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Review Article

Dental Caries Diagnostic Methods

Zangooei booshehry, M. * Fasihinia, H. ** Khalesi, M. *** Gholami, L. ****

*Assistant Professor of Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Shahid Sadoughi
University of Medical Sciences , Yazd, Iran.
*General Physicion
**Student of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
***Post-graduate student of Prosthodontics, Faculty of Dentistry, Hamadan University of Medical Sciences.
**** Post-graduate student of Periodontics, Faculty of Dentistry, Hamadan University of Medical Sciences.

Dental caries, a progressive bacterial damage to teeth, is one of the most common diseases that
affects 95% of the population and is still a major cause of tooth loss. Unfortunately, there is
currently no highly sensitive and specific clinical means for its detection in its early stages. The
accurate detection of early caries in enamel would be of significant clinical value. Since, it is
possible to reverse the process of decay therapeutically at this stage, i.e. operative intervention might
be avoided. Caries diagnosis continues to be a challenging task for the dental practitioners.
Researchers are developing tools that are sensitive and specific enough for the current presentation
of caries. These tools are being tested both in vitro and in vivo; however, no single method will
allow detection of caries on all tooth surfaces. Therefore, the purpose of the present review was to
evaluate different caries diagnostic methods.
Keyword: Dental Caries, Diagnosis, Radiography

INTRODUCTION possibility of reversal. Rather, clinicians are

A diagnostic method for dental caries forced to measure a dynamic process as a
should allow the detection of the disease in dichotomous variable of the presence or
its earliest stages and for all pathologic absence of disease using clinical criteria (e.g.
changes attributable to the disease to be color, softness, resistance to removal), which
determined from early demineralization to are all rather subjective, and tools (e.g. sharp
cavitations. Unfortunately, none of the explorer and dental radiographs) which are
currently accepted clinical caries diagnostic becoming less useful.
methodologies have the ability to account for Although, no single method is currently
the dynamics of dental caries, including the developed that will allow detection of caries
Corresponding Author: M. Khalesi, Address: on all tooth surfaces, these technologies have
Department of Prosthodontics, Faculty of Dentistry, the potential to offer higher specificity and
Hamadan University of Medical Sciences. Tel:
sensitivity with respect to caries detection
+989126778160 Fax:+98(351)6250344, Email:
and quantification as well as to facilitate the

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development of more effective preventive The technique of temporary elective tooth

interventions. This article aims to review separation as an aid to diagnosis of caries in
some dental caries diagnostic methods proximal smooth surfaces is now regaining
available including: popularity, albeit with less traumatic methods
CLINICAL VISUAL INSPECTION that seem acceptable to most patients and
The coronal carious lesion starts as a dentists. This method permits a more definite
clinically undetectable subsurface assessment of whether radiographically
demineralization. With further progression, it detectable proximal enamel (D1, D2) and
will (eventually) become clinically dentin lesions (D3) are cavitated.
detectable, and can, then, be classified Temporary elective tooth separation,
according to type, localization, size, depth, complemented by a localized impression of
and shape. the opened interproximal space, allows a
more sensitive diagnosis of cavitations than
The visual method, a combination of light,
does the purely visual separation method. (2)
mirror, and the probe for detailed
Ekstrand et al. evaluated the visual and tactile
examination of every tooth surface, is by far
assessment of arrested initial enamel carious
the most commonly applied method in
lesions and showed that dentists were not
general practice worldwide. Although
able to reliably and reproducibly determine
sensitivity is low and specificity is high, it
the subtle visual and tactile differences
may be possible to detect noncavitated
between active and inactive enamel lesions.(3)
enamel lesions (D1) on the free smooth
In another study, Sheehy performed a
surfaces (buccal and lingual), most anterior
comparison between visual examination and
proximal surfaces, and the opening of some
a laser fluorescence system for In vivo
fissures; clinically detected cavities limited to
diagnosis of occlusal caries and concluded
the enamel (D1, D2); dentin lesions (D3)
that since the laser fluorescence instrument
with cavitations into the dentin on the buccal
can not be expected to differentiate caries
and lingual surfaces, but there is limited
from hypomineralizations, it should be used
detection of posterior approximal and
as an adjunct to a clinical examination. On
occlusal lesions.
the other hand, there are some questions
A major shortcoming is this method was very
about the use of dental explorer to probe
limited for detecting noncavitated lesions in
suspected carious lesions. Hamilton reported
dentin or posterior proximal and occlusal
that until to the time those facts emerge from
acceptable long-term clinical trials, dentist

