Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
caries is a multifactorial disease with
the
microflora, and the diet. If not disturbed, bacteria accumulate at specific tooth sites to form what is known as
bacterialPlaque (biofilm). The development of caries
requires both the presence of bacteria and a diet containing ferl;llentable carbohydrates. Caries is an infectious disease since it is the lactic acid produced by
bacteria from the fermentation of carbohydrates that
causes the dissolution, or demineralization, of the
dental hard tissues.The mutans group of streptococci
plays a central role in the demineralization. In the
initial stagesof the diseasebacteria are located on the
tooth surface. It is only after severedemineralization or
cavity formation has occurred that bacteria penetrate
into the hard tissues.The demineralized tooth surface,
called the cariouslesion,is thus not the diseasebut is a
reflection of ongoing or past microbial activity in the
plaque.
The initial carious lesion is a subsurface loss of
mineral in the outer tooth surface. It appears clinically
as a chalky white (indicating present activity) or an
opaque or dark, brownish spot (indicating pastactivity).
A lesion beneath active bacterial plaque will progress,
slow or fast, but if this biofilm is removed or disturbed,
the lesion will arrest. An arrested lesion may become
re-active,however,and progress any time there is activity in the biofilm. Alternatively, remineralization in the
outer parts of an arrested lesion can occur, for example,
after the use of fluorides. Caries is therefore an everdynamic process.
The rate and extent of mineral loss depends on
many factors. Mineral loss occurs faster in an active
lesion when intercrystalline voids form. Demineraliza-
tion may extend well into dentin before a breakdown
of the outer surface (cavitation) occurs, resulting in a
clinically visible cavity. With lesion progression and no
intervention, demineralization may progress through
the enamel, the dentin, and eventually into the pulp
and may destroy the tooth (Fig. 16-1).
Radiography is useful for detecting dental caries
becattse the caries process causes demineralization of
enamel and dentin. The lesion is seen in the radiograph as a radiolucent (darker) zone since the demineralized area of the tooth does not absorb as many
x-ray photons as the unaffected portion. It is important
to keep in mind, though, that the lesion detected in the
radiograph is merely a result of the bacterial activity on
the tooth surface and radiography cannot reveal
whether the lesion is active or arrested. An old inactive
lesion will still appear as a demineralized "scar" in the
hard tissues (Fig. 16-2). This is because remineralization takes place only in its outermost surfat:e, as
mineral-containing solutions from saliva cannot diffuse
into the body of the lesion. Since the radiograph only
mirrors the current extent of demineralization, one
radiograph alone cannot distinguish between an active
and an arrested lesion. Only a second radiograph taken
at a later time can reveal whether the diseaseis active.
When a decision is made to monitor a lesion, factors
such as oral hygiene, fluoride exposure, diet, caries
history, extent of restorative care, and age should be
considered in determining the time interval between
the radiographic examinations (see Chapter 14).
297
PART V
RADIOGRAPHIC
INTERPRETATION
OF
PATHOLOG~
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
Radiography is a valuable supplement to a thorough
clinical examination of the teeth for detecting caries. A
careful clinical examination assessing the carious activo
ity on the tooth surface may be possible for smooth sur.
faces and to some extent for occlusal surfaces. However,
when the surface is clinically intact-that
is, no break.
down leading to cavitation has occurred-even
the
most meticulous examination may fail to reveal demo
ineralization beneath the surface, including occlusaJ
surfaces. Clinical access to proximal tooth surfaces in
contact is quite limited. Indeed, numerous clinicaJ
studies have shown that a radiographic examination
can reveal carious lesions both in occlusal and proximaJ
surfaces that would otherwise remain undetected.
Radiographic Examination
to Detect Caries
FIG. 16-2
Microradiograph
of an inactive carious lesion
(dark region) in enamel with an intact, well-mineralized
surface (arrow).
The bitewing projection is the most useful radiographic
examination for detecting caries (see Chapter 8). The
use of a film holder with a beam-aiming device (&eeFig.
8-6) reduces the number of overlapping contact points
and improves image quality, thus minimizing interpretation errors. Periapical radiographs are useful primarily for detecting changes in the periapical bone. Use
of a paralleling technique for obtaining periapical radiographs increasesthe value of this projection in detect
ing caries of both anterior and posterior teeth
especially with heavily restored teeth.
