Technology Enhances Caries Diagnosis and Treatment

Technology Enhances Caries Diagnosis
and Treatment
INTRODUCTION
Modern restorative dentistry (MRD) relies on
the protocol that all sound tooth structure
should be saved during tooth preparation, and
modern adhesive protocols should be utilized
to restore form and function.1 Dentists have
used many different tools to ascertain the
presence of dental caries versus
healthy/uninfected tooth structure including
radiographs, tactile feel with explorers and
excavators, and caries dye indicators. Defining
new diagnostic and treatment strategies and
related instrumentation that assists to identify
carious lesions is consistent with the principles
of MRD.
Dentists are adopting a more minimally
invasive approach to restorative care, and as a
result, patients are able to keep more of their
tooth structure.2 Preservation of enamel vastly
improves the seal of our adhesive restorations,
and the preservation of dentin is critical to
maintaining tooth strength.3 Therefore, the use
of technology that allows clinicians to detect
caries earlier will improve the lifespan of their
patients' dentition.
Processes focused on diagnosing early
lesions with optimum sensitivity have
employed laser, fluorescence, autoflorescence,
image processing under magnification, and
even electric current.4 Though these devices
are readily available, their high cost and
excessive variable sensitivity have prohibited
their use on a daily basis.
LED TECHNOLOGY FOR CARIES
DIAGNOSIS INTRODUCED
Now, there is a promising technology that
offers the ability to detect tooth decay at
different stages of its development with an
accuracy that may often be missed by x-rays.
The technology is based on the principle of
fluorescence, where a specific wavelength of
light shines on the tooth and is then reflected
back in 2 basic colors: green when the dentin
is healthy, and red when the dentin is infected.
A device that combines high magnification
intraoral imaging with fluorescence becomes a
powerful time-saving tool for diagnosing and
proposing treatment. The same device can then
guide the clinician through the treatment of
caries removal. This process has been named
light-induced fluorescence evaluation for
diagnosis and treatment (LIFEDT).
The SOPROLIFE Camera (ACTEON
North America) is a new intraoral LED camera
working as 2 devices in one; operating as an
intraoral camera as well as a caries detection
device. Patients who are routinely seen in
hygiene and exam areas with the question in
their mind, "Will my dentist find something
today?" will find the diagnosis of early caries
of asymptomatic teeth much easier to process.
A moment of truth or trust issue at the time of
this diagnosis can be much easier with this
unique intraoral camera showing the patient
through magnification the carious grooves and
suspicious shadows of interproximal decay.
An explanation of the fluorescence concept
and reference colors facilitates a co-diagnostic
experience.
For the dentist, use of the fluorescence
mode becomes a treatment aid to differentiate
diseased versus healthy tissue. Another benefit
to using the SOPROLIFE camera is that a
history of carious lesions can be documented,
and changes in their development can guide
treatment decisions. Instead of informing
patients that you will "watch" this tooth, a
pictorial reference is easily made into the
patient record.
SCIENCE OF FLUORESCENCE AND
AUTOFLUORESCENCE
Fluorescence is the emission of light by a
substance that has absorbed light or other
electromagnetic radiation of a different
wavelength. Dental tissues have fluorescent
molecules (fluorophores or fluorchromes)
which absorb light, then emit the energy back
as fluorescent light—this is called
autofluorescence. This process was described
by Banerjee, et al5 in 2000. It became the basis
for a new method of diagnosing initial caries.
Scientists and clinical researchers at SOPRO, a
company specializing in dental imaging, found
that a blue LED emitting light at 450 nm was
able optimize the autofluorescence of the
dental structures. The fluorescence signal
reflected was extremely low intensity
compared to the 450 nm intensity sent by the
blue LEDs. By amplifying the fluorescent
signal, a new level of tissue distinction could
be made.
Healthy dentin could be clearly
discriminated from carious dentin as it
fluoresced a bright green signal. The
wavelength of the autofluorescence signal
varies according to the density and chemical
intraoral and macro views.
The diagnostic mode, labeled mode I on
the images, filters out colors of the
surrounding soft tissues of the mouth,
rendering them black and white. It amplifies
and displays in color the fluorescence signal
response sent by the dentin. A healthy tooth
appears white with a homogeneous green hue
on top of it. The diagnostic mode is focused
more on enamel. Differences in thickness of
enamel as well as material deposits will affect
the fluorescence response. Thicker enamel
reduces the fluorescence response and gives a
slightly blue image. Demineralized enamel
gives a white, color-free response. Since
demineralization is the first stage of the caries
destruction, noting white colors can be very
important.7
Significant amount of material deposits
tend to give a black signal, which is
considered an alert to clean the deposits and
reassess the signal. Infected dentin gives a
dark red autofluorescence signal. Incipient and
evolving lesions magnified in the diagnostic
mode tend to have mixed signal colors of red
centers surrounded by black grooves and green
islands. This is because material deposits
shown as black can minimize the red signal of
dentin caries.
The treatment mode, labeled mode II on
the images, also filters out the surrounding soft
tissues of the mouth, rendering them black and
white. This mode also amplifies and displays
in color the fluorescence signal of the dentin.
The only difference in the treatment mode is
that the red wavelengths are amplified more
and the blue wavelengths are decreased.
Carious dentin gives a red fluorescence signal
so the amplified red color in the treatment
modes assists in the excavation process—a
photographic caries detector of sorts.
Tables 1 and 2 summarize the signal
colors and their relevance to tissue
characteristics.
METHODS AND MATERIALS
Clinicians continue to be confronted with how
to identify carious tissue and when to stop the
caries excavation process. The goal of these
case studies was to evaluate a protocol using
LIFEDT with the SOPROLIFE Camera for
caries treatment decisions as to when to treat
and to what extent the caries removal should
be performed. In addition, we compared use of
the SOPROLIFE camera in the treatment
mode to the use of caries dye indicators with
the assumption light evaluation could expedite
the excavation process by eliminating the
repetitive cycle of dye application and rinsing.
The protocol:
1. Initial observation of suspicious grooves,
fissures, and shadows in the daylight, then
diagnostic modes.
2. Fluorescence analysis and therapeutic
decision with the diagnostic mode.
3. Radiographic evaluation/correlation.
4. Fluorescence assisted lesion removal in
treatment mode.
5. Restorative treatment.
CASE REPORTS
The 2 cases presented in this article were
chosen because the lesions were considered to
be conservative in size and amenable to the
direct composite resin restorative technique.
Case 1
A 23-year-old female was seen in the hygiene
clinic with the suspicion of occlusal caries of
tooth No. 29. The SOPROLIFE light was set
to daylight mode and the 30x to 100x
magnification helped locate the areas of the
lesion and established a need for treatment
(Figure 1).
Figure 1. Case Figure 2. Image

