Radio Graphic Caries Diagnosis

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The following slides describe the radiographic

diagnosis of caries.

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Caries Diagnosis

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Caries

Caries is the breakdown of tooth structure

caused by acid-producing bacteria in the mouth.These bacteria are found in the white or pale

yellow plaque that builds up on the teeth if they

are not cleaned properly on a regular basis. The

bacteria break down carbohydrates (sugars) toform the acid that demineralizes tooth structure,

leading to caries.

The diagnosis of caries is made through a

combination of the clinical examination andradiographs.

Unless fairly large, interproximal caries in the

posterior region usually requires radiographs to

make a diagnosis.


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The bitewing film is primarily used for caries

identification, but the periapical film is also helpful.The difference in angulation between the two films

gives two different perspectives and can be especially

helpful in diagnosing recurrent caries around existing

restorations.There is a lot of discussion on which film speed (D or

F) should be used. Many dentists use D-speed film

because they feel it provides sharper images as a

result of the smaller grain size. Most educators, on theother hand, recommend the F-speed film (Insight)

because of the significant reduction in x-ray exposure

to the patient (approximately 60% less than when using

D-speed film).

Radiographs


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Approximately 40-50 % demineralization is required

for radiographic detection of a lesion. As seen in the

occlusal view, above right, the thickness of the tooth

buccolingually masks the carious lesion when it is

small.

The actual depth of penetration of a carious lesion

is actually deeper than it appears on the radiograph.

Proximal caries susceptible zone

caries

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Buccolingual thickness of tooth.The thicker the

tooth, the more difficult it is to see the extent ofthe caries.

Limitations of two-dimensional film.The extent of

carious involvement can not be seen in a

buccolingual (cheek to tongue) direction.

Factors affecting appearance of caries

on radiographs:


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X-ray beam angle(horizontal or vertical). This isespecially important when trying to identifyrecurrent caries, since changes in angulation maycause the superimposition of the existingrestoration with the carious lesion. Overlap due toimproper horizontal angulation makes it verydifficult to diagnose early interproximal caries.

Exposure factors. Caries detection is improvedwith a lower kVp setting, which provides a higher

contrast. If the overall density of the film is too

light or too dark, the diagnostic potential of the

film is limited.

Factors affecting appearance of caries

on radiographs (continued):


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In the anterior region,interproximal caries can

often be diagnosed using

transillumination, which

involves directing a brightlight through the contact

areas. Combining

transillumination with

radiographs enhances the

diagnostic information

obtained.

Transillumination

transilluminator


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I

M = Moderate (Stage II)

I = Incipient (Stage I)

A = Advanced (Stage III)

S = Severe (Stage IV)

Caries Classification

S

AMA


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Interproximal Caries(Incipient)

I

Up to half the thickness of enamel

Usually not restored unless patient

has high level of caries activity (high

risk). Treat with fluoride.


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The arrow points to incipient lesions on the

mesial of # 19 and the distal of # 20.


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Incipient

Moderate

Advanced


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M

Interproximal Caries(Moderate)

More than halfway through the

enamel (up to DEJ)


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The bottom arrow points to a moderate lesion

on the distal of # 20. The upper arrow points to

one of several incipient lesions on the molar

and premolars.


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Moderate lesion seen on previous film


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Class III moderate lesion seen in the

anterior region


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AA

Interproximal Caries

(Advanced)


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Advanced lesion identified by arrows.


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Advanced lesions seen on previous film


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Advanced lesion


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Advanced lesion


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More than halfway

through the dentin

S

Interproximal Caries

(Severe)


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Severe lesion


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Severe lesion


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Must have penetrated into dentin

Diagnosed from clinical exam

May be seen as thin radiolucent line orcup-shaped zone underlying occlusal

enamel, but difficult to see on

radiographs unless lesion is large.

Some feel that a sharp explorer used tooforcefully may contribute to spread

of caries by opening up pit or fissure

Occlusal Caries


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Occlusal caries


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Occlusal caries


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Should be identified from clinical

exam. Sometimes seen as well-defined circular area in middle of

tooth, although it is not very

radiolucent. Depth can not bedetermined radiographically.

Buccal/Lingual

Caries


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Lingual caries (Cant tell whether its buccal

or lingual from one radiograph


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Buccal caries with severe interproximal

caries on # 12


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Saucer-like cratering on the roots of the

teeth, involving the cementum. Usually

found on older individuals withprominent recession and/or

periodontitis. May have xerostomia due

to medications. May be confused with

cervical burnout (discussed on later

slide).

RootCaries


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Root caries


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Root caries


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Cervical Burnout

Cervical burnout is an apparent radiolucency

found just below the CE junction on the rootdue to anatomical variation (concave root

formation posteriorly) or a gap between the

enamel and bone covering the root(anteriorly). Mimica root caries. Posteriorly,

this radiolucency usually disappears when

another film of the region is examined. Caries

does not occur on the root of the tooth unlessthere is loss of alveolar bone and gingival

tissue due to recession or periodontitis.

P t i i l b t Th i i ti


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Posterior cervical burnout. The invagination

of the proximal root surfaces allow more x-

rays to pass through this area, resulting in a

more radiolucent appearance on theradiograph. X-rays directed at a different

angle usually pass through more tooth

structure and the radiolucency disappears.


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Radiolucency seen at left (arrow)disappears on periapical film of

same tooth. This is cervical burnout.


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bone level

Anterior cervical burnout. The space between

the enamel and the bone overlying the tooth

will appear more radiolucent than either the

enamel or the bone-tooth combination.


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Cervical burnout in theanterior region due to

gap between enamel

(red arrows) and

alveolar bone over root(blue arrows).


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Found around the margins of existing

restorations. May be due to unusualsusceptibility to caries, poor oral

hygiene, failure to remove all of the

caries during cavity preparation, adefective restoration or a combination

of the above.

Recurrent Caries


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Recurrent caries


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Recurrent caries


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Recurrent caries


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Rampant Caries

Extensive and rapidly progressingcaries usually found in children

and teens with poor diet and

inadequate oral hygiene


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Found in head/neck radiation

therapy patients with xerostomia

Fluoride used for control

Radiation Caries


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Before radiation


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1 year after radiation

M h B d


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Mach BandOptical illusion giving appearance of increased

radiolucency at the junction of differing tissuedensities, such as enamel and dentin. If you block

off the enamel with a fingernail, the radiolucency

will disappear if due to the mach band effect. If the

radiolucency persists, it may be caries.

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This concludes the section on Caries.

Additional self-study modules are availableat: http://dent.osu.edu/radiology/resources.htm

If you have any questions, you may e-mail

me at:[email protected].

Robert M. Jaynes, DDS, MS

Director, Radiology Group

College of DentistryOhio State University

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Radio Graphic Caries Diagnosis