Diagnosis of dental caries

It is important to realize that all lesions, irrespective of their stage of progression, are arrestable if the biofilm that drives their progress can be removed. Thus two important questions for the practitioner to answer are: 1) is the lesion active or arrested? 2) if it is active, is a restoration needed so that the patient can clean effectively? It is also important to recognize active carious lesions as soon as possible so that preventive treatment has a chance to arrest lesion progression. The methods for caries diagnosis are:

 good lighting clean teeth a three-in-one syringe so that teeth can be viewed both wet and dry sharp eyes with vision aided by magnification. This is particularly necessary for older dentists who are unlikely to be able to see as well as they did in their youth bitewing radiographs.

 The white spot lesion, although caused by plaque, is also obscured by it. A logical way to proceed is for the dentist to examine the teeth both before and after removal of plaque. A white spot lesion that is visible only once the enamel has been thoroughly dried has penetrated about halfway through the enamel. A white or brown spot lesion that is visible on a wet tooth surface has penetrated all the way through the enamel and the demineralization may be in the dentine.

Before brushing and drying

after brushing and drying

 On no account should a white spot lesion be jabbed with a sharp probe to see if the probe sticks in the tissue. The probe is likely to break the relatively intact surface zone of the enamel lesion and cause a cavity.

 good bitewing radiographs are essential for the diagnosis of approximal lesions where a contact point is present.

Visual examination and examination of the bitewing radiograph are both important. On un-cavitated lesions: The active, uncavitated lesion is white, The inactive lesion may be brown. These enamel lesions are not visible on a bitewing radiograph. On cavitated lesions: Cavitated lesions may present as microcavities with or without a greyish discoloration of the enamel. Cavitated lesions are usually visible in dentine on a bitewing radiograph. Cavitated occlusal lesions, whether microcavities or cavities that clinically expose dentine, are usually active because the patient cannot clean plaque out of the cavity.

Diagnosis of caries on occlusal surfaces

Diagnosis of caries on approximal surfaces

It is difficult to see a carious enamel lesion on an approximal surface because the lesion forms just cervical to the contact area and vision is obscured by the adjacent tooth. If the lesion is discovered clinically, it is usually at a relatively late stage when it has already progressed well into dentine and is seen as a pinkish grey area shining up through the marginal ridge. Bitewing radiographs are of paramount importance in diagnosing approximal caries in both enamel and dentine. The approximal enamel lesion appears as a dark triangular area in the enamel on a bitewing radiograph

Early enamel lesion

Nine months later : late enamel lesion

Twelve months later: marked dentinal spread

Eighteen months later: approaching carious exposure.

 Transmitted light can also be of considerable assistance in the diagnosis of approximal caries, particularly in anterior teeth. The oper ating light is reflected through the contact point with the dental mirror, and a carious lesion appears as a dark shadow following the outline of the decay. In posterior teeth a stronger light source is required (fibre-optic lights). The technique has particular advantages in 1. posterior crowding 2. in pregnant women

Diagnosis of caries on exposed smooth surfaces

Caries on smooth surfaces can be seen at the stage of the white or brown spot lesion before cavitation has occurred, provided that the teeth are clean, dry, and well lit. Uncavitated active lesions are close to the gingival margin and have a matt surface. Inactive lesions may be further from the gingival margin, white or brown in colour with a shiny surface.

Root surface caries, in its early stages,

appears as one or more small well-defined discoloured areas located along the gingival margin. Active lesions are soft, plaque-covered, and close to the gingival margin. Arrested lesions are hard and shiny, plaquefree, and some distance from the gingival margin. As with enamel caries, great care should be taken when using a probe on these lesions; otherwise, healing tissue may be damaged