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International Medical Journal Vol. 20, No. 3, pp. 395 - 398 , June 2013

DENTAL SCIENCES

Radiographic Diagnosis of Approximal Caries and Restorative

Treatment in Patients Attending Hospital Universiti Sains

Malaysia (HUSM)

Tan Ying Yin1), Mon Mon Tin-Oo2), Mohammad Khursheed Alam1)

ABSTRACT

Background: Bitewing examination is helpful for detecting hidden lesions in the approximal surface and is an essential aid

for clinical diagnosis.Objective: This study aim to assess the prevalence of approximal carious lesions from radiograph and treatment given.

Methods: A retrospective record review study was carried out on 239 clinical records of patients age 14 and above who

attended in dental clinic of HUSM from January 2008 to December 20011. Readable bitewings of second molar to first premolar

were assessed for the absence or presence and depth of caries. Caries prevalence, distribution of caries and treatment given

were calculated by frequency (%).

Results: A total of 4538 surfaces were examined. Lesions confined to the outer half of the enamel and inner half of enamel

were found in 7.1% and 3.5% of surfaces respectively. Lesions in outer half of dentine were 2.8% and lesions beyond the outer

part of the dentine were 3.8%. No treatment was given for most of the surfaces with radiolucency in the enamel. Topical fluo-

ride was given in the 4% of outer and 8.8% of inner half of the enamel. While surface with caries extend into dentine (59.7%)

and more than half of dentine (58.6%) were replaced with restoration. The more extensive treatment such as RCT and extrac-

tion were found in 22.7% of dentinal caries surface.

Conclusion: Both enamel and dentine caries prevalence was low. Most enamel caries were not intervened. Preventive inter-

vention was given more in enamel caries. Dentinal caries were restored according to the depth.

KEY WORDS

bitewing, approximal caries, treatment

Received on June 12, 2012 and accepted on September 20, 2012

1) School of Dental Sciences, Universiti Sains Malaysia

16150, Kubang Kerian, Kota Bharu, Kelantan, Malaysia

2) Dental Public Health Unit, School of Dental Sciences, Universiti Sains Malaysia

Correspondence to: Mon Mon Tin-Oo

(e-mail: [email protected])

395

INTRODUCTION

Bitewing as an aid to clinical diagnosis is essential if muchapproximal caries not to be missed. Bitewing radiographs are widelyused in dentistry, both to detect the presence of approximal caries andto monitor the progression of previously detected lesions. The evalu-ation of the size of approximal carious lesion, through interpretationof bitewing radiographs is the main tool in reaching a decision totreat approximal caries (Weiss et al. 1996).

Enamel caries with intact surface and small detectable cariouslesions limited to enamel at approximal surfaces can be detected bybitewing X-rays however, mistaken diagnosis is common. There canbe considerable variation in the interpretation of radiographs andtreatment decisions make by dentists (Purmal et al. 2012). The clini-

cian is the predominant factor in determining the extent of cariouslesions. Decisions of giving treatment or not giving appear to beinfluenced by a number of factors including the ability to detect thepresence or and the dentist's belief in the likely progression and even-tual outcome of the lesion. Over diagnoses became evident at thetreatment planning stage where many surfaces were incorrectlyplanned for restoration (Maupome and Sheiham 1993). On the otherhand underestimation of approximal caries tends to miss preventivecare and fail to precede restorative treatment.

The management of approximal caries varies according to thestate of disease of surface and the presence or absence of a cavity isvery relevant. Caries confined to enamel surface on bitewing radi-ograph where there is unlikely to be a cavity, should be encouragedto arrest. Dietary advice and proper oral hygiene instruction shouldbe given to patient, and in some cases, where patient cooperation isdoubtful, chair side application of fluoride by the dentist may be indi-cated. In contrast, when a cavity is present, operative treatment isusually indicated (Kidd and Nyvad, 2003).

C 2013 Japan International Cultural Exchange Foundation

& Japan Health Sciences University

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396

In the study by Poorterman et al. (2002) on Dutch adolescentsfound, of all enamel lesions 20% were not performed restorations. ASwedish study showed 50% of the lesions in the outer half of thedentin were restored when they were first detected (Lith et al. 2002).Stenlund et al. 2003 found the caries rate of an approximal tooth sur-face was 1.6-32.3 times higher if the adjacent surface was in a cariesstate compared to when the latter was sound.

There are different intervention taken by different practitionerstoward approximal caries detected on bitewing X-rays. This study

aims to explore the distribution of approximal caries presence andintervention undertake among patient attending Dental Clinic,HUSM.

