Caries Investigations - L3 - PDF

Chapter 2 Caries investigations By DR.SUDHA  It is a process of information gathering Patient'shistory Helps to verify or make the final diagnosis Possible etiology All investigations are prone to false positive and false negative outcomes  To asses the value of invest...

Chapter 2 Caries investigations By DR.SUDHA  It is a process of information gathering Patient'shistory Helps to verify or make the final diagnosis Possible etiology All investigations are prone to false positive and false negative outcomes  To asses the value of investigation we have two factors Sensitivity-the measure how effective is the investigation in detecting a true disease Specificity-the measure how effective 8 is the investigation in assessing the true health Investigations done in relation to caries is  Radiographs  Pulp vitality test  Percussion tests  You need radiographs to see the posteriors. Radiographs Image you’ll be taken to see the structures that you can’t see Pulp/gums show black in the radiographs cuz they’re not mineralized. clinically. Intraoral radiographs are the most common for caries. Bitewing radiographs A Extraoral radiographs are done for orthodontist treatment and patients who can’t open their mouth and such. itpatienthaspaininteethcuzthat usually there'saproblemwperiapicalarea means fused Periapical radiographs B Q) What’s the di ? When you wanna know about the structures that are A) In A, you can’t see the whole tooth, mostly the crowns surrounding the root, you go for the periapical radiographs. and only a part of the root. In B, you can see the structures that are beyond the root. alveolar bone g restoration Ap Tipof theroot B'at c 00 O Ohariahere 00,00 no toothsonoborelsoaset aries black appear pulp Both show posteriors  I 1 Disadv of the radiographs: Bitewing usedtosee alveolarbon  Taken to aid in lesion detection in proximal surface of posterior tooth especially when direct vision is not possible.  Film holder and beam aiming devices to be used routinely for optimal angulation and reproducibility  Beam perpendicular to the contact points ThismakesitmorereliableYouneedtotilttheperiapicalradiograph  9 beam y Filmholder aiming  etiidairier  Incipient occlusal lesions difficult to detect  later stage occlusal lesions clearly visible  Depth of proximal lesions on anterior- un f periapical radiograph Yeethe epth  In radiograph, if something has to appear it’ll take time. For something to appear in a radiograph, it will take at least 6 months. Doesn’t show initially. If the Caries just started then it won’t show.  The radiographic appearance of caries is 6 months behind the actual histologic spread blackareain radiographs p  The radiographic appearance is radiolucency of White areain radiographradiopacity E&D eg enamel Clinicallyenamel  Hence radiographically in enamel is But istranslucent histologically in outer third of dentin in radiograph it's radio opaque  Correlation of MICDAS and radiographic lesion depth Clinically Enamel lesion mICDAS Clinically, if you call it E1 Out. half of 0,1 0 or 1, it’s in the outer enamel or half of the enamel. E2 Inn. half of 1 enamel Dentine lesion D1 Out.third of dentin 2 D2 Mid. Third of 3 dentin D3 Inn.third of dentin 4 Sometimes, clinically you’re gonna see the enamel and point it out mICDAS score 3. And then when you see the radiograph you’re gonna see that the lesion has reached 22 in book the pulp. But that doesn’t mean you’re gonna change the mICDAS score 4. Yes it’s equvilient to mICDAS 4 in a radiograph but clinically it’s still score 3. So mICDAS is pg only for clinically, not radiographically.  Clues in interpretation  Outline of pulp horns-shrinkage –indicates tertiary dentin is formed Irregular, not a well de ned border indicates that caries are rapidly happening.  Moth eaten appearance of the advancing edge- If you see a well de ned radioopaque border surrounding the radiolucent caries, then it active caries activity indicates that there’s a remineralization happening also in part with the demineralization. So reminerlization and demineralization are happening hand in hand and the demineralization has not exceeded the reminerlization and that’s the reason why we’re darkarea whitelinesurroundingthe able to see the well de ned border. There’s enough time for reminerlization and the definedM radioopaque reminerlization is on a higher side than demineralization. So slow progression of caries.  