Radiology of Dental Caries

Adeyinka F. Dayo, BDS, MSa,*, Mark S. Wolff, DDS, PhDb,

Ali Z. Syed, BDS, MHA, MS, DABOMRc, Mel Mupparapu, DMD, MDS, DABOMRb

KEYWORDS
 Dental caries  Biofilm  Ecosystem  Caries detection  Sensitivity  Radiography
 Reflectance  Fluorescence

KEY POINTS
 Dental caries is a preventable, reversible, multifactorial, complex biofilm disease that pro-
gresses with time.
 Dental caries is a dynamic continuum of tooth demineralization/neutrality/remineralization
with a net demineralization initiating caries lesion.
 Visual examination and intraoral radiographs are still vital in diagnosis of dental caries.
 Early caries detection is paramount to effective chemotherapeutic, noninvasive
management.
 Sensitive caries detectors serve as adjuncts for early caries detection that help to shift the
dental practitioner toward minimal intervention dentistry.

DENTAL CARIES

Dental caries is a complex biofilm disease that creates prolonged periods of low pH in
the mouth, resulting in a net mineral loss from the teeth.1 Dental caries forms through a
complex interaction over time between acid-producing bacteria and fermentable car-
bohydrate, and many host factors, including teeth and saliva. The disease develops in
the crowns and roots of teeth, and it can arise in early childhood as an aggressive
tooth decay that affects the primary teeth of infants and toddlers.

CARIES PROCESS AND CURRENT CONCEPTS

Cariogenic bacteria are essential to the disease process. At least 2 major groups of
bacteria, namely, the streptococci species (chiefly Streptococcus mutans) and the
Iactobacilli species (chiefly Lactobacillus fermentum, Lactobacillus casei/paracasei,

a
Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, 240
South 40th Street, Philadelphia, PA 19104, USA; b University of Pennsylvania School of Dental
Medicine, 240 South 40th Street, Philadelphia, PA 19104, USA; c Department of Oral and
Maxillofacial Medicine and Diagnostic Sciences, CWRU School of Dental Medicine, Office # 245
C, 9601 Chester Avenue, Cleveland, OH 44106, USA
* Corresponding author.
E-mail address: [email protected]

Dent Clin N Am 65 (2021) 427–445

https://doi.org/10.1016/j.cden.2021.02.002 dental.theclinics.com
0011-8532/21/ª 2021 Elsevier Inc. All rights reserved.
428 Dayo et al

and Lactobacillus salivarius),2 can produce organic acids during metabolism of

fermentable carbohydrates and are known as acidogenic. Acids produced by these
bacteria include lactic, acetic, formic, and propionic acid, all of which readily dissolve
the mineral content of enamel and dentin.

FROM HISTORICAL DEFINITION TO CURRENT EVIDENCE

The definition of dental caries has expanded to a more complex discussion of the
caries process that represents a continuum of tooth demineralization/remineralization.
This “modern” view started with the definition by Miller3 1890 of a 2-step process
whereby bacteria on the tooth, exposed to fermentable carbohydrates, produce
acid, and in a second step, dissolve the surface of the tooth. Stephan4 demonstrated
that this production of acid after exposure to fermentable carbohydrate resulted in a
localized drop in pH within the plaque followed by a subsequent return to the baseline
pH over time hence establishing the concept of caries being a cyclic event of demin-
eralization/neutrality/remineralization. Englander and colleagues5 demonstrated the
role of saliva in neutralizing the decrease in plaque pH after exposure to fermentable
carbohydrate. Although considerable attention has been placed on a few bacterial
species as the cause of dental caries (eg, S mutans, Lactobacillus), there is general
agreement today that the dental biofilm exists as a complex ecosystem that can shift
from a neutral pH to a more acidic ecosystem.6 Today, dental caries is accepted as an
imbalance in the biofilm-induced cyclic process of demineralization and remineraliza-
tion of tooth structure, by the acidic by-products resulting in a pH maximal drop fol-
lowed by the return of the pH to initial pH modulated by saliva. The mixed ecology
of the biofilm may be naturally shifted in composition to a more acidic ecology by
repeated exposure to fermentable carbohydrate.3,5,7 Saliva helps modulate both the
composition of the biofilm and the recovery of the biofilm pH after sugar challenge.5
The susceptibility of tooth to demineralization may be modulated by the incorporation
of fluoride in the tooth structure.7 Dental caries is a continuum of demineralization and
remineralization with a net demineralization resulting in tooth surface alterations that
eventually result in cavitation. The caries process is influenced by several factors,
such as increase in frequency of sugar consumption and increase in sugar retention
time, which directly relates to an increase in demineralization of teeth resulting in cavi-
tation, measured clinically as decay/missing/filled/teeth.8 However, it must be remem-
bered that in this balance, frequent/longer acid cycles result in a shift in the biofilm
flora in favor of acidogenic bacteria.6 Importantly, an increase in the quantity of sugar
consumed alone is not a predictor of increased caries, as many communities around
the world have increased caries preventive strategies over the same time period as
sugar consumption has increased.9 Decreases in saliva flow can also favor a shift in
the caries balance toward demineralization, resulting in an increase in caries progres-
sion. The caries balance is affected by multiple social determinants favoring deminer-
alization. Research has demonstrated that acid is not the only product of the mixed
ecology. Alkali production has potential in changing the pH of the oral biofilm, which
impacts demineralization.10

