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Vol. 19(1), 2007
Diagnosis of initial carious …
Diagnosis of initial carious lesion by clinical and conventional radiographic methods in comparison to direct digital radiography.
Sulafa El-Samarrai BDS,M.Sc., PhD(1) Maha M.Misbah BDS, M.Sc. (2)
Background: Digital radiographic system is still not widely used in routine dental practice. Their superiority in the early detection of carious lesion compared to clinical examination and conventional radiography is still questioned. For this reason this study was designed. Materials and Methods: Children aged 7-9 years attending the dental clinic were examined for initial caries clinically using d1-4, D1-4 index. Two radiographic images were taken for posterior teeth, in addition to a direct digital radiograph following parallel technique. Results: For both dentitions, the direct digital radiographs were more precise in the detection of decayed surfaces compared to both clinical and conventional radiographic examinations. Statistically significant differences were recorded. Results however varied when studying lesions according to grades of severity as clinical examinations appeared to be sufficient in caries detection. Conclusion: Clinical examination need to be supplemented by radiography in the diagnosis of early lesion. Key words: Initial carious lesion, digital radiography. (J Bagh Coll Dentistry 2007; 19(1): 77-80).
The primary goals of an effective dental diagnosis and treatment programs are the early detection of caries lesion and the limitation of caries activity prior to tooth destruction(1). Diagnosis of carious lesion is principally based on clinical inspection and probing. This however, needs to be supplemented by radiographic examination, especially for approximal surfaces (2) . Classically dental radiography relies on films, which is based on shades of gray (from white to black) known as continuous tone image (3). This traditional dental X- ray seems to be surpassed by the development of digital technology. The image in this relatively new digital radiography is converted in to minute bits of information called picture elements or pixels. Each pixel contains information about light intensity (brightness) and location(x, y coordinates) of the image. These are quantified by the computer to produce a digital radiographic image (3, 4). There are two types of digital radiography systems, a directly obtained digital image (DDR) or an image that are transformed from analog to digital (3). To obtain a digital image with a direct system, a wire based sensor containing a computer chip inside a protective casing is connected to a computer. The sensor is placed in the patient mouth by a holder,
where a charge- coupled device captures the light information emitted by the phosphor plate (within a sensor) when activated by the x- ray beam. The charge coupled device is also referred to as the heart of the digital dental radiography (3,5). Recorded parameters are directly sent to the computer and presented as an image on the computer screen. The direct digital radiography allows the analysis and manipulation of the displayed image (3). The direct digital radiography system was introduced only recently in the Department of Paedodontics and Preventive Dentistry / College of Dentistry. Still it is not yet used in the routine dental examination for the detection of initial caries lesion, as there are still questions regarding the superiority of this technique to traditional methods. For this reason this study was designed.
MATERIALS AND METHODS
Through a three weeks period (June, 2005) children attending the clinic, Department of Paedodontics, College of Dentistry, University of Baghdad for the first time were involved in the present investigation. They were all fulfilling the following criteria:
Healthy children with no history of serious illness or chronic systemic diseases. Had full set of upper and lower posterior teeth. Had no open cavities or severely destroyed posterior teeth because of caries.
(1) Professor, Head of department of Paedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad. (2) Lecturer, department of Paedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad.