more boundary-more mineral deposited to wall off the lesion- metabolic balance towards healing  Dental panoramic Shows all the teeth in 1 radiographs along with the supporting and surrounding structures. radiographs  Also called as OPG Cuz won’t let you concentrate to the details like the other radiographs. It has all of the details.  Not used routinely for caries detection due to their limited resolution and increased radiation dose. Sometimes you’ll have to go for the OPG to see the 3rd molars, tumors, mixed dental stage and so on.  Pulp vitalty test Part of routine investigation AISASensibilitytest E ects of nerves depend on the vascularity of the area. So in real scenarios, you’ll try to test the pulp by using a pulp sensibility testing and that’s done by testing the nerves.  This term implies the status of pulpal Good blood ow = pulp is good blood flow Restricted blood ow = pulp isn’t in a good condition Most dental clinics don’t have this. Mostly used as part of research.  Can be done using laser Doppler flowmetry  Clinical signs of non vital necrotic pulp include Vital tooth - good pulp Non vital tooth - necrotic pulp  Discoloration and darkening of tooth  Sinus track from the periapical tissues to the mucosal surface adjacent to the apex. Used to fill therootcanal up  Gutta percha sticks inserted inside the sinus track shows the direction of the sinus track and the tooth involved Even if there is a disease in the pulp it will always appear as radiolucent We can tell if there is a disease by looking at the Periapical areas There is no partial treatment of pulp; if there is a disease/ infection then the whole pulp is considered to be infected The pulp exits the tooth through apical foramen & blend with the nerves (mental nerves, inferior alveolar etc etc) The reason for the sinus to appear is because the caries (or any other reason) has reached the apex of the tooth & it seeps out of the tooth into the surrounding areas (periopical areas where the surrounding structures (bone tissues etc) will undergo destruction too When the destruction happens, it will cause an accumulation of pus which will eventually pierce & leaves the area The nerves of the a ected teeth would be completely destructed The pus isn't always related to the tooth it is close to; the pus may move & accumulate in a wider area & erupt from a di erent point startedfromthis areaAreawherethe When you say vitality, it indicates blood ow. When you say sensibility, it indicates the innervation of the tooth. indicatesbloodflow Pulp vitality tests ofthetooth innervation Sensibility test to asses the effect of caries process in the tooth.  Temperature  Electrical  Test cavity  Temperature Sources Di from gotta percha sticks  Heat from warm gutta percha sticks mentioned previously. Those were for root canal. spray  Cold from ethyl chloride cotton wool pledgets or ice sticks Moreeffective Preffered  Procedure-dry the tooth, check equivalent contrangle and then the adjacent tooth[internal control]  Ask pt to rise hand when sensation is felt  Even if it’s only part of the pulp that’s necrotic, it’ll still get a root canal treatment.  Vital teeth responds quickly A person can not di erentiate if they feel the cold from the gingiva or dentin - positive cold They can’t feel anything - pulp is necrotic Delayed response - partially necrotic pulp The pain remains even after removing the stick - severe pulp in ammation necrotic  False positive –responds slowly- conduction thro dentin/metallic restorations into the periodontal membrane Not a real/right response of the disease. P  Electrical  Monopolar electric pulp tester passes a small current thro’ the patient and the tooth it is in Attach the tip that has a rotatable cable. There are di types of electrical pulp testers. contact with  Electrolytic coupling agent applied after drying the tooth-usually a small amount of onlyonthatonespeci insulator tooth prophylactic paste Allows the current to be transferred. With the naked hand. No gloves cuz gloves acts as an insulator.  Patient must hold the metallic part of handle to complete the circuit Dr can’t hold it cuz the dr needs to wear gloves for infection control and gloves act as an insulator.  The current is gradually increased till they feel the tingling sensation.  At this point the pt needs to break the circuit by unholding the handle If the device/tooth paste happens to touch the gingiva - it’ll be a false positive.  