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should feel comfortable using the dental allows instantaneous images to be made and
explorer to probe suspected carious lesions. projected, and images taken during different
FIBER OPTIC TRANSILLUMINATION examination can be compared for clinical
METHODS changes among several images of the same
Fiber optic transillumination (FOTI) tooth over time. (1)
allows for the detection of carious lesion However, Caution must be taken, when
because of the changes in the scattering and interpreting a proximal DIFOTI image that is
absorption of light photons resulting from a taken at a view similar to that of a
local decrease of transillumination due to the conventional bitewing radiograph. Although,
characteristics of the carious lesion. the images may look similar, proximal
Enamel lesions appear as gray shadows and lesions can be detected using DIFOTI only
dentin lesions appear as orange-brown or by careful angulation, remembering that the
bluish shadows. In an in vitro study, FOTI, resulting image is that of a surface or what is
performed along with visual examination, near the surface. This also may explain why
had higher specificity both for enamel and the DEJ is not always seen with conventional
dentinal lesions and had a better correlation radiography, when the incident beam is
with histology. Rousseau reported on the transmitted through the entire tooth, often
development of a fiber-optics-based confocal masking early changes in the surface.
imaging system for the detection and However, this method is much better for
potential diagnosis of early dental caries. A evaluating lesion depth at the proximal
novel optical instrument, capable of surface. In addition, another possible
recording axial profiles through caries lesions drawback of DIFOTI is the inability to
using single-mode optical fibers has been quantify lesion progression, even though
developed which may provide additional images can be compared over time. One
diagnostic information for a general in- vitro study indicated that the method has
practitioner. higher sensitivity than does a radiographic
Digital Imaging Fiber Optic examination for detecting lesions on
Transillumination (DIFOTI) is a relatively interproximal, occlusal and smooth
new methodology that was developed in an surfaces.(11)
attempt to reduce the perceived shortcomings CARIES INDICATOR DYES
of FOTI by combining FOTI and a digital In 1972, it was suggested that caries-
CCD camera. Images captured by the camera detector dyes could help differentiate infected
are sent to a computer for analysis using dentin from affected dentin. However, more
dedicated algorithms. The use of the CCD recent studies have shown that these dyes are

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non specific protein dyes that stain with a depth of only 25 m have been
collagen in the organic matrix of less measured in vitro. The restriction of light
mineralized dentin, whether it is infected or scattering for caries diagnosis to smooth
not, rather than being specific for the surfaces is a significant drawback to this
pathogenic bacteria. technique, although, there is continuing
Al-Sehaibany et al. evaluated the use of research to develop a QLF system to detect
caries detector dye in the diagnosis of occlusal caries. (13)

occlusal carious lesions. The purpose of their Kuhnisch et al. evaluated the in vivo
study was to compare the accuracy of detection of non-cavitated caries lesions on
diagnosis of carious lesions in the occlusal the occlusal surfaces by visual inspection and
pit, fissure, and groove system of lower quantitative light-induced fluorescence. It
molars examined by two methods: the caries was concluded that QLF detects more non-
detector dye versus traditional tactile cavitated occlusal lesions and smaller lesions
examination using a dental explorer. compared to visual inspection. However,
Histological cross sections confirmed a ratio taking into consideration time-consuming
of 1:1 (100%) accuracy by caries detection image capturing and analysis, we can
dye in diagnosing decay underlying the understand that QLF is not really of practical
occlusal surface. Concurrent examination of use in the dental office. (14)

the same occlusal surface by traditional Laser induced fluorescence

explorer examination was only reliable in a In 1998, Hibst and Gall described the
1:4 ratio (25%). (12) successful use of red light (655nm) to
FLUORESCENT METHODS differentiate between sound and carious
Quantitative light induced fluorescence tissues and on this basis, the Diagnodent
(QLF) system (DD) was developed. When using
QLF is based on the auto-fluorescence of light with an excitation wavelength of
teeth. When teeth are illuminated with high 655nm, we can detect that more intense
intensity blue light, they will start to emit fluorescence in the 700-800nm wavelength
light in the green part of the spectrum. The region is observed from a carious lesion
fluorescence of the dental material has a compared with a sound spot on enamel. DDS
direct relation with the mineral content of the utilizes a 655-nm 1-mW laser diode
enamel. No threshold for the detection of excitation light source that is modulated to
white spot lesions using light scattering differentiate it from ambient light. The light
techniques has been determined, but lesions