MATERIALS AND METHODS

This retrospective record review study was carried on randomlyselected 239 folders of patients who had attended in dental clinic of HUSM from Jan 2008 to Dec 20011. Inclusion criteria were foldersof patients who were minimal age 14 years and above with completed

treatment cases, bitewing radiograph with optimal density and withteeth images that have no overlap contacts. Patient's folder will beexcluded if bitewing present with more than two missing teeth in twoquadrants, surface with restoration and fixed prosthesis and surfaceunreadable radiograph.

Folders that selected were requested from Record Unit for

review. Patient's age and gender were recorded. Bitewing radiographsfrom each folder were extracted and viewed in the dark environmenton the viewing light box. The bitewing radiographs were inspectedfor approximal caries present from mesial surface of second molarsto distal surface of first premolar in both maxilla and mandible.Dental caries criteria adopted for radiographic analysis were similarto that proposed in previous study (Lunder and Fehr FR von der1996): R0: no visible radiolucency; R1: Radiolucency in 1/2 outerenamel; R2: Radiolucency in 1/2 inner enamel up to the dentinoe-

namel junction (DEJ); R3: Radiolucency in > 1/3 of outer dentin; R4:Radiolucency in > 2/3 of outer dentin; R5: Radiolucency throughoutdentin. Interexaminer agreement was obtained by viewing of secondexaminer on 20% of bitewings. Cohen's Kappa test was employed tocheck the inter-examiner reproducibility.

Consequently, patient's record was reviewed carefully whetherany intervention was carried out on the approximal surface and mate-rial used for restoration was also recorded. In addition information of patients' age and gender were recorded.

The data were entered in SPSS version 12.0 soft ware. A descrip-tive analysis was used to describe the percentage distribution of enamel caries and dentine caries. The percentage distribution of radi-ographic scores assigned to proximal surfaces and frequency of treat-ments given on proximal molar surfaces were calculated.

Ethical consideration

Ethical approval was obtained from the Human Ethics Committeeof Universiti Sains Malaysia. All patients' identification and datawere kept confidential.

Tan Y. Y. et al.

Table 1. The depth of interproximal caries found at distal surface (D) and mesial surface (M) of each tooth at maxilla and

mandible

Depth of caries Tooth number and number of surfaces Total

14 15 16 17 24 25 26 27 surfaces

D M D M D M D M D M D M n %

R0 163 163 148 151 176 199 138 149 138 142 161 191 1926 (84.0)

R1 10 6 17 10 6 7 11 8 17 16 9 10 127 (5.5)

R2 5 8 4 1 4 2 11 13 10 9 5 2 74 (3.2)

R3 5 11 10 11 1 3 6 9 7 6 0 1 70 (3.0)

R4 5 4 20 13 8 1 7 8 18 8 8 1 101 (4.3)

34 35 36 37 44 45 46 47

D M D M D M D M D M D M

R0 178 181 143 124 106 159 187 192 146 152 108 147 1823 (81.0)

R1 9 11 21 16 18 21 10 7 19 12 23 32 199 (8.8)

R2 3 3 8 5 8 8 3 3 18 4 12 11 86 (3.8)

R3 0 1 9 7 9 6 1 2 6 4 13 1 59 (2.6)

R4 2 2 10 6 16 2 0 1 12 3 16 3 73 (3.2)

Table 2. Frequency distribution of interproximal caries and treatment given (N = 4538)

Radiographic reading of interproximal caries n% of surfaces given various treatment

Total surfaces No treatment Restoration RCT Extraction Topical

n % given fluoride

R1: Radiolucency in 1/2 outer enamel 326 (7.1) 303 (93.0) 10 (3.0) 0 (0.0) 0 (0.0) 13 (4.0)

R2: Radiolucency in 1/2 inner enamel 160 (3.5) 118 (73.8) 27 (16.9) 0 (0.0) 0 (0.0) 14 (8.8)

R3: Radiolucency in >1/3 of outer dentin 129 (2.8) 45 (34.9) 78 (61.2) 2 (1.5) 1 (0.8) 4 (3.1)

R4: Radiolucency in >2/3 of outer dentin 174 (3.8) 30 (17.2) 102 (58.6) 12 (6.9) 29 (16.7) 1 (0.6)