Traditionally, size-2"adult" films are used for a bitew
ing examination from the age of approximately 7 to 8
years onward. When it is necessaryto examine all the
contact surfaces from the cuspid to the most dista
molar, usually two bitewing films per side are required
(Fig. 16-3). The use of a single size-3film often results
in overlapping contact points and "cone-cut" images
and is not recommended. In small children the sizeor "child" film may be used (Fig. 16-4).
In recent decadesthere has been a dramatic decline
in the prevalence of caries in all Western countries
leaving a smaller fraction of the population with rapidly
progressing carious lesions. Accordingly, the interval
between examinations should be customized for each
individual patient and based on the perceived caries
activity and susceptibility. For caries-freeindividuals the
interval may be lengthened, whereas for caries-activ
individuals the interval should be shorter.
Radiographs used to detect carious lesions should be
mounted in frames with dark borders and interpreted
using a magnifying glass, particularly when evaluating
the extent of small superficial lesions. Fig. 16-5 is a
series of radiographs showing early lesions with and
without magnification.
CHAPTER
16
DENTAL
299
CARIES
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
B
A
FIG. 16-3
Two bitewings from the patient's left side covering the surfaces from the
distal surface of the canine to the distal surface of the most posterior molar.
like plate that is processed (scanned) after exposure.
These receptors are described in Chapter 12. The
holders available for bitewing examinations with phosphor plates appear similar to those for film, and
recently universal sensor holders have also become
available. However, there may be some problems when
solid-state sensors are used for bitewing examination.
First, the surface area of the sensoris smaller than the
surface area of a size-2 film, resulting in the display of
an averageof three fewer in terproximal tooth surfaces
per bitewing image than with film. Furthermore, the
stiffness and increased thickness of these sensors may
result in more projection errors and retakes. When
digital bitewing images are used, they should be displayed on a monitor in their full resolution (Fig. 16-6)
for interpretation and viewed in a room with subdued
light.
FIG. 16-4
Posterior bitewing using a size-Ofilm, demonstrating both permanent and deciduous teeth. Note the
proximal carious lesions (arrows).
for a Bitewing Examination
Digital image receptors have recently become available
for intraoral radiography. There are two different
methods available: solid-statesensors (CCD and CMOS
technology), in which a cord connects the receptor to
the computer, and storage phosphors that use a film-
Radiographic Detection
of Lesions
PROXIMAL SURFACES
The shape of the early radiolucent lesion in the enamel
is classicallya triangle with its broad base at the tooth
surface (see Fig. 16-5), spreading along the enamel
rods, but other appearances are common, such as a
"notch," a dot, a band, or a thin line (Fig. 16-7). When
the demineralizing front reaches the dentinoenamel
junction (DE]), it spreads along the junction, frequently forming the baseof a second triangle with apex
directed towards the pulp chamber. This triangle typically has a wider base than in the enamel and progresses
cF~oo
IG.
I'ART
V
{ADIOGRAPHIC
INTERPRETATION
OF PATHOLOGY
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
A
16-5
A magnifying glass is important for examining the extent of carious lesions.
A and C are not magnified. Band D are magnified.
towards the pulp along the direction of the dentinal
tubules. Again, more irregular shapesof decalcification
may be seen (Fig. 16-8).
A lesion in proximal surfaces most commonly is
found in the area between the contact point and the
free gingival margin (Fig. 16-9). The fact that the lesion
does not start below the gingival margin helps distinguish a carious lesion from cervical burnout (see Fig.
9-2). Close attention should be paid to intact proximal
surfaces adjacent to a tooth surface with a restoration
since occasionallythis surface is inadvertently damaged
during the restorative procedure and is thus at greater
risk for caries (Fig. 16-10).
Becausethe proximal surfacesof posterior teeth are
often broad, the loss of small amounts of mineral from
incipient lesions and the advancing front of active
lesions are often difficult to detect in the radiograph.
Lesions confined to enamel may not be evident radiographically until approximately 30% to 40% demineralization has occurred. For this reason, the actual
depth of penetration of a carious lesion is often deeper
than seenradiographically.