False positive responses-stimulation of nerve fibres in the periodontium,multirooted teeth[where sometimes a mixture of vital and non-vital pulp tissue is found]  Test cavity When you still don’t know if it’s vital or non vital tooth  Rarely used Cuz invasive method. You won’t use anesthesia on the patient and drill the tooth.  Last resort method to check the innervation of dentin-pulp complex  Performed by drilling vital dentin  If pt feels pain then at least partial innervation of the pulp remains. Tap over the tooth and the patient will say if they have pain or not. This is done to see if there’s in ammation or not cuz the radiograph wouldn’t show that. It will only show in ammation after 6 months. Percussion test  Gently tapping down on the axial surface and then obliquely finger  Done with a probe or mirror handle  Asses the physical condition of the periapical If the main has pain, avoid using mouth mirror which will give and periodontal tissue severe pain. Just tap with your nger.  In periapical periodontitis-acute tenderness  The inflammation is due to the toxins from non- vital pulp  Lesion activity-risk assessment  Once a carious lesion is detected ascertain it is active or inactive. Clues to find out this is Not always considered as a measure Most reliable way to con rm if it’s active or inactive. Rough area indicates it’s active. Surface i cuz it can change. texture is between smooth & rough.  colour and surface texture We should not depend on the colour of teeth, Because sometime it looks dark, but it's inactive caries. Texture is more reliable. smooth texture is inactive. rough texture is active. soft material= inactive.  Gingival bleeding Means there’s plaque retention in that tooth. May also indicate the presence of periodontitis.  Presence of plaque You can’t see the plaque so you have to use a speci c solution. Oral hygiene  Accessibilty to OH procedures r Dry mouth = a lot of caries activity cuz saliva acts as a bu er  Use of saliva test Quality/quantity/consistency/pH of saliva Presence of the bacteria that’s usually related to caries. Diet plays a role in formation of caries. To see the patients diet. Diet analysis People who barely have carbs are less likely to get a lot of Caries. Water/sugar/carbs intake. Times of consuming food/water & brushing teeth Time is imp It’s imp to check the weekend cuz our diets change on weekends. Diet in take Q) What is the relationship between diet and caries? A) Frequent consumption of carbohydrates in the form of simple sugars increases the risk or dental cares. Some of the medications can also cause damage to teeth. Water intake and brushing is also play a role here. Tooth wear is from acids but (non) microbial disease. It the irreversible loss of tooth structure, which is often painful, unsightly and impairs the function of teeth. The damage can also be costly and di cult to repair.  Caries detection didn't technologies study In vivo optical/light scattering MICDAS classification Fibre optic transillumination UV illumination Quantitative laser fluorescence Diagnodent Mineral density Radiography Radiovisiography Computer tomography Cone beam CT Fluorescence Quantitative laser fluorescence Dye enhanced laser fluorescence Uv illumination Diagnodent Tissue porosity Electrical conductance measurement AC impedance Dye enhanced laser fluorescence Dye penetration Ultra sound In vitro optical/light scattering Polarized transmitted light microscopy Spectroscopy Reflected light confocal microscopy Mineral density SEM Quantitative back scattered SEM Micro radiography Microfocal CT X-ray microtomography X-ray micro analysis Fluorescence Confocal laser scanning fluorescence microscopy Tissue porosity Polarised transmission Light microscopy Acoustic microscopy Quiz time  What is that applied on the tooth called as? indicator solution Plaque  Name any two bacteria’s involved with caries process Lactobacillus Streptococcus Bifidabacterium Draw stephans curve Ans in the next slide  Loss of minerals Drop in pH It’s not advised to snack in between meal cuz that’ll keep reducing the pH of the teeth. grid O Fido to Reduces Forittogoback I tonormal pit is in 10 takesaroundan i i not hourSoit's mins to advisable At 20min I brushrightafter 00 the educesbelow eating articalph Bu ering is imp. Bu ering includes drinking water and gargling with water.  List out the etiologies of the caries Fermentable carbs Time Bacteria surface Susceptible tooth