1: Preoperative in diagnostic
magnified image mode. (Note the
of tooth No. 29 green and red
displayed to colors indicating
patient to healthy and
demonstrate affected dentin,
carious lesion. respectively.)
Figure 3. Image Figure 4. Image

in treatment in treatment
mode, after mode, after
initial water-assisted
penetration of air abrasion.
enamel.
Figure 5. Caries Figure 6. Case

removal 1: Tooth No. 29,
evaluation of the final
final restoration.
preparation,
imaged in
treatment mode.
The patient was placed in a restorative chair
with the intent of performing minimalist
preparation guided through the use of the
SOPROLIFE light's diagnosis and treatment
mode. The camera was switched to the
diagnostic mode and the infected dentin was
imaged (Figure 2). A conservative tooth
preparation was preformed with a fissurotomy
bur (Micro STF [SS White Burs]) and water-
assisted air abrasion (PrepStart H2O [Danville
Engineering]). After initial enamel
penetration, the caries excavation was
monitored by switching the camera to the
treatment mode (Figures 3 and 4).
The final conservative preparation (Figure
5) was selectively etched at the surrounding
enamel for 15 seconds with 37% phosphoric
acid. An adhesive bonding resin (G Bond [GC
America]) was used on the enamel and dentin
surfaces, followed by a liner layer of flowable
composite resin (Gradia Direct Flo [GC
America]) and a highly radiopaque composite
resin (Gradia Direct X [GC America]). The
final restoration can be seen in Figure 6.
Case 2
A 27-year-old pregnant female was seen for
replacement of failed full coverage crown No.
18. Her caries risk assessment was rated low
but the presence of an endodontically treated
tooth suggested a "heightened" proactive
caries management approach.
Figure 7. Case Figure