Orthodontics, Pedodontics and Preventive Dentistry 77
test were applied for statistical analysis at level of significance 5%. no significant difference was seen between ) examination and conventional clinical ( radiography. 2007 Diagnosis of initial carious … In the dental clinic and following the approval from parents.5 seconds. while different versions of the results were recorded for d1/D1. Analysis of variance and Student’s t.vales and probabilities between mean values of decayed surfaces are shown in Table 2 and 3.J Bagh Coll Dentistry Vol. An x-ray machine with closed cone (General) was used and operated at 70 kVp at 8 mA. A uni bite film holder was applied for the standardization of the film position and distance with the x. .Grade 1 Chalky spot less than 2 mm in extent. It is actually not an easy process v a u especially when carious lesion is still limited in (1) the enamel e layers of tooth surfaces .Grade 0 Healthy. exposure 70 kV.Grade 2 Thin brown to black line. On the other conventional hand.Grade 2 Radiolucency in the inner half of the enamel only. A higher value of decayed surfaces was recorded by the DDR compared to both conventional radiography and clinical examination. This is not difficult to explain. Clinical inspection alone may not be sufficient for the early diagnosis of carious lesions. However. DDR were taken for each child (Dimax / Procline CC2002. general electric/ USA). Planmeca).Grade 2 Chalky spot greater than 2 mm. chalky margin of fissure or pits. children were examined for dental caries in the posterior segment under standardized condition using plane mouth mirrors and sharp dental explorers (6). the only significant difference in D2 was seen between that recorded by conventional radiography and DDR. In regards to d2/D2 results coincide completely with that of the total d/D fractions. The sensor size used was (B1). 19(1). Grade 1 Thin light line. For permanent teeth. d a r The present study goes with those previous observations. The image taken by DDR was more obvious and better in quality compared to conventional x.Grade 1 Radiolucency in the outer most half of the enamel. For primary teeth no significant differences were seen between values of d1. . . results varied between d1/D1 and d2/D2. While for d2 highly significant differences recorded between clinical examination and conventional radiography and DDR. Studies show a n that it needs to be supplemented by radiographic s t a n especially for the detection of examination proximal lesions (9-11). as seen in Table 1. Radiographic examination . exposure time was 1. value of D1 was the highest recorded by the conventional radiography with statistically significant differences compared to those recorded by other methods. d e v as results showed that radiography whether taken by conventional technique or DDR a t i in the detection of initial caries is more precise compared to clinical examinations. Statistically significant and highly significant differences were seen in values of total d/D. while no significant difference was observed between results recorded by clinical examination and the other methods. in primary and permanent teeth respectively. Two bite-wing radiographs were taken for posterior teeth (7).ray machine. The t.ray (Figure 1). Table 1 illustrates the mean values and standard deviation of decayed surfaces in both dentitions by the three methods of examinations. As for the total D fraction. Direct digital radiography. Diagnosis and recording of dental caries were according to the following criteria (8): Fissure and pits caries - Grade 0 Healthy. Two images were taken for posterior teeth using parallel technique (7).05s.Grade 0 Healthy. In permanent teeth. The differences between the last two methods were statistically significant. highly T and significant differences recorded significant between DDR and clinical examinations and b l method respectively. if we know that y e the criteria of recording d1/D1 involve changes in the color of pits and fissure which DISCUSSION m s u r a c i n Orthodontics. 8 mA. 0. no n differences were recorded between the significant three methods in the detections of grade 1 lesion d e severity. T h Early detection of carious lesion is considered to be onen of the most important aspects in clinical dentistry. For the primary teeth the mean value of d1 was the highest recorded by the clinical examination followed by conventional X. Pedodontics and Preventive Dentistry 78 b o t h . Data processing and analysis were carried out using SPSS package version 10. d. A film size 2 was used (Kodak ultra speed. . The distant and direction of the machain head from the sensor was also standardized using the same uni bit holder. When decayed surfaces were studied by grades of lesion severity. RESULTS The total number of children involved was 10 (seven boys and three girls). .ray then DDR with statistically significant differences. Smooth surface caries .
3+0.0+1.2+0.2+0.J Bagh Coll Dentistry Vol.S .018 0.389 4.000 8 Conventional X-ray Direct digital radiography Figure 1: Direct digital radiography and Conventional X-ray for posterior teeth.2+0.3+0.49 0.420 1.014 0.000 H.522 3.003 8 8 8 8 8 D mean+SD 1.193 N.047 0.S d2 D t-test P-value Sig t-test P-value Sig 14.67 3.4+0. Methods of examination Clinical Conventional DDR F-test P-value Df No.344 Sig N.2+0. It provides better diagnostic performances as seen by previous studies (11.404 5.483 0.9. 14).S 5.016 S 6.406 0.026 0.880 0.194 0.000 0.S 3. Results of the present comparative study are in agreement with these studies. H.22 0.5+0.970 0.S = not significant.820 0.004 S 5.S 0.5+1.8 1.S = highly significant Table 3: Comparison between mean value of decayed surface for permanet teeth. Pedodontics and Preventive Dentistry 79 .00 0.873 0.62 1.678 N.037 0.484 0.7+1. Methods of examination d1 t-test P.343 N.70 24. regarding the superiority of the DDR in the detection of initial caries compared to conventional radiography.4+1.42 10 2. In addition.33 0. 12).000 H.S = highly significant Orthodontics. Table 2: Comparison between mean values of decayed for primary teeth.85 2.value Clinical &conventional 0.000 N.62 10 2. Although the DDR systems are not yet used for routine examinations. tooth surfaces examined in the present study involved proximal as well as other surfaces which could be detected more precisely clinically. N.011 S S= significant.S Clinical &conveational 1.2+0.0+1.58 1. N.S 4.620 0.018 S 7.5). 2007 Diagnosis of initial carious … could be easily detected clinically. a similar diagnostic efficacy of both radiographic techniques (13.S Clinical &DDR S Conventional & DDR 0.332 0.429 0. it has been described as a vision for the future (2.900 15. Table 1: The mean values and standard deviation of decayed surfaces in both dentition by the three methods of examination. d1 d2 d D1 D2 mean+SD mean+SD mean+SD mean+SD mean+SD ــــــــ 2.S N. Other reported however.420 ــــــــ 10 2. 19(1).S = not significant.8+1.268 0.42 1.656 0.001 S= significant.000 0.8+1.000 H.1.83 1. Methods of examination D1 D2 D t-test p-value sig t-test p-value sig t-test p-value Sig .000 1.63 3.91 2.500 Clinical &DDR Conventional & DDR 0.S N. H.029 S 15.