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397

RESULTS

The inter-examiner reproducibility value regarding the radi-ographic reading was 0.74 (Kappa's value). The folders of 239

patients [126 (52.7%) female and 113 (47.3%) males] were reviewed.Their age ranged from 14 to 60 years with the mean (SD) age of 27.6(10.51) years. Total 4538 tooth surfaces from bitewings were studied.Readable maxilla posterior teeth surfaces in bitewings were 2240 and2298 surfaces of mandibular posterior teeth. Table 1 describes thedepth of approximal caries found at distal surface (D) and mesial sur-face (M) of each tooth in bitewings. Percentage of surfaces involvedapproximal caries of R1, R2 and R3 categories were higher inmandibular teeth than maxilla teeth. Tooth surfaces where radiolu-cencies with obvious spread in outer half of dentine were higher inmaxillary teeth (4.3%) than mandibular teeth (3.2%). Radiolucencyin 1/2 outer enamel (R1) was most common in mandibular secondmolars, distal surfaces of mandibular first molars and distal surfacesof second premolars. Among maxillary molars, R1 was commonlyseen in distal surfaces of maxillary second premolars. As for dentinalcaries highest rate was found in maxillary teeth.

Out of total 4538 surfaces inspected, 82.0% were caries free withno radiolucencies (R0) detected. Among all tooth surfaces readablebitewings 10.7% were detected to have enamel caries (R1 and R2).Caries that had been broken into enamel-dentinal junction withoutobvious was 129 (2.8%) and spread to outer half of dentine wasfound to be 3.8% (Table 2).

Subsequent to the radiographic reading folders were reviewedwhether the approximal surfaces were given treatment or were notgiven. Frequency distribution of approximal caries and treatmentgiven were shown in Table 2. Approximal surfaces that radiolucencyin outer half of enamel were 326 and 93% of them were not beentreated. Four percent were applied with topical fluoride and only 3%had been restored. Radiolucency in the inner half of enamel wasfound on 160 approximal surfaces. Among them 73.8% were notgiven any treatment. Restoration was done on 27 % of them and 8.8%were applied with topical fluoride. 61.2 % of caries that bitewings

show radiolucency in dentine broken e-d border had been restoredand 34.9% were not given any intervention. More than half of approximal caries (58.6%) that have radiolucency with obviousspread in outer half of dentine were being restored; 17.2 % of themwere not given any treatment and 16.7% were extracted. There wereonly 6.9 % of caries that extend into outer half of dentine were givenroot canal treatment.

DISCUSSION

Among all readable 4538 surfaces the total of enamel caries was10.7%. Similarly, the study of bitewings of 120 Dutch persons anenamel lesion was found to be 12 to 15% of the unfilled surfaces(Poorterman et al. 2001). A study in New Zealand examined the 2710surfaces on bitewings of 123 subjects. Carious lesions were found in173 (6.38%) surfaces. Among all the carious lesions 79% were enam-el caries (R1 and R2) and 21% were dentine caries (Chandler et al.2005).

Prevalence of caries in enamel is higher compare to dentinalcaries in most of the study. Hintze, (2001) reported that enamel anddentine caries was found in 9% and 6% of the approximal surfacesrespectively. In this study distal surface of mandibular first molarwas found to have highest number of surface with radiolucency in 1/2outer enamel surfaces caries and dentinal caries. This result is com-parable with Hintze et al. (2001) study whereby the highest cariesexperience surface was in distal surface of first permanent molars in

mandible and mesial surface of first permanent molar in maxilla.Hopcraft and Morgan (2006) stated that first molar was the most sus-ceptible to dental caries.

Stenlund et al. (2003) reported that distal surfaces of the firstmolars were more prone to caries than the mesial surfaces of secondmolars. In this study enamel caries was more common on mesial sur-

faces of second molars than distal surface of first molar in both max-illa and mandible. As for dentine caries distal surface of first molarswere more affected than mesial surface of second molars. Study of Stenlund et al. (2003) have shown that the more recently eruptedapproximal surface the more being caries resistance than neighbour-ing surface with more mature enamel. Furthermore, older enamel isless penetrable to different agents, including fluoride, than newlyerupted teeth (Brunn et al. 1973, Mellberg and Nicholson, 1968) and

mature enamel is more caries susceptible (Burchell et al. 1984). Thismight helps to explain the higher caries susceptibility of the olderapproximal surface when it reaches contact with its neighbor.However, Nordblad and Larmas (1986) observed no differences incaries susceptibility between distal surface of first molar and mesialsurface of second molar.