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is transmitted though a descending optical fiber to a hand-held probe. The probe is

placed close to the measured surface, two instruments were developed and tested in
thereby illuminating it with the laser light. the 1980. The Vanguard Electronic Caries
Carious tooth structures emit fluorescence Detector (Massachusetts Manufacturing
above 680 nm when encountering this light Corp., InterLeuven laan, Cambridge, MA)
and this fluorescence is detected and and the Caries Meter L (G-C International
quantified by the DD unit as a number Corp., Leuven, Belgium). Both instruments
between 0-99. The laser fluorescence measure the electrical conductance between
device represents high reliability in the the tip of a probe placed in the fissure and a
detection of occlusal caries in teeth and its connector attached to an area of high
performance is similar to direct visual and conductivity (e.g. gingiva or skin). The
radiographic examination. So, the measured conductance, which was a
DIAGNOdent may be a useful adjunct to continuous variable, was ,then, converted to
conventional methods for occlusal caries an ordinal scale: 0 to 9 for the vanguard
detection. system and four colored lights for the caries
ELECTRICAL CONDUCTANCE Meter L (green = no Caries, yellow = enamel
MEASUREMENTS (ECM) caries, orange = dentine caries and red =

The idea of an electrical method of caries pulpal involvement). To prevent polarization,

detection dates back to 1878, while it is both systems used a low- frequency-

believed to have first been proposed by alternating voltage, 25Hz and 400Hz,

Magitot. The basis of the use of ECM is respectively. Moisture and saliva were

observations which show that sound surfaces removed by a continuous stream of air in the

possess limited or no conductivity, whereas vanguard system to prevent surface

carious or demineralized enamel should have conductance. Conversely, to assure a good

a measurable conductivity that will increase electrical contact and minimize the effect of

with the increase of demineralization. By saliva, the Caries Meter L requires that the

decreasing thickness and increased porosity, pits and fissures be moistened with saline.

the performance of electrical resistance has Electrical conductivity has been shown to

been reported to be as valid as or better than have an overall satisfactory performance in

traditional means of diagnosing fissure detecting occlusal caries in vitro and in vivo

caries. (19) and approximal caries in vitro. (13)

Based on the differences in the electrical

conductance of carious and sound enamel,

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X RAY- BASED IMAGING DIAGNOdent is very high and its diagnostic

Intra Oral Radiography (INR) validity is higher than that of bitewing

The history of dental radiography begins radiography for proximal caries detection in
with the discovery of the x- ray. The x- ray primary teeth.

revolutionized the methods of practicing Now, for the purpose of carious lesion

medicine and dentistry by making it possible detection, intra oral radiography is a standard

to visualize internal body structures. (17) procedure and is essential for diagnosing
(22, 23)
Radiography is useful for the detection of inter proximal caries.

dental caries because the caries process Extra Oral Radiography (EOR)
causes tooth demineralization. The lesion is Extraoral radiographic techniques for
darker than the unaffected portion and may proximal caries detection have been studied
be detected in radiographs. An early carious and proven to be inferior to intraoral
lesion may not have yet caused sufficient techniques. However, the main focus was on
demineralization to be detected in conventional panoramic radiography.
radiographs. It is often useful to mount Clifton et al. used multidirectional
successive sets of bitewing radiographs in tomography and panoramic radiography as
one film holder to facilitate comparison and well as intra-oral D-speed film for combined
evaluation of evidence of progression. assessment of proximal and occlusal caries. It
Intra oral radiography can reveal carious was concluded that when proximal surfaces
lesions that otherwise might go under were evaluated alone, D-speed film was
detection during a thorough clinical significantly better. For occlusal caries, there
examination. was no statistically significant difference
On the other hand, early carious lesions are between multi directional tomography and
difficult to detect with radiographs, D-speed film. (24)
particularly, when they are small and limited One study has demonstrated that scanogram
to the enamel. Therefore, clinical and x-ray images have the potential to be the first
examinations are necessary in the detection practical extraoral imaging modality for
of dental caries. proximal caries detection. Influencing factors
Posterior bitewing radiographs are the most to be discussed are the sample, exposure
useful x-ray projections for detecting caries techniques, resolution and contrast
in the distal third of a canine and the enhancement. In this study, the performance
interproximal and occlusal surfaces of of screen-film and enhanced digital
(20) scanograms were not statistically different
premolar and molars. However, Virajsilp
V et al. reported that the reliability of from Insight film for proximal caries