However. A comparison between subtraction radiography and conventional radiographic technique. J Scand Dent Res 1992. 14. Statistical contrast enhancement of subtraction images for radiographic caries diagnosis J. CV Mosby 1994 p. 12. Deletion of mineral loss in approximal enaml by subtraction radiography. 13. Basic method of the oral health surveys. Application of digital radiography to implantology. Influence of variations in projection geometry on the detectability of periodontal bone lesions. 5. Further. Dentistry for the child and adolescent 6th ed. Marti-Bonmati L. 2007 Diagnosis of initial carious … Besides the good quality of the image. J Caries Research 1994. 6. J Clinical Periodontol 1999. McDonald R. 26: 294-300. J Oral Radiology 2002 . 15). Grondahl HG. St Louis. 74. . Digital Radiology. Direct digit radiography in the dental office. the high cost of the sensor and its design may limit the use of this relatively new technique. J Dental Hygiene 2002. World Health Organization. It was some time difficult to be used for children as observed by the present study. 77: 177– 82. 20 . 10.Thylstrup A. Digital radiography of interproximal bone loss. 3. Grondahl HG. An important conclusion of the current study is that in spite of the superiority of the DDR in caries detection. image manipulation and archiving may improve patient dental education and over all the decrease of radiation to the patients (4. The sensor is thick and rigid and the positioning of the cord in the mouth can some times create a difficultly to be used in patients with limited mouth opening or gag reflux (16).Jeffcoat MK. Mauriello SM. Grondahl K . Variations among dentists in radiographic detection of dental caries. 100: 144-8. J Clinical Perio 1984. 11: 411-20. 4. Evaluation of caries preventive measures.Espelid L.Kallestal C. Radiovisiographic diagnosis of dental caries: initial comparison by basic mode videoprints with bite wing radiography. Riess T.J Bagh Coll Dentistry Vol. Pedodontics and Preventive Dentistry 80 . 9.Russell M. elimination of harmful processing solutions and the dark room environment. 45: 27–34. J Oral Surgery Oral Medicine Oral Pathology 1994. Flinck A. 24 :1-11. 11. J Int Dent 1995.Muhlemann H. Munksgaard. but is an important supplement for the inspection of dental caries. 10: 30-3. the DDR system has other advantages as quick image acquisition. J Dental Symposia 1993. Gron danl K.Eickholz P. 53 : 219-223.2nd ed. 19(1). Introduction to oral preventive medicine Quintessence 1976. 27: 65-70. Research 1994.Avery D.WHO. Tveit AB. 1982 . it can not substitute the clinical examination what so ever. 15. 1: 30-3 16. 8.Nytun RB. Fejerscove O. Orthodontics. Text book of clinical cariology . Geneva 1997.Wenzel A. 7. Espelid I. J Swed Dent 2000.Arana E. 28: 169-75.Malarkey T.Grondahl HG. 2. 6 (1): 26–33. p 73–77. Diagnosis of dentin involvement in occlusal caries based radiographic examination of the teeth. Copenhagen 1996.Hales A. A comparing intraoral Film and CCD – Based systems. REFERENCES 1. Raadal M. Pitts NB . Oral Surgery Oral Medicine Oral Pathology. 4th ed.