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Stephen F. Rosenstiel, B.D.S., M.S.D.:

Clinical Diagnosis of Dental Caries: A North American Perspective

The most common methods used by U.S. dentists for clinical diagnosis of pit and fissure caries are visual/tactile inspection and visual inspection aided by radiographs (Stookey, Jackson, Zandona, et al., 1999). There is also considerable interest in commercially available and innovative diagnostic systems, such as laser fluorescence (Alfano, Yao, 1981). One commercially available product, known as Diagnodent and produced by KaVo Dental of Germany, is being used by 20 percent of Canadian dentists 2 years after its introduction (Fischman, 2000); this product was introduced to the U.S. market in the spring of 2000.

The Research Triangle Institute (RTI) review concluded that the available evidence on the validity of these innovative methods is poor. However, this rating may have been affected by the reviewers¹ decision to exclude non-English-language publications. That decision understates the body of evidence, since many innovative diagnostic systems have been developed and evaluated by researchers in non-English-speaking countries (Lussi, Hotz, Stich, 1995).

A second limitation of the RTI report is the requirement for histological validation of caries diagnosis. While ensuring a "gold standard," this requirement presents a serious limitation to in vivo studies of permanent teeth. As the report¹s authors point out, it effectively limits the validity of in vivo studies to those that involve third molars and first premolars, but the fissure patterns and caries presentation of these teeth may not apply to permanent teeth that are clinically more significant. Omitted from the report is mention of the useful work done when investigators "dissect" carious lesions to identify false positives (Miller, Ismail, MacInnis, 1995; Lussi, 2000).

In light of all this, dental educators should emphasize to students and practitioners that current techniques have significant limitations, and test results should be interpreted accordingly (Basting, Serra, 1999). The probability is high that North American dentists have inaccurate beliefs regarding the sensitivity and specificity of their techniques for occlusal caries identification, causing them to overestimate their ability to diagnose caries correctly.

The Clinical Dilemma

Dentists often comment about the difficulty of diagnosing pit and fissure caries in permanent posterior teeth, citing examples of "hidden" lesions (Kidd, Ricketts, Pitts, 1993). They are often uncertain about when to intervene, and can find no unequivocal clinical guidelines as to the management of stained pits and fissures (Clinical Research Associates, 1999). Indeed, some speakers in continuing education programs currently advocate instrumentation of all stained fissures.

A recent Web-based study involving more than 400 dentists confirmed the difficulty of diagnosing stained occlusal fissures based on visual appearance alone (Rosenstiel, Rashid, in press). Practicing dentists are aware that they must choose between restorative intervention, with the attendant risk of overtreatment, and "watchful waiting," with the attendant risk of supervised neglect.

Most U.S. dentists also appreciate that the dentist¹s penalty for overtreatment is considerably less than for undertreatment (see table 1). Financial rewards aside, contemporary restorative techniques, such as air-abrasion and adhesive restorative materials, permit precise removal of only diseased or structurally compromised tissue (Goldstein, Parkins, 1995). These techniques are used to provide minimally sized, tooth-colored, preventive resin restorations (Ripa, Wolff, 1992; Hamilton, 1999).

Dentists and their patients also want to avoid the considerable costs of endodontic treatment and fixed or implant prosthodontics, should nonrestorative management of a "hidden" lesion be unsuccessful. There have been reports that patients prefer restorative intervention to more conservative measures (Clinical Research Associates, 1999). Although some studies of resin restorations show them to have considerable promise (Mertz-Fairhurst, Curtis, Ergle, et al., 1998), practitioners still lack comprehensive information as to their long-term effectiveness.

Clinical Recommendations

Practicing dentists have an advantage over epidemiologists in that they obtain immediate false-positive feedback when they instrument a tooth with no clinical caries, and false-negative feedback when a recall patient exhibits progression of what was an equivocal lesion. Therefore, a rational approach to caries diagnosis in the absence of reliable tests may be to treat the susceptible surfaces as a unit rather than as a series of unrelated clinical observations. A dentist could evaluate the risk factors for a particular patient to identify the most likely fissure to be carious. If the dentist then decides that surgical intervention is justified, he or she can use feedback from that procedure‹particularly the extent or absence of caries‹to determine if additional intervention is indicated (see figure 1). Support for this approach can be found in studies that identify examiner prediction of future caries activity as a significant predictor of caries risk (Disney, Stamm, Graves, et al., 1990).