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detection. Unenhanced digital scanograms Digital radiography

exhibited a statistically significant lower The use of digital radiography addresses
diagnostic accuracy than Insight film. two primary disadvantages of dental film,
including image manipulation and a periapical diseases as it was previously
reduction in radiation required to obtain a thought.
diagnostic image. In addition, Alkurt MT Increasing the diagnostic yield for caries may
showed that the diagnostic performance of E- be possible with three-dimensional (3D)
and F- speed films and direct digital imaging methods. However, general dentists
radiography are similar for proximal caries currently use two-dimensional (2D) images,
detection. and although CT/MRI modalities exist for
Three dimensional x-ray imaging hospitals, there are no systems for general
Since the discovery of the x-ray in 1895 practitioner caries diagnosis. The choices for
and its application to dentistry, radiographic 3D imaging of dentoalveolar diagnostic tasks
imaging of oral anatomy has consisted are currently limited to different forms of
primarily of viewing 3-D structures collapsed local CT including x-ray microtomography
onto a two-dimensional (2-D) plan. This form (XMT), tuned aperture computed
of imaging, known as transmission tomography (TACT) and super-ortho-cubic
radiography, is characterized by a point CT. (27)
source of radiation producing a beam which X-ray microtomography
passes through the patient and strikes a X-ray microtomography is a miniaturized
relatively flat image receptor (usually a film). version of computerized axial tomography
This produces essentially an attenuation map with a resolution of the order of micrometres.
of the structures through which the beam has In the biomedical field, it is particularly
been transmitted. While the dental profession useful in the study of hard tissue because of
has relied on this method for obtaining its ability to accurately measure the linear
information about the hard tissues of the oral attenuation coefficient. From this, the mineral
cavity, it inevitably superimposes anatomy concentration can be computed, which is one
and metallic restorations which confound the measure of bone quality. Using
problem of identifying and/or localizing microtomography we can form three-
diseases or objects in three dimensions. dimensional images of bone from which
Moreover, studies have shown that intra-oral structural parameters can be derived which
films produced in this way are not sensitive could not be measured using conventional
for the detection of caries, periodontal, and histomorphometry.

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Daatselaar et al. described the development mineral content in the lesion area (Delta Z/
of a bench top local CT device which is able Lesd in Vol %), the mineral Vol % and
of producing spatial and contrast resolutions position of the subsurface layer and lesion
necessary for improved detection of body.The accuracy of TMR for enamel and
interproximal caries as well as other dentine in lesion depth is about 200 Vol %.
dentoalveolar conditions. The authors m in deltea Z. With mineral details of
concluded that ‘local CT reconstruction are approximately 2-3 µm can be detected. The
feasible’ and ‘the resolution of the local CT time required for making 5 scans plus
images produced from basis projections that evaluation is 3-4 minutes (which is less than
were acquired using standard dental CCD 1 minute for a scan). The time required for
sensor was diagnostically suitable. This acquiring step wedge data is one minute or
makes local CT a potential technique for the less depending on the number of step wedge
diagnosis of interproximal caries. steps. Statistical analysis of many scans is
Transverse microadiography(TMR) supported. (30)