2: No. 19 8. Preoperative
preoperative image of
image of suspicious distal
suspicious white and brown
occlusal groove. spot lesions.
Figure 9. Image Figure

in diagnostic 10. Image of the
mode. distal surface
was evaluated in
diagnostic
mode.
Figure 11. A Figure

conservative 12. Occlusal
preparation was caries evaluation
done using a in treatment
safe-sided mode.
piezoelectric
diamond tip.
Figure 13. Final Figure 14. Case

caries removal 2: Tooth No. 19,
evaluation in the
treatment mode. finished occlusal
and proximal
restoration.
During the preparation process, the
SOPROLIFE camera set to daylight mode on a
macro setting illuminated suspicious occlusal
groove anatomy on tooth No. 19 (Figure 7) as
well as a suspicious proximal distal surface of
tooth No. 18 (Figure 8). Switching to
diagnostic mode fluoresced a red signal
indicative of dentinal caries occlusally (Figure
9). The proximal surface's fluorescence signal
was white surrounded by green, indicative of
enamel caries (Figure 10). There was an
opportunity to conservatively prepare the
distal surface without compromising the
surrounding enamel or marginal ridge. A
piezoelectric cavity preparation device (P5
Newtron [SATELEC, ACTEON North
America]) was used with a safe-side diamond
tip (Excavus [SATELEC, ACTEON North
America]) (Figure 11) to ultrasonically prepare
a conservative beveled slot on the distal
enamel. The occlusal caries was
conservatively removed using a fissurotomy
bur, and the remaining caries was removed
with a No. 6 round bur (SS White Burs) at low
speed. The removal of infected dentin was
monitored with the camera's treatment aid
mode (Figure 12); a diffuse red signal (Figure
13) revealed the end of infected dentin and the
remaining dentin to be affected.
The prepared and unprepared enamel was
selectively etched for 15 seconds with 37%
phosphoric acid. An adhesive resin (G Bond)
was used on the enamel and dentin surfaces,
followed by a liner layer of flowable
composite resin (Gradia Direct Flo). Then a
highly radiopaque composite resin (Gradia
Direct X) was used to finish the restoration.
The final restoration can be seen in Figure 14.
DISCUSSION
Caries management cannot be based solely on
the diagnostic modalities of examination,
radiography, and LIFEDT. Caries risk levels
should be assigned based on: diet/fermentable
sugar intake, acid attacks, fluoride history,
hygiene, and presence of existing lesions, to
name just a few factors. In the cases described
above, we used the SOPROLIFE camera to
convey magnified images of suspected carious
lesions to patients under white light in daylight
mode. Then, we shifted to blue light images in
the diagnostic mode and carried out the early
caries detection process while maintaining
communication with the patient. In addition,
we correlated visual color diagnostic protocols
that separated lesions into enamel caries,
dentin infected caries, and dentin affected
caries. Once the type of lesion was
determined, the camera was used in the
treatment mode to navigate the caries
excavation process. The information provided
by this new LIFEDT appeared to be very
accurate and similar to other studies of this
technology.4,8
CONCLUSION
It is the author's opinion that LIFEDT
technology shows great promise to improve
the early diagnosis, education, and
communication of dental caries, while
expediting conservative caries removal thus
preserving healthy tooth structure.

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Technology Enhances Caries Diagnosis

Figure 1. Case Figure 2. Image

Figure 3. Image Figure 4. Image

Figure 5. Caries Figure 6. Case

Figure 7. Case Figure

Figure 9. Image Figure

Figure 11. A Figure

Figure 13. Final Figure 14. Case

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