In this study approximal caries R1, R2 and R4 were highly sus-ceptible in distal surface of maxillary and mandibular second premo-lars. In Hopcraft and Morgan (2006) study caries experience in pre-molars was low, although distal and occlusal surfaces were more thantwice as susceptible as mesial surfaces. Likewise our study Hopcraftand Morgan (2006) documented that mesial and distal surfaces of second premolars were more susceptible to caries. In fact the risk of developing caries on an approximal surface would also increase whencaries is detected on the adjacent approximal surface. A sound sur-face next to sound surface had a relatively small risk of developing

caries while the risk increased 1.6-32.3 times if the neighboring sur-face was in a caries states as judged radiographically (Stenlund et al.2003).

In present study, mesial surface of first molar in maxilla wasdetected to have the second highest caries rate's surface. This findingmay therefore be reasonable to assume that the caries rate of anapproximal surfaces may also depended on the caries status of theadjacent tooth.

Rate of caries progression has an influence towards caries preva-lence and caries depth (Arrow, 2007). The authors reported that themedian time to occurrence of enamel caries was 6.1 months; whilemedian time to dentine caries was 77.7 months. Their study showedthat time to occurrence of enamel lesions in approximal surfaces isrelatively rapid while progression into dentine is relatively slow.

On the contrary, Shwartz et al. (1984) found that about 10 percent of new lesions will progress through the enamel in one year and

25 per cent in two years. However, over 40 per cent of the lesionswill not have progressed in 4 years. Therefore, most of the lesionsdetected from bitewing were still confined to enamel rather than pro-ceed to dentine. Generally, caries progression rate is slow but contin-uous. Since there are patients with enamel caries in our study thesepatients should be recalled for posterior bitewing examination at 18 -36 months intervals and very firm preventive measures must be for-mulated.

The implicit valuation which dentists place on the outcomes of their treatment decisions may be a major contributory factor in den-tists' decisions about when to restore teeth (Kay and Nuttal, 1994).Regarding the treatment given for caries detected in this study, notreatment was given for most of the surface with radiolucency in theouter half of enamel (93%) however restoration was given on 3%.Furthermore, caries involvements at inner half of enamel surfaces73.8 % were not treated and 16.9% were given treatment. Shwartz et

al. (1984) stated that large proportions of carious lesions confined tothe inner or outer half of the enamel up to, but not beyond the amelo-dentinal junction do often progress for many years. Thus, suchlesions should also be kept under observation and the preventiveregime initiated. Restoration done on enamel surfaces found in thisstudy might be due to other causes that indicated for filling.Preventive intervention such as topical fluoride application was givenmore in enamel (12.8%). However, applying topical fluoride in den-tine caries 3% was arguable for its effectiveness.

In this study the surfaces with caries extend into dentine (61.1%)and more than half of dentine (58.6%) was replaced with restoration.The more extensive treatment such as RCT and extraction wereincreased in dentinal caries. Enamel caries are difficult to detect andit is equally as difficult to decide how to treat them. One treatmentoption is to not treat the lesion surgically but to treat the factors thatcaused the lesion and to observe its progression or reversal. Many

dentists are reluctant to only monitor the lesion over t ime(Anusavice, 1997). Most of the dentists would choose to restorelesions that were within the enamel surface for a patient who is highrisk. The survey on dentists' decision of treatment for a high risk caries patient, 66% of dentists indicated that they would restore prox-imal enamel lesion. While 24 % would do once the lesion had

Radiographic Diagnosis of Approximal Caries

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reached into outer third of dentine. For a low risk patient, only 39%of respondents reported they would restore an enamel lesion, and54% would do once the lesion reached into outer third of the dentine(Valeria et al. 2009). Likewise, in the study of Lith et al. (2002) alsofound out that the dentists in Scandinavia chose not to restore lesionsthose were limited to enamel; restorative treatment was predominant-ly recommended for surface that involved dentine. Moreover thepractitioners may approach a carious lesion as a separate entity andnot as part of a disease. In addition, the cure of caries should not only jus t rely on treatment given but also on individual assessment of caries risk and patient education (Normastura et al. 2009).

CONCLUSION

In this study we revealed, enamel caries prevalence was highercompare to dentinal caries as it progress slowly. The treatments givenfor caries are mostly related to caries depth. Most of the enamel

caries were not intervened with treatment; however preventive inter-vention was given more in enamel caries compare to other treatment.Besides, Dentine caries were restored accordingly. Extensive treat-ment such as root canal treatment and extraction were mostly done onthe dentine caries.

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