contour of enamel. The combined use of all examination methods may be helpful in arriving at an accurate final diagnosis. • Inactive proximal surface caries: Brown spots on intact, hard proximal surface enamel adjacent to and usually gingival to the contact area are often seen in older patients, in whom caries activity is low. These discoloured areas are a result of extrinsic staining during earlier caries demineralizing episodes, each followed by a remineralization episode. These areas are no longer carious and are usually more resistant to caries as a result of fluorohydroxyapatite formation. Restorative treatment of these areas is not indicated. Inactive proximal caries lesions sometimes are difficult to correctly diagnose because of faint radiographic evidence revealing previous mineral loss. • Anterior proximal surface caries: Proximal surface caries in anterior teeth may be identified by radiographic examination, visual inspection (with optional transillumination), or probing with an explorer. In addition to transillumination, tactile exploration of anterior teeth is appropriate to detect cavitation because the proximal surfaces generally are more visible and accessible than in the posterior regions.

Clinical Examination of Smooth Surface Caries

Smooth-surface caries may occur on the facial and lingual surfaces of the teeth of patients with high caries activity, particularly in the cervical areas that are less accessible for cleaning. The earliest clinical evidence of early enamel lesions on these surfaces is a white spot that is visually different from the adjacent translucent enamel that appears when the surface is dried. Rewetting results in partial or total disappearance. This appearing–disappearing phenomenon distinguishes the smooth-surface early enamel lesion from the enamel white spot that results from non-hereditary enamel hypo-calcification (see section on Clinical Examination for Additional Defects). Both types of white spots are undetectable tactilely because the surface is intact, smooth, and hard. For white spot lesions, non-surgical remineralization therapies (discussed in Chapter 2) should be instituted to promote remineralization. The presence of several facial (or lingual) smooth-surface caries lesions within a patient’s dentition suggests a high caries rate, which means that if the existing risk factors are not addressed, the patient is at high risk for developing more lesions in the future. Advanced smooth-surface caries exhibits discolouration and demineralization and feels soft as the explorer is translated across the suspicious area. The discolouration may range from white to dark brown, with rapidly progressing caries usually being light in colour. Slowly progressing caries, in a patient with low caries activity, darkens over time because of extrinsic staining and physical changes in the structure of the dentine–collagen matrix. Remineralization of the decalcified tooth structure will return the tactile hardness of the lesion and is an evidence that the caries has been arrested. The dentine in an arrested remineralized lesion has become sclerotic (see Chapter 1). Such an arrested lesion at times may be rough, although cleanable, and restoration is not indicated except to address the esthetic concerns of the patient or to assist with patient control of biofilm accumulation. These lesions are inactive but remain susceptible to new caries activity in the future.

Clinical Examination of Root Surface Caries

Clinical Examination of Amalgam Restorations

Evaluation of existing restorations should be accomplished systematically in a clean, dry, well-lit field. Clinical evaluation of amalgam restorations requires visual observation, application of tactile sense with the explorer, use of dental floss, interpretation of radiographs, and knowledge of the probabilities that a given condition is sound or at risk for further breakdown.

At least 11 distinct conditions might be encountered when amalgam restorations are evaluated: (i) amalgam ‘blues’, (ii) proximal overhangs, (iii) marginal ditching, (iv) voids, (v) fracture lines, (vi) lines indicating the interface between abutted amalgam restorations placed at separate times, (vii) improper anatomic contours, (viii) marginal ridge incompatibility, (ix) improper proximal contacts, (x) improper occlusal contacts, and (xi) recurrent caries lesions.

Clinical Examination of Indirect Metal Restorations

Clinical Examination of Composite and Other Tooth-coloured Restorations

Clinical Examination of Dental Implants and Implant-supported Restorations

Others Non-hereditary developmental enamel hypo-plasia Amelogenesis imperfecta Dentinogenesis imperfecta Horizontal or vertical fracture