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Dr. John Flucke is in private practice in Lee’s Summit, Mo. He also serves as technology editor for Dental Products Report magazine and keeps an active blog filled with thoughts and tidbits on the world of technology at blog.denticle.com.
As the “technology evangelist,” I sometimes lose myself in reading about and researching different aspects of technology. On occasion, I can go down the technology rabbit hole and disappear for hours at a time.
One of the subjects that has fascinated me over the years is stealth. While I “get” the concept, it still amazes me that an object as large as the B-2 Spirit stealth bomber (172 feet wide by 69 feet long) can be virtually invisible to radar.
Obviously, in some cases, stealth is a really good thing. However, in healthcare, it can be a serious challenge. No one likes surprises in dentistry … not patients, not doctors and not staff. Also, as a profession that prides itself on being conservative, wouldn’t it be great to not only see decay before it surprises you but also detect it at its earliest and smallest stages?
We are entering a phase in our profession where the “sharp explorer diagnosis” as the primary means for caries diagnosis will take a backseat to other modalities. While the explorer can still detect carious lesions, those lesions are larger than ones that can be detected by other modalities. This means conservative examination and diagnosis can be more reliably performed through the use of other diagnostic means and devices.
To me, this is a fascinating subject because I feel caries diagnosis has become more like a mosaic. By that I mean I acquire diagnostic info from several different modalities, which are like the mosaic tiles, and then when I step back and view all of the “tiles,” I can see the picture the individual tiles create.
First and foremost, I want to make it clear that my diagnostic process is data-driven. The more information I can get, the better I feel about my decisions. Now, we’ve always been data-driven in diagnosis; it’s just that we may not have really been aware of it. Any time we look at a bitewing, drag an explorer across the occlusal surface or look at a big gap in the margin of an old amalgam on the occlusal of tooth No. 30, we are gathering data.
So when I sit down with a patient to do an exam, I’m using several different modalities to gather data. While I don’t depend on the explorer nearly as much as I used to, it is still used on occasion. I’m also doing my exams utilizing magnification.
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My Orascoptic EyeZoom surgical telescopes provide up to 5.0x magnification. Pairing that level of magnification with a bright glasses-mounted LED “headlight” makes it much easier to see the breakdown of the enamel. It’s also not uncommon for me to notice an area of decalcification under a marginal ridge that is indicative of an interproximal lesion. Sometimes these interproximal areas have been noticed on a bitewing and I can confirm during the intraoral exam, and sometimes the areas are discovered by the intraoral exam alone.
It also helps to have an intraoral camera available, as well. While 5.0x is certainly nice, intraoral cameras can enlarge much more than that. Magnification of 28x to 32x is not uncommon, and being able to see images on a monitor from different angles can also make a tremendous difference. The other great feature of intraoral photos is that they can be saved and reviewed at the next periodic examination. This provides even more data on areas that might have been determined not to need restorative at previous appointments. Allowing for a compare and contrast to previous points in time is a tremendous advantage.
However, there are even more ways to evaluate your patient’s condition and generate more data. Once again, I’d like to emphasize these devices are just more ways of gathering data. It is up to the doctor to evaluate that data and determine what course of action (if any) is necessary. Let’s take a look at some of them now.
If you use Carestream for your digital radiography, you should check out Logicon. It is an optional component of the Carestream software. This software performs an analysis of bitewings and helps locate interproximal lesions. It uses a database of confirmed areas of interproximal caries and compares them to the radiographs just taken to see if lesions exist.
There are two different devices from ACTEON that can help generate more data. The first is the SoproLIFE (light-induced fluorescence evaluator). This device functions as two devices in one. It has a series of white LEDs that let it perform the functions of an intraoral camera, and it also can be switched over to violet LEDs that provide visual caries detection.
Under the violet light, caries glows (fluoresces) and this can be seen in the images taken by the device. The glowing areas are often smaller than what can be detected by a sharp explorer, making this (and all the visual devices discussed here) more accurate and more conservative than an explorer. The device is recognized by dental software as an intraoral camera. That means you can store the images and associate them with teeth, allowing you to keep a visual history of changes over time.
The second ACTEON device is the SoproCARE. This functions as a three-in-one device. Like its little brother, it functions as a true intraoral camera and fluorescent caries detector. However, it also functions as a detector of potential perio problems by also having a “perio mode.” The “perio mode” uses a different set of LEDs that allow for the identification and illumination of gingival inflammation, plaque and calculus. When paired with a monitor for patient viewing, this means hygienists can share with patients areas of periodontal concern with pictures that show patients inflammation in their own mouths. Combined with the regular intraoral camera and caries detection modes, this device can do it all. It also interfaces with your dental software to store the images.
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The CariVu is a very interesting device. Rather than using fluorescence, the CariVu functions as a transilluminator. It shines an invisible (to the naked eye) near-infrared light into the tooth from buccal and lingual simultaneously. While these two light sources provide transillumination, there is a camera built into the handpiece that allows viewing and capture from the occlusal surface. The result is a very brightly illuminated tooth with a crisp black-and-white image from the occlusal.
The result is that caries, both on the occlusal and interproximal surfaces, can be seen and captured. Also, if the device is tipped to the buccal or lingual it can provide images of those surfaces as well. While it is not a replacement for the bitewing, CariVu can definitely help find interproximal lesions radiographs might miss as well as confirm areas that might be questionable on a bitewing. The infrared energy provides illumination that is right in the “Goldilocks zone” (not too bright and not too dim) so that the tooth is perfectly transilluminated.
The device connects only through the DEXIS Imaging Software, but that allows the CariVu images to be stored and compared side by side with DEXIS bitewings, which is a really nice feature. The system is compact and easy to use.
The Spectra is another fluorescence device. This one only performs one function, which is caries detection. However, it also adds a nice feature. After the Spectra image is saved or “frozen” on the computer screen, a software algorithm is applied to the image. This takes less than a second, and then an image is overlaid on the picture of the tooth. This overlay has the appearance of doppler weather radar. This means it is a combination of blue, red, orange and yellow, with each color corresponding to deeper penetration of the caries causing bacteria. The colors are a great communication tool for patients, and they also provide a great source of information for the practitioner, as it is easy to see the size of the lesion in all three dimensions. This makes restoration more predictable and helps the doctor decide whether anesthetic is needed or not. Like the other devices, the images can be stored in your practice management software and monitored if need be.
Putting it all together
By using a combination of the suggestions and devices in this article, a doctor can create quite a few data points. However, there is one more data point I haven’t covered yet that extends to patient history as well. The longer patients are in my practice, the better I get to know them, their habits, homecare, etc. This helps me determine if I restore, remineralize, monitor or something else!
By combining all the info I can, a more complete picture can be obtained that helps me make better clinical decisions. In the end, the question I need to answer is “what is in the best interests of the patient?” That answer lies within as many data points as I can gather.
About the author
John Flucke, DDS, is the technology editor for Dental Products Report and dentistry’s “technology evangelist.” He practices in Lee’s Summit, Mo., and has followed his passions for both dentistry and technology to become a respected speaker and clinical tester of the latest in dental technology with a focus on things that provide better care and better experiences for patients. He blogs about technology and life at blog.denticle.com.