Even experienced dentists often do not agree ~n the
presence or absenceof caries when examining the same
set of radiographs, especially when the lesions are
limited to the enamel. On occasion a lesion may be
detected when the tooth surface is actually unaffected
(a false-positive outcome). Various dental anomalies
such as hypoplastic pits and concavities produced by
wear can mimic the appearance of caries. In casesin
which the demineralization is not yet radiographically
visible, failure to detect the lesions is a false-negative
outcome (Fig. 16-11). Approximately half of all proximal lesions in enamel cannot be detected by radiography. The possibility of false-positivediagnosesof small
lesions, combined with the knowledge that caries progressesslowly in most individuals, argues for a conservative approach to caries diagnosis and treatment. A
lesion extending into the dentin in the radiograph may
be easierto detect with greater agreement among experienced observers. Occasionallydemineralization in the
enamel is not obvious, and a dentinal lesion is overlooked (see Fig. 16-8).
Potentially, a progressing proximal lesion may be
arrested if cavitation has not developed. If cavitation
has occurred, the lesion will alwaysbe active since the
bacteria that colonize within the cavity cannot be
removed. Unfortunately, the presence of cavitation
cannot be accurately determined radiographically,
although the greater the radiographic depth of the
CHAPTER 16
DENTAL
301
CARIES
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
of the lesion, becausethe progression rate differs highly
among the various tooth surfaces.Care should be taken
to reproduce the same image geometry in the followup radiographs to provide a means of accurate comparison of depth of the lesion. When digital images are
made with reproducible geometry, they can be superimposed and the information in the one image can be
subtracted from the other (subtraction image), which
displays the changes that have occurred between the
two examinations (Fig. 1&-12).
Progression of a lesion indicates the need for operative therapy. With highly motivated patients who clean
the surface and with topical fluoride treatment, more
than half of shallow dentinal lesions can be arrested,
thus avoiding restorative therapy.
OCCLUSAL
FIG. 16-6
Two bitewings captured on storage phosphor
plates and displayed on a 17-inch monitor.
lesion, the greater the likelihood of cavitation. Since
extensive demineralization must occur before the
surface breaks down, the percentage of enamel lesions
with surface cavitation is very small. Approximately half
of lesions that are just into dentin have surface cavitation. The;deeper the lesion has penetrated into dentin,
the more likely it is cavitated, and dentinal lesions
extending more than half way to the pulp are always
cavitated. Temporarily separating proximal surfaces
with orthodontic elastics or springs may allow direct
inspection to determine whether there is cavitation.
This method is easier in children than in adults.
The above considerations mean that operative treatment is usually not needed for lesions detected in
enamel, and the dentist and the patient may arrest
lesion progression with conservative intervention. Cavitated lesions, on the other hand, need operative treatment. For dentinal lesions, the decision whether to
provide operative treatment is individualized for each
patient. In casesin which it is decided to monitor the
lesion, a follow-up radiograph should be taken to evaluate whether the lesion has arrested or is progressing.
The interval between the radiographic examinations
should also be determined individually, taking into
account previous caries history, age, and not least, site
SURFACES
Carious lesions in children and adolescentsmost often
occur on occlusal surfacesof posterior teeth. The demineralization process originates in enamel pits and fissures, where bacterial plaque can gather. The lesion
spreads along the enamel rods and, if undisturbed,
penetrates to the DE], where it may be seen as a thin
radiolucent line between enamel and dentin.
Occlusal lesions commonly start in the sides of a
fissure wall rather than at the base and then tend to
penetrate nearly perpendicularly toward the DE]. Early
lesions appear clinically a~ chalky white, yellow, brown,
or black discolorations of the occlusal fissures.Findings
such as discolored fissures in a clinically intact occlusal
surface suggestthat a radiographic examination is indicated to determine whether a carious lesion exists. A
clinical cavityis an indication that the lesion has already
penetrated well into dentin. Therefore, a careful clinical examination must alwaysprecede the radiographic
examination.
When an occlusal lesion is confined to enamel, the
surrounding enamel often obscures the lesion. As the
carious process progresses,a radiolucent line extends
along the DE]. As the lesion extends into the dentin,
the margin between the carious and non carious dentin
is diffuse, and may obscure the fine radiolucent line at
the DE]. Therefore, false-positive detection rates may
be as high as false-negativeones (Fig. 16-13). A falsenegative outcome may not represent a severemistake
since in most casesthe process progresses slowly and
the lesion is detected at a later time. A false-positive
outcome may result in a sound surface being irreversibly damaged. Also, when there is a sharply defined
density difference, such asbetWeenenamel and dentin,
there may appear to be a more radiolucent region
immediately adjacent to the enamel. This is an optical
illusion referred to as the mack band.This illusion can
PART V
302
RADIOGRAPHIC
INTERPRETATION
OF PATHOLOGY
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
FIG. 16-7
Incipient proximal enamel lesions. Arrows indicate the areas showing
demineralization. Note the shape, size, and location of these 14 early lesions.
contribute to the number of false-pQsitiveinterpretations; therefore, when there are no clinical signs of a
lesion, it is reasonable to observe these casesand withhold operative treatment.
The classic radiographic appearance of occlusal
caries extending into the dentin is a broad-based,radiolucent zone, often beneath a fissure, with little or no
apparent changes in the enamel. The deeper the
occlusal lesion, the easier it is to detect on the radiograph (Fig. 16-14). This figure shows examples of
occlusalcaries with radiolucent changes indicating the
need for operative treatment. A pitfall in the interpretation of dentinal occlusal lesions is superimposition of
the image of the buccal pit, with or without a carious
lesion, which may simulate an occlusal lesion (Fig. 1615). Direct clinical inspection of the tooth most often
eliminates any such confusion. Occasionally demineralization in dentin may be quite extensive with a clinically intact surface and may only be detected
radiographically.
As occlusal caries spreads through the dentin, it
undermines the enamel, and eventually masticatory
forces cause cavitation. Breakdown of the surface is clinically obvious if a thorough cleaning of the surface precedes the clinical examination.
Severe, rapidly progressing carious destruction of
teeth is usually termed rampant cariesand is usually seen
in children with poor dietary and oral hygiene habits.
This condition, however, is becoming increasingly rare
because of widespread availability of water fluoridation
and enlightened
practices of good nutrition and
hygiene. Rampant caries may also be seen in people suf- j
,
CHAPTER 16
DENTAL
303
CARIES
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
FIG. 16-8
Dentinal proximal caries. Note the size, shape, and location of these 15
lesions and the radiographic changes (increased radiolucency) of both enamel and dentin.
fering xerostomia. Radiographs (Fig. 1t}-16) of individuals with
rampant
caries demonstrate
severe
(advanced) carious destructions, especially of the
mandibular anterior teeth.
BUCCAL AND
LINGUAL
SURFACES
Buccal and lingual carious lesions often occur in
enamel pits and fissures of teeth. When small, these
lesions are usually round; as they enlarge, they become
elliptic or semilunar. They demonstrate sharp, welldefined borders.
It may be difficult to differentiate between buccal
and lingual caries on a radiograph. When viewing
buccal or lingual lesions, the clinician should look for
a uniform non carious region of enamel surrounding
the apparent radiolucency (see Fig. 1(}-15). This welldefined circular area represents parallel noncarious
enamel rods surrounding the buccal or palatal lesion.
It may at times be necessaryto examine more than one
view of the area, because the buccal or lingual lesion
may be superimposed on the DE] and suggestocclusal
caries. Occlusal lesions, however, ordinarily are more
extensive than lingual or buccal caries, and their
outline is not as well defined. Clinical evaluation with
visual and tactile methods is usually the definitive
method of detecting buccal or lingual lesions.
ROOT SURFACES
Root surface lesions involve both cementurp and dentin
and are associatedwith gingival recessio~.The exposed
304
PART V
~ADIOGRAPHIC
INTERPRETATION
OF PATHOLOGY
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
cementum is relatively soft and usually only 20 to 50 flm
thick near the cementoenamel junction, so it rapidly
degrades by attrition, abrasion, and erosion. Root
surface caries should be detected clinically, and often
radiographs are not needed for diagnosis. IJ:}proximal
root surfaces radiographic examination, ~J reveal
lesions that have gone undetected (Fig. 16-1~): A pitfall
in the detection of root lesions is that a surface may
appear to be carious as a result of the cervical burnout
phenomenon (seeFig. 9-2). The true caries lesion may
be distinguished from the intact surface primarily by
the absence of an image of the root edge and by the
FIG. 16-9
Proximal caries-susceptible zone. This region
extends from the contact point down to the height of the
free gingival margin. It increaseswith recession of the alveolar bone and gingival tissues.
appearance of a diffuse rounded inner border where
the tooth substancehas been lost.
ASSOCIATED WITH
RESTORATIONS
DENTAL
A carious lesion developing at the margin of an existing restoration may be termed secondary
or recurrent
caries.It should be noted, though, that a lesion developing in a restored surface is most frequently a new
primary demineralization, either because of faulty
shaping or inadequate extension of. the restoration
leading to plaque accumulation (Fig. 16-18). These
lesions (secondary caries) should be treated like any
new caries lesion. It is important not to confuse secondary (primary) caries with residual caries, which is
caries that remain if the original lesion is not completely removed.
A lesion next to a restoration maybe obscured by the
radiopaque image of the restoration. Thus the detection of secondary caries also depends on a careful clinical examination.
Recurrent lesions at ~the
mesiogingival and distogingival margins are most frequently detected radiographically. Examples of caries
lesions next to dental restorations are seen in Fig. 1618 on the mesial, distal, and occlusal borders of
amalgam, gold, and composite dental restorations.
Restorative materials vary in their radiographic
appearance depending on thickness, density, atomic
number, and the x-ray beam energy used to make the
radiograph. Some materials can be confused with
caries. Older calcium hydroxide liners without barium,
lead, or zinc (added to lend radiopacity) appear radiolucent and may resemble recurrent or residual caries.
1-1
u. ..()-.. U A pair ot Dltewlngs. Note (encircled)that lesions have developed in surfaces
adjacent to a restored surface but not in the same surfaces in the opposite side.
CHAPTER 16
305
DENTAL CARIES
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
B
A
FIG. 16-11
A, Radiograph of an extracted tooth with a lesion just into dentin in the
left side (circle) but no visible lesion in the right side. 8, The same tooth after sectioning
assessedunder a microscope reveals lesions in both sides; the lesion in the right side is
only in enamel.
FIG. 16-12
Subtraction image made trom two radiographs taken with 2 years' interval. The contours of four
maxillary teeth can be seen. Between the two examinations
a filling was placed (rectangle), a new deep lesion has developed (large circle), and a lesion has progressed from enamel
into dentin (small circle).
Despite the calcium present, the relatively large proportion of low atomic number material in calcium
hydroxide causes its radiodensity to be similar to a
carious lesion. Composite, plastic, or silicate restorations also may simulate lesions. It is often possible,
however,to identify and differentiate these radiolucent
materials from caries by their well-defined and smooth
outline reflecting the preparation (Fig. 16-19).
AFTER RADIATION
THERAPY
Patients who have received therapeutic radiation to
the head and neck may suffer a loss of salivary gland
function, leading to xerostomia (dry mouth).
Untreated, this induces rampant destruction of the
teeth, termed radiation caries(see Chapter 2). Typically,
the destruction begins at the cervical region and may
aggressivelyencircle the tooth, causing the entire crown
to be lost, with only root fragments remaining in the
jaws. The radiographic appearance of radiation caries
is characteristic: radiolucent shadowsappearing at the
necks of teeth, most obvious on the mesial and distal
aspects. Variations in the depth of destruction may
be present, but generally there is uniformity within a
given region of the mouth. Fig. 16-20 shows examples
of radiation caries in patients with xerostomia following therapeutic radiation for cancer of the head
and neck. Use of topical fluorides as remineralizing
solutions and meticulous oral hygiene can markedly
reduce the radiation damage to teeth resulting from
xerostomia.
Alternative Diagnostic Tools
to Detect Dental Caries
Other methods have been developed, in addition to
clinical inspection and radiography, to detect carious
lesions. These include light fluorescence (QLF),
"Diagnodent" laser-light, fibre-optic transillumination
306
PART V
RADIOGRAPHIC
INTERPRETATION
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
OF PATHOLOGY
.9i.~
."!: >
-~
?:'-U
<II"'tij
> .~
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com.!:
C
:=
.-U
~ ~
U
<II
0
~
C
:J
V)
l0
-I-
~
<II
v).!:
;;},
U
<II
U.!:
0 ~
<11-0
.!:
<II
""'
C
~
.-u
c'C
.~
c .-c
<II V)
-0 .c
c
.-<II
E E
~~
V) <II
<II':
.0 .
c
C
<II .0
U
:J"'"
-~
.-V)
0
-0.~ C'I
I-
<II
I-
U
<II
C >
~
.~
.!!!
Q
'Vi
0
0d>
~.!!!.
~~
~
~
~
0
I.;)~
-.!!!
L.L.
.,;
.!!!
X
I-
<II
PART V
308
RADIOGRAPHIC
INTERPRETATION
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
FIG. 16-15
Note the uniform enamel surrounding the radiolucency.
tion is the definitive method for making treatment decisions.
FIG. 16-16
DDS, Alhambra,
Rampant
Calif.)
(advanced) caries in young children.
Clinical observa-
(Courtesy Raphael Yeung,
OF PATHOLOGY
c:
~
~
'iii
QJ
E
.c
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
fQJ
vi
QJ .
'c c:
~
u .-0
V)
"""'v)
E QJ
~ ~
Ic:QJ
~
E .~
QJ OJ
u c:
-;.0,
u~ 0
't~-
'" a
0
0
l-
I-QJ
~
V)
-o~
QJ-o
a.QJ
~
V)
.c
0
I-'-:' a.
x
QJ
U
QJ
~
QJ
~
V)
l~
-0
0
QJ 0
c:
I-
'tQJ
-0£
-!.=
0
V)
c:
,..
~ .-0
, t
IC 0
~a.
.~
I.J~
Li:'6
310
PART V
RADIOGRAPHIC
IN,ERPRETATION
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
OF PATHOLOGY
CHAPTER 16
DENTAL
311
CARIES
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
FIG. 16-19
Restorative materials that resemble carious lesions. Note the smooth classic
outlines of these radiolucent areas,which are actually cavity preparations.
(FaT!), electrical conduc.tance measurements (ECM),
and ultrasound. QLF may be used to quantify mineral
loss on smooth surfaces, whereas Diagnodent and
ECM have been applied on occlusal surfaces. These
two methods operate by displaying a value that provides quantitative information on the depth of the
lesion. None of the methods can unequivocally distinguish between enamel and dentin lesions or between
shallow and deep dentin lesions. Fiber optic transillumination (FaT!) has been used primarily for
proximal surfaces but may also be applied to occlusal
surfaces. FaT! is less sensitive than radiography for
distinguishing shallow and deep lesions. ECM is
better than FaT! in identifying occlusal caries in young
children. There is little evidence yet that these methods
can substitute traditional diagnostic methods in the
clinic.
Treatment Considerations
Carious lesions in enamel require interceptive treatment but rarely operative treatment. The radiographic
detection of small areas of demineralization require a
decision of whether these represent active or inactive,
arrested lesions. When the radiograph shows a lesion
limited to enamel, the probability of cavitation is low
and the prospect of arresting or reversing the caries
process is good. Also, if the radiograph showsa lesion
just into the dentin, treatment should include a means
to stop the microbiologic activity and possibly reverse
the demineralization process.Treatment of suchlesions
may include reductions in sugar intake, proper oral
hygiene to reduce bacteria, and use of topical fluorides
to inhibit microbiologic activity, retard demineralization, and promote remineralization o( the outermost
312
PART V
RADIOGRAPHIC
INTERPRETATION
OF PATHOLOGY
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
A
parts of the lesion. This may be successfulif the surface
of the tooth is intact and a follow-up radiograph shows
no progression of the lesion. However,when the surface
of a lesion is cavitated or follow-up radiographs reveal
progression of the lesipn, a restoration is required.
Cavitated carious lesions require removal of the
infected tissues and restoration of the tooth to form
and function.
HIHLIUClRAI.lHY