TMR or contact- microradiography is the Longitudinal Micro Radiography (LMR)

most practical and widely accepted method LMR is a method to determine mineral
used to assess de- and re- mineralization of loss in tooth slice samples in vitro. In this
dental hard tissues in studies. It is a highly method, a microradiogram of a slice of a
sensitive method to measure the change in tooth is prepared. Mineral content is then
mineral content of enamel and dentine computed by performing measurements of
samples. In TMR, the tooth sample to be the optical density of the microradiogram and
investigated is cut into thin slices (about 80 by comparing these values with that of an
m and 200 m for dentine samples). A aluminum step wedge. LMR is based on the
microradiographic image is made on high same principle as TMR. In contrast to TMR,
resolution film X-ray exposure of the where a transversal slice of the tooth is
sections together with a calibration step created, LMR is based on longitudinal slices.
wedge. The microradiogram is digitized by a The LMR system is highly automated.
video camera or photomultiplier. The mineral Scanning the sample is performed using a
can be automatically calculated from the gray XY scanning table and all calculations are
levels of the images of section and step performed automatically.
wedge. Parameters of interest are mineral Tuned Aperture Computed Tomography
loss (Delta Z in Vol %. m ), lesion depth (TACT)
(Lesd in m ), ratio or average loss of

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It has been shown in controlled in vitro Computer- aided radiographic method

studies that it can enhance the clinician’s exploits the measurement potential of
ability to detect and localize disease, computers in assessing and recording lesion
anatomically significant structures and size. In the new Trophy 97 system, artificial
abnormalities. TACT promises to overcome intelligence software (Logicon caries
some of the current limitations of detector) is integrated: approximal carious
conventional dental technologies and lesions are diagnosed and evaluated with the
increases the 3-D information currently aid of unique histologic database, allowing
available in ways that can influence graphic visualization of the size and
significantly the diagnosis and management progression of the lesion.
of dentoalveolar diseases and abnormalities. At both D1 and D3 thresholds, computer-
With TACT, the patient has to remain aided methods offer high levels of sensitivity
motionless only during each individual for approximal lesions. Earlier soft wares
exposure. The time between exposures is paid some trade off high with specificity, but
determined by convenience, diagnostic task, newer methods also have high values for this
economics or other factors, because delays measure. Furthermore, Wenzel reported
have no impact on the accuracy of the that the major advantages may be the
reconstruction. This approach also permits significant dose reductions and the ability for
the signal-to-noise ratio to be tuned image quality manipulation.
interactively to the needs of the Terahertz Pulse Imaging (TPI)
examination. Terahertz pulse imaging (TPI) is s
Harse et al. performed a study to compare the relatively new imaging technique that has
difference in the accuracy of proximal caries been demonstrated in both non-biological
detection by extraoral tuned aperture applications. Although, the TPI system is a
computed tomography (TACT), intraoral new technique for imaging caries using non
TACT, and film radiography. It was ionizing impulses of terahertz radiation, (an
concluded that extraoral TACT was not electromagnetic radiation) and its ability to
statistically different from intraoral TACT or detect early stages of caries lesions in various
film radigraphs for proximal caries detection. sections of teeth and a hope in future when
This suggested that extraoral TACT may this technique could indicate caries in all
have some clinical utilities. areas of teeth. Terahertz systems are
Computer- Aided Radiographic Method relatively expensive and do not offer the
(CARM) resolving power of radiographic examination.
This system also needs more researches to

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make it possible to be inserted into the mouth the TPI system uses only micro-watts of
for in vivo studies, while it is expected that radiation of a type that is non-ionizing.
technological developments will improve the Because the exposure levels from this system
systems to bring them within easy reach of are orders of magnitude smaller than
dentists. The coherent detection scheme of exposure levels that occur naturally, this
system will be safer than those employing X- of TMR depth plus an intercept of micron,
rays. Unlike radiography TPI also delivers a whereas further calculations allowed the
spectrum of different frequencies for each TMR depths to be determined to within 5%
pixel measured. This offers the possibility of using TPI. (36)
using that spectrum for diagnosis that goes These are some caries diagnosis methods
beyond simply measuring mineralization used today. In this era of evidence based
levels. dentistry, systematic reviews and validation
Pickwell et al. compared terahertz pulsed studies of caries detection methods have been
imaging (TPI) with transmission addressed in some studies but there is still
microradiography (TMR) for depth need for more studies in the future to clearly
measurement of enamel demineralizations. It determine the best and most accurate ways of
was concluded that TPI measured caries diagnosis.
demineralization in the range of 47% of that
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