INTRAORAL RADIOGRAPHY

Intraoral radiography has been an integral part of the diagnostic arsenal for more than
100 years. Intraoral radiographs typically consist of periapical and bitewing radio-
graphs, and both have excellent spatial resolution. Periapical means surrounding
the apex of the root of a tooth (Fig.1); hence it captures the complete crown and
root of a tooth with about 2mm beyond the root apex. On the other hand, bitewing
 Radiology of Dental Caries 429

Fig. 1. Mandibular right molar periapical radiograph showing both the erupted molars and
the partially visible impacted third molar.

radiographs capture the crown and a third of the root of the maxillary and mandibular
teeth with its accompanying interalveolar bone (Fig. 2) and are used in clinical practice
to evaluate interproximal caries; crestal bone height in the interproximal region; calcu-
lus; and periodontal disease.
Bitewing radiographs are obtained for examination of interproximal surfaces as well
as crestal bone levels. Based on the orientation of the detector in the mouth, they can
be either vertical (see Fig. 2) or horizontal. Technological innovations and advance-
ment in radiography with a focus on minimizing the amount of radiation to the patient
when acquiring radiographs led to a shift of radiographic image receptors from analog
films to direct digital sensors. Analog films are still being used in clinical practice; how-
ever, it is recommended that no dental radiographic film with speeds lower than E- or
F-speed shall be used for intraoral radiography, as the dose is essentially halved from

Fig. 2. A vertical left premolar bitewing showing interproximal contacts and crestal bone
levels.
430 Dayo et al

the older D-speed to E-plus or F-speeds.11 Phosphor plates may be compared with
analog films in terms of flexibility and is suitable for pediatric and special needs pa-
tients. One major disadvantage of the phosphor plates is that after extensive usage,
they sustain irreversible damage because of their susceptibility to scratches, bite
marks, and creasing. Solid-state sensors, also known as direct digital sensors, are
of 2 types depending on how the image is captured: charge coupled device (CCD)
and complementary metal oxide semiconductors. Alcaraz and colleagues12 showed
dose reduction using direct digital sensors in comparison with the analog films. Digital
radiographic sensors are an objective and reproducible technique; however, its sensi-
tivity for detection of early and recurrent caries is suboptimal,13,14 with reported sensi-
tivity being as low as 0.30.13,15 Caries detection can be affected by a variety of factors
during acquisition or interpretation, such as variation in image capture, detector place-
ment, status of the detector, focus to object distance, kilovolt or milliampere used for
capture of the radiograph, ambient lighting for interpretation, or the experience of the
clinician.