Future Research Directions

The recommendations of the RTI review for future research provide useful guidance for researchers seeking to advance knowledge of caries diagnosis. For in vivo work they recommend a standardization of histological validation methods for carious lesions. They also recommend a standard format for the reporting of trials of methods of clinical caries diagnosis. These recommendations, however, do not overcome some of the problems inherent to in vivo studies of permanent teeth, particularly the requirement for extraction subsequent to the test. Information is being obtained on a daily basis by dental practitioners when they determine the extent of suspicious lesions through operative intervention and when they recall patients previously deemed to not require operative intervention. Careful, well-designed sampling of the outcomes of these procedures could be an important source of helpful clinical guidance.

	Overtreatment with preventive resin restoration	Undertreatment with remineralization strategies and watchful waiting
Immediate Advantages	Increased knowledge of caries extent Satisfies patient preference Additional fee to dentist*	No restorative intervention needed Lower cost to patient
Immediate Disadvantages	Additional clinical procedure needed Additional cost to patient and/or third party	Uncertainty about caries extent Patient response is variable No fee to dentist*
Long-Term Advantages	Reduced likelihood of extensive carious lesions	Reduced number of restorations requiring evaluation, maintenance, and replacement Emphasis on prevention may reduce progress of other lesions
Long-Term Disadvantages	Average lifetime of restorations is unknown No well-developed guidelines for the replacement of suspicious preventive resin restorations	Increased likelihood of extensive carious lesions requiring endodontic treatment May require more frequent recall
*With most current reimbursement methods.

Figure 1. Management of pit and fissure caries.

References

Alfano RR, Yao SS. Human teeth with and without dental caries studied by visible luminescent spectroscopy. J Dent Res 1981;60:120­2.

Basting RT, Serra MC. Occlusal caries: diagnosis and noninvasive treatments. Quintessence Int 1999;30:174­8.

Clinical Research Associates. Newsletter. 1999;23(12):2.

Disney JA, Stamm JW, Graves RC, Abernathy JR, Bohannan HW, Zack DD. Description and preliminary results of a caries risk assessment model. In: Bader JD, ed. Risk assessment in dentistry. Chapel Hill: University of North Carolina Dental Ecology, 1990:204­14.

Fischman J. "Families a stoplight for tooth decay." U.S. News and World Report. October 30, 2000.

Goldstein RE, Parkins FM. Using air-abrasive technology to diagnose and restore pit and fissure caries. J Am Dent Assoc 1995;126:761­6.

Hamilton J. Microdentistry: the new standard of care? Part 3. Is air abrasion safe? CDS Rev. 1999 (Sep):16­22.

Kidd EA, Ricketts DN, Pitts NB. Occlusal caries diagnosis: a changing challenge for clinicians and epidemiologists. J Dent 1993;21:323­31.

Lussi A. Clinical performance of the laser fluorescence system Diagnodent for detection of occlusal caries. [in German]. Acta Med Dent Helv 2000;5:15­9.

Lussi A, Hotz P, Stich H. Fissure caries. Their diagnosis and therapeutic principles. [in German]. Schweiz Monatsschr Zahnmed, 1995;105:1164­73.

Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998;129:55­66.

Miller PA, Ismail AI, MacInnis WA. Restorative management of carious pits and fissures: A new approach. [abstract]. J Dent Res 1995;74:248.

Ripa LW, Wolff MS. Preventive resin restorations: indications, technique, and success. Quintessence Int 1992;23:307­15.

Rosenstiel SF, Rashid RG. Visual assessment of occlusal caries: a web-based dentists¹ survey. [abstract]. J Dent Res. In press.

Stookey GK, Jackson RD, Zandona AG, Analoui M. Dental caries diagnosis. Dent Clin North Am 1999;43:665­77.

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The main page for this site is located at http://www.lib.umich.edu/dentlib/nihcdc/ and is maintained by the University of Michigan Dentistry Library (dentistry.library@umich.edu) in partnership with the National Institutes of Health, National Institute of Dental and Craniofacial Research. Please see also the Consensus Development Program pages, and in particular the NIH Consensus Development Conference on Caries. Copyright © 2000 Regents of the University of Michigan. All rights reserved. URL of current page: http://www.lib.umich.edu/dentlib/nihcdc/abstracts/rosenstiel.html Last Update: 10:32 AM EST on Monday, December 31, 2007

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