EXTRAORAL BITEWING RADIOGRAPHY (USING PANORAMIC RADIOGRAPHS)

Initial ex vivo studies have shown that intraoral bitewing radiography (IOBWR) is supe-
rior to extraoral bitewing radiography (EOBWR).16 Another study compared the detec-
tion accuracy of proximal caries and crestal bone loss using EOBWR or IOBWR and
concluded that although EOBWR has promise, clinicians should be aware of the false
positive diagnoses of proximal caries and crestal bone loss when using EOBWR.17
Despite these diagnostic issues, during the COVID-19 pandemic, the use of EOBWR
(Fig. 3) was recommended as a guideline, because of the possibility of creation of
aerosols during intraoral procedures, more so in exaggerated gag and cough reflex
cases (Personal communication from Dr. David MacDonald, University of British
Columbia (UBC), Vancouver, Canada - Oral and Maxillofacial Imaging guidelines dur-
ing COVID-19 pandemic. Submitted to Oral Surg Oral Med Oral Pathol oral Radiol,
2020).

Fig. 3. Extraoral bitewing of a patient showing bilateral premolar and molar contact areas.
There are other significant periapical findings in this radiograph, especially apical regions of
maxillary right canine, premolars, and molars.
 Radiology of Dental Caries 431

CARIES DETECTION: DIGITAL VERSUS CONVENTIONAL RADIOGRAPHY

Sensitivity and specificity values for direct digital radiography were 73% and 95% at
the buccal and lingual line angles, and 29% and 90% at the midgingival floor, respec-
tively.18 Corresponding values for conventional radiography were 63% and 93% at the
buccal line angle, 61% and 93% at the lingual line angle, and 44% and 95% at the
mid-gingival floor, respectively.18 The total sensitivity and specificity values were
58% and 93% for digital radiography and 56% and 93% for conventional radiography
with no significant difference (P 5 .104). The sensitivity and specificity of film, CCD,
and photostimulable phosphors (PSP) for the detection of enamel caries were 38%
and 98%; 15% and 96%; and 23% and 98%, respectively. The sensitivity and spec-
ificity of film, CCD and PSP for the detection of both dentin and enamel caries, were
55% and 100%; 45% and 100%; and 55% and 100%, respectively.19 Sensitivity of all
3 receptors (CCD, PSP, film) for detection of enamel lesions was low (5.5%–44.4%),
but it was higher for dentin lesions (42.8%–62.8%); PSP with 70 kVp and 0.03-second
exposure time had the highest sensitivity for enamel lesions, but the difference among
receptors was not statistically significant (P>.05). PSP with 60 kVp and 0.07-second
exposure time had higher sensitivity and lower patient radiation dose for detection
of cavitated and noncavitated lesions, but the difference was not significant (P>.05).20

RADIOGRAPHIC INTERPRETATION OF CARIES

Imaging is an integral component of caries detection. Radiographically, dental caries

is essentially a process of demineralization leading to density changes within the
enamel or dentine and hence detectable using radiographic imaging. Radiographic
detection of dental caries and the methods used for detection have changed over
the years. In the early days, the focus of radiographic imaging was on the periapical
areas of teeth, as the investigation was based on pain or infection, which was the
late stage of dental caries that had led to cavitation and pulp exposure with tracking
of bacteria through pulpal blood vessels to the periapical region causing an inflamma-
tory process. Currently, there is a shift toward early detection and minimal intervention
dentistry (MID).

INTERPRETATION OF CARIES

Accurate interpretation of carious lesions starts with accurate radiographic depiction

of adjacent contact points of teeth using bitewing radiography. To obtain bitewing ra-
diographs that are of optimum diagnostic values, contacts should be opened using
appropriate horizontal angulation and XCP positioning device. Appropriate kilovolt
and milliampere as well as standardized exposure time are essential for optimally
exposed radiographs. A good contrast is essential for the diagnosis of dental caries,
as both underexposures and overexposures will lead to erroneous interpretation of
dental caries, as demonstrated in Fig. 4.
Radiographically, dental caries appears as radiolucency leading to loss of normal
homogeneity of the enamel, as the lesion extends further toward the dentino-
enamel junction (DEJ), the DEJ line loses its continuity in the region. The inherent
low-contrast resolution of plain radiographs makes it impossible to determine the
full extent of dentin involvement. The line pair resolution of digital dental radiographs
is about 20 line pairs per millimeter.21 Small occlusal lesions, buccal and lingual pit
cavities, are better studied clinically, as radiography plays a small role in the detection
of these lesions.22 Dental caries recurs if not completely excavated before restoration,
and lesions appear as radiolucency adjacent to or beneath the restoration. Because
432 Dayo et al

Fig. 4. Mandibular central incisor periapical radiograph. Poor contrast (A); appropriate
contrast (B).

radiographs are a 2-dimensional representation of a 3-dimensional tooth structure, it

is not always possible to determine caries extension to the pulp chamber or pulp horn
because of anatomic variations and presence of radiopaque restorations in the
crowns. In the presence of caries, pulp is generally reactive and lays down new dentin
called, “secondary dentin,” which functions to wall off the receding pulp from the
carious attack. The only radiographically certain way of determining pulp exposure
is the visualization of secondary caries and periapical changes in the alveolar process,
such as widened periodontal ligament space or lack of continuity of lamina dura.
Rarely, cavitated dental caries undergoes spontaneous arrest.22

RADIATION CARIES

Radiotherapy for head and neck cancers lead to decreased salivation especially if the
salivary glands are in the “direct path of radiation.” It is known that the short-term loss
of function in the salivary glands leads to clinical xerostomia, which further accentu-
ates clinical caries, especially rapidly advancing root caries. The lack of lubrication
and buffering action from saliva, increased salivary pH (acidic), and increased coloni-
zation of acidogenic bacteria (especially S mutans) all lead to caries of smooth sur-
faces, and this is termed “radiation caries,” although it not directly caused by
radiation. Advanced radiation-induced hyposalivation may lead to tooth fracture,
dental abscess, tooth loss, or osteoradionecrosis. Direct-acting cholinergic parasym-
pathomimetic agents, such as Pilocarpine hydrochloride, or muscarinic agonist, like
Cevimeline, are used for treatment of xerostomia. A thiol-containing agent, like Ami-
fostine, has been used for its radioprotective properties in the prevention of
radiation-induced changes by scavenging free radicals.

CLASSIFICATION OF CARIES ACTIVITY AND RADIOGRAPHIC DETECTION

Caries is a dynamic disease that requires a classification system that is sensitive

enough to monitor the disease activity, the surface of involved teeth, and the depth
 Radiology of Dental Caries 433

of caries penetration. There are several caries classification systems, and the Amer-
ican Dental Association Caries Classification System23 is as follows:
 Sound surface: Healthy sound enamel with no detectable lesion with normal
glossy surface.
 Initial caries lesion: Early lesions that demonstrate net mineral loss in enamel or
exposed dentin that may only be visible when the tooth is dried by air or color
change toward white.
 Moderate caries lesion: Moderate mineral loss with loss of tooth surface integrity/
anatomy with deeper demineralization. There may be shallow or microcavitation.
There may be color changes in enamel with brown or gray shadows and/or
translucency.
 Advanced caries lesion: Advanced mineral loss with cavitation through enamel.
Dentin is exposed.
Caries activity is defined as active or inactive/arrested. Active lesions are shiny/
glossy and smooth to touch; inactive/arrested lesions are frosty/matte in luster with
a roughened surface. Caries can also be detected radiographically by looking at the
approximal surface of teeth. Lesions are classified based on the depth of demineral-
ization detected on the approximal surface. The stage of the lesion is based on depth
of penetration from the outer tooth surface, as follows:
 E0: Intact tooth surface (see Fig. 2)
 E1: Radiographic penetration less than halfway into enamel, initial lesion (Fig. 5)

Fig. 5. Right premolar bitewing showing carious lesions (E1, E2) in the maxillary right
premolars.
434 Dayo et al

 E2: Radiographic penetration more than halfway into enamel but not penetrating
the dentin, initial lesion (see Fig. 5)
 D1: Radiographic penetration to the outer one-third of the dentin, initial lesion
(Fig. 6)
 D2: Radiographic penetration to the middle one-third of the dentin, moderate
lesion (Fig. 7)
 D3: Radiographic penetration to the inner one-third of the dentin, advanced
lesion (see Fig. 7)
Teeth with E1 lesions do not have cavitation; E2 lesions demonstrate surface cavi-
tation less than 11% of the time, and D1 lesions demonstrate surface cavitation 41%
of the time.24
Appropriate classification of the caries lesion is needed for adequate treatment
planning and restoration of the affected tooth. In addition, what was previously termed
“preeruptive caries” is now thought to be either progressive or nonprogressive. “Pre-
eruptive intracoronal radiolucency (PEIR)” (Fig. 8) has been studied extensively, and in
1 study, for 9 years clinically and radiographically. They are generally noted just below
the DEJ within dentin with no direct communication to either enamel or pulp. All
nonprogressive lesions are managed nonoperatively by sealants.25 There is evidence
to support use of silver diamine fluoride to treat dentine caries in primary teeth and in
also preventing recurrence.26

EVOLUTION OF CARIES DETECTION TECHNIQUES (OVERVIEW)

Current understanding of the dynamic caries process has led to a paradigm shift in
dentistry from Black’s model of “extension for prevention” to the concept of MID.

Fig. 6. Right premolar bitewing showing a D1 lesion in the mesial proximal surface of
mandibular right second premolar.
 Radiology of Dental Caries 435

Fig. 7. Right premolar bitewing showing several D2 and D3 lesions.

Caries detection is a process of recognizing and recording in a standardized format,

changes in dental hard tissues that are caused by the caries process. Sensitive
caries-detecting techniques allow monitoring of dental caries, which involves the
assessment of the severity, extent, or activity of caries over time. Clinical visual in-
spection and intraoral radiographs are vital for caries diagnosis and management,

Fig. 8. Panoramic radiograph with unerupted mandibular right first premolar demon-
strating the pre-eruptive intracoronal radiolucency.
436 Dayo et al

although not a sensitive modality for early caries detection.13–15,27 Approximately 30%
to 40% of mineral loss is necessary before an early enamel caries lesion is visible
radiographically,28 and bitewing radiographs are associated with a relatively high pro-
portion of false positive and negative scores.29 Meja’re and colleagues29 reported 203
white spot lesions out of 305 being incorrectly scored as sound on radiographs. At the
stage of cavitation, dental caries cannot be controlled by chemotherapeutic treat-
ments or noninvasive procedures. Visual inspection is based on changes in color,
transparency, and hardness of the dental tissue; however, it is a subjective method
with low reproducibility in detecting occlusal caries, because it is influenced by the
knowledge and clinical experience of the examiner.23,24 Adjunctive modalities are
needed for early caries detection, especially in an “at-risk” population.27,30,31

CURRENT TRENDS OF CARIES DETECTION

Globally, it is recognized that the development of new technologies that are sensitive
for early caries detection is essential to quantitatively and qualitatively monitor dental
decay.30–32 Gomez and colleagues33 in a systematic review on the performance of
caries detection methods reported a sensitivity ranging from 0.12 to 0.84 and 0.20
to 0.96 for radiographic and visual diagnosis of caries, respectively; this lower limit
is suboptimal. Early detection of dental caries will ultimately provide health and socio-
economic benefits through timely preventive interventions, reduced treatment cost,
and facilitation of clinical dental research on potential anticaries agents. Here, the au-
thors describe some of the advanced, sensitive, nonionizing radiation technologies
available to the dental practitioner as an adjunct to clinical visual examination and
radiographic evaluation for early detection of dental caries and possible monitoring
of interventional treatment over time. Dental caries is a dynamic process, and at
any point in time, it may be in the active, inactive (arrested), or reversed phase of
development. Subclinical and early clinical stages can be reversed by nonsurgical mo-
dalities, such as fluoride application, diet modification, antimicrobials, sealants, and
no treatment.30,32 Hence, the evolution of new sensitive technologies can qualitatively
detect and monitor the activity of caries lesion by quantification of changes in mineral
content of the lesion over time. Some of these technologies are as follows (Table 1).

FIBEROPTIC TRANSILLUMINATION

Fiberoptic transillumination uses the principle of light transmission using a narrow

beam of intense white light to illuminate the tooth. Carious enamel has a lower index
of light transmission than sound enamel, so more light is absorbed because of
changes in the light scattering and absorption properties. Demineralized areas in
dentin or enamel appear as darkened areas. DiagnoCam is a digitalized and computed
version of fiberoptic transillumination (FOTI), replacing white light with near infrared
(NIR; 780 nm) and adding a digital CCD camera. It images the light emerging from
the surface closest to the CCD camera.

MIDWEST CARIES I.D.

The Midwest caries ID is a small, battery-operated piece of equipment that emits a soft
light-emitting diode (LED) light between 635 nm and 880 nm to measure the reflec-
tance and refraction of light from the tooth surface for detecting and quantifying caries.
Demineralized or carious areas turn the LED from green to red, which is converted by
fiberoptics into an audible signal. A buzzer beeps with different frequencies to indicate
the intensity of demineralization detected. Sensitivity and specificity are reported to be
Table 1
The salient features of various caries detection systems

Type of
System FOTI DIAGNOCam Diagnodent ECM QLF OCT PTR-LUM
Technique High-intensity High-intensity Laser diode Weak Optical Low Combination
white light white light (generates alternating imaging coherence of laser
via fiberoptic via fiberoptic a pulsed current system interferometry light-induced
illuminator illuminator and 655-nm (488 nm) Uses infrared LUM and
CCD camera laser beam) and red LED heat (659
and 830 nm)
Mechanism Carious enamel Carious enamel has Stimulated  Measures  Assessment  Illuminates Measures
has a lower a lower index fluorescence the electrical of the tissue with the modulated
index of light of light transmission due to resistance or lesion based low-power thermal
transmission than sound demine- impedance on loss of NIR light, infrared
than sound enamel (scattering ralization  Decrease in a fluorescence collects the radiation
enamel from the porous and presence electrical signal backscattered (PTR) and
(scattering enamel and of bacteria resistance  Decrease in light, and modulated
from the absorption in and their seen as fluorescence analyzes the LUM of tooth
porous demineralized metabolites lesions increase is related intensity surface
enamel and dentin) in porosity to the  The interference
absorption in and become scattering signal is
demineralized water filled properties of acquired
dentin) carious by a
enamel photodiode

Radiology of Dental Caries

or CCD
Usage Proximal and Caries on all Smooth and Incipient and Incipient and Incipient enamel Quality, depth
occlusal caries tooth surfaces occlusal occlusal caries smooth and root caries characterization,
surface surface monitoring
caries caries caries
progression

(continued on next page)

437
 438
Dayo et al
Table 1
(continued )
Type of
System FOTI DIAGNOCam Diagnodent ECM QLF OCT PTR-LUM
Best Assessment Incipient caries, DIAGNOdent Can monitor Assessment Interproximal Depth
application of the depth depth of pen for lesion of smooth and margins profilometric
of occlusal occlusal caries, proximal progression, surface of restorations technique
lesions fractures, caries arrest, or lesions, Permit
cracks, secondary remineralization enamel detection up
caries fluorosis to 5 mm from
tooth surface
Other uses N/A  Quantitative  Quantitative  Quantitative  Quantitative  Quantitative  Quantitative
method method method method method method
 Patient education  Convenient  Objective  Monitor  Assess  Can assess
and motivation and fast reading tooth periodontal caries under
whitening tissues, restorations,
implants, sealants
versatile  Not affected
 Not affected by staining
by staining or calculi
or calculi
Appearance Enamel and  Enamel and  Infrared Score of 0–9: Caries lesions Cross-sectional Canary
dentine dentine caries fluorescence directly appear dark images numbers
caries appear as of caries proportional surrounded from 1 to 100:
appear as shadows  Score of to the degree of by highly 1–20 (healthy),
shadows  Create high- 0–99.9 demineralization luminescent 21–70 (early
resolution sound caries lesion),
digital images enamel 71–100 (decay)
Disadvantage  Nonquan-  Limited depth Organic and  It is time Stains on Penetration Sensitive to
titative of detection nonorganic consuming tooth depth and angulation
method  Stains or calculi materials  Limited surface and scanning
 Cannot can give (stains, scan area fluorosis give range are
assess all false positives plaque,  Sensitive false limited
surfaces or calculus, to saliva or positives
early caries amalgam temperature
 False overhang, changes
negative and
hypoplasia)
fluoresce
giving false
positives
Cost Low cost Low cost Low cost — — High cost High cost

Radiology of Dental Caries

439
440 Dayo et al

higher than that of DIAGNOdent.32 It has good reproducibility but false positive signals
from malformed teeth, dark stains, dental fluorosis, hypoplasia, plaque, and calculus,
because of alteration in the translucency of enamel caused by these conditions.

ELECTRICAL CARIES MONITOR

The technology of the electrical caries monitor (ECM) is based on the electrical con-
ductivity differences between sound and carious dental tissues. Caries causes demin-
eralization of enamel and results in increased porosity of the enamel with the influx of
saliva into its pores forming conductive pathways for electrical transmission. There is
increased conductivity with increased demineralization. ECM measures the electrical
resistance or impedance of an area on the tooth; high measurements indicate well-
mineralized tissue, whereas low values indicate demineralization. The tooth is dried
to avoid electrical conductance via saliva.

ALTERNATING CURRENT IMPEDANCE SPECTROSCOPY, CarieScan PRO

This technology, alternating current impedance spectroscopy, CarieScan pro, uses

alternating current impedance spectroscopy involving the passing of an insensitive
level of electrical current through the tooth to identify and localize decay. Healthy or
sound enamel exhibits high electrical resistance (impedance), and demineralized
areas have lower resistance. CarieScan is not affected by optical factors, such as
staining or discoloration of the tooth. A green color display indicates sound tooth tis-
sue; a red color indicates deep caries requiring invasive treatment, and a yellow color
is associated with a range of numerical figures from 1 to 99, depicting varying severity
of caries that can be treated via noninvasive techniques. The device is indicated for the
detection, diagnosis, and monitoring of occlusal and accessible smooth surface
dental caries. It cannot be used to assess secondary caries or the integrity of a
restoration.

QUANTITATIVE LIGHT-INDUCED FLUORESCENCE, QUANTITATIVE

This technology of quantitative light-induced fluorescence (QLF), quantitative was

introduced in 1995.34 QLF uses the natural fluorescence of teeth (light absorption
and scattering properties) and its ability to differentiate between caries and sound
enamel. A broad beam of blue-green light from argon laser of 488-nm wavelength is
used to induce fluorescence. The QLF system is made up of an intraoral camera de-
vice connected to a computer fitted with a frame grabber with the QLF software. Any
area with a drop in fluorescence radiance of more than 5% is a lesion.35 It can detect
and monitor caries in real time, both in children and in adults with high sensitivity.35

DIAGNOdent LASER SYSTEM

The DIAGNOdent laser system technique is based on the resultant increase in the fluo-
rescence of demineralized tooth at specific excitation wavelengths. DIAGNOdent has
a laser diode that generates a pulsed 655-nm red laser beam via a central fiber, which
is transported to the tip of the device and into the tooth. The intensity of fluorescence is
directly proportional to the degree of demineralization or bacterial concentration in the
area scanned. This infrared fluorescence corresponds to a numerical value between
zero and 99 that represents lesion severity. A laser fluorescence pen, DIAGNOdent
Pen, is also available.
 Radiology of Dental Caries 441

POLARIZATION-SENSITIVE OPTICAL COHERENCE TOMOGRAPHY

The polarization-sensitive optical coherence tomography (OCT) was first demon-

strated in 1991.36 OCT creates a cross-sectional, 2-dimensional map of tissue micro-
structure by illuminating the tissue with low-power NIR light, collecting the
backscattered light, and analyzing the intensity. It provides high spatial resolution
(10–20 mm) and real-time, 2-dimensional depth visualization.32 It has been used to im-
age tooth structure.37 Factors, such as lesion staining, ambient lighting, and the pres-
ence of saliva or bacterial plaque, which have been identified to adversely affect other
technologies, do not influence OCT imaging and measurements.

FREQUENCY-DOMAIN INFRARED PHOTOTHERMAL RADIOMETRY AND

MODULATED LUMINESCENCE

Frequency-domain infrared photothermal radiometry (PTR) and modulated lumines-

cence (LUM) is a noninvasive energy conversion technology that measures 2 different
signals: modulated thermal infrared radiation (PTR) and modulated LUM; thus, it mea-
sures the heat and light responses38 (Figs. 9 and 10). The first response signifies the
conversion of absorbed optical energy into thermal energy that results in a modulation
in the temperature of tooth structure (PTR). The second response signifies the conver-
sion of absorbed optical energy to radiative energy (LUM). It enables the clinician to
examine lesions up to 5 mm below the surface.39 Dayo and colleagues,13 in their study
comparing intraoral radiograph (IR), cone-beam computed tomography (CBCT), and
PTR/LUM for detection of recurring caries lesion, reported sensitivity for PTR/LUM
as 0.89 (0.78–0.99), whereas the average sensitivity among 6 observers was 0.38
(0.31–0.44) for IR. Training and calibration are required because it is sensitive to
angulation.
Other techniques using fluorescence and inherent properties of the teeth include the
Spectra Caries Detection System, endoscopically viewed filtered fluorescence, video-
scope, and intraoral television camera among others.

Fig. 9. The PTR/LUM technology. The radiative orange arrow is the laser light. Radiated en-
ergy in the PTR/LUM technology can be related by Planck constant “h” and emitted photon
frequency “v” (hv). The plot is illustrating the progress of temperature (T) as a function of
depth (X) from the tooth surface.
442 Dayo et al

Fig. 10. Canary system (Quantum Dental Technologies, Toronto, Ontario, Canada) with the
probe positioned perpendicular to the tooth surface to be scanned. (From Dayo, A., Amae-
chi, B., Noujeim, M., Deahl, T., Gakunga, P. And Katkar, R., 2019. Comparison Of Photother-
mal Radiometry And Modulated Luminescence, Intraoral Radiography, And Cone Beam
Computed Tomography For Detection Of Natural Caries Under Restorations. Oral Surgery,
Oral Medicine, Oral Pathology and Oral Radiology, 128(4), p.e153; with permission)

SPECIES SPECIFIC MONOCLONAL ANTIBODIES

Shi and colleagues40 in 1998 identified specific monoclonal antibodies that recognize
the surface of cariogenic bacteria. Three highly species-specific monoclonal immuno-
globulin G antibodies targeted against S mutans were used, and the probes are
tagged with fluorescent molecules that measure quantitatively with a spectrometer.
It can be used chairside by the dentist, giving quick results, and an overall risk assess-
ment can be made. It also provides useful information for analyzing the role of S
mutans in dental caries.

ARTIFICIAL INTELLIGENCE

Advances in digital radiography with computer-assisted diagnostic systems that can

read and interpret radiographs have been explored. In radiology, a rapidly evolving
new area of medical research is deep convolutional neural networks (CNNs) used in
diagnosis and prediction.41–44 Deep CNN algorithm has been documented to be an
effective, efficient, and accurate modality for detection and diagnosis after image pro-
cessing and pattern recognition training. Lee and colleagues45 have reported a diag-
nostic accuracy ranging from 82% to 89% and stated that it provided considerably
good performance in detecting dental caries in periapical radiographs. This field is
exciting and promises to yield adaptable techniques that can be helpful to the dental
practitioner.

SUMMARY

Dental caries is a globally widespread, preventable, and reversible condition with

detrimental socioeconomic and mental impact. It affects both young and adult and
can lead to early tooth loss with a resultant poor quality of life. The dental practitioner
can use adjunctive techniques to detect noncavitated lesions that are hidden from vi-
sual inspection and/or radiographic evaluation and a candidate for chemotherapeutic/
noninvasive procedures of MID, thereby avoiding unnecessary tooth tissue loss. Early
caries detection ultimately positively impacts general well-being of an individual. How-
ever, care should be taken in the use of these sensitive systems as adjuncts to visual
inspection and IR because false positives may result in overtreatment. CBCT demon-
strated a significantly lower specificity for detection of recurrent caries compared with
intraoral radiography and PTR and modulated LUM in 1 ex vivo study.13
 Radiology of Dental Caries 443

CLINICS CARE POINTS

 Caries is a dynamic pathologic process that can be prevented, arrested, or treated.

 Proper staging of dental caries is needed for appropriate management of the disease.
 Sensitive caries diagnostic tools can serve as adjuncts to radiographs for early detection and
the opportunity for minimally invasive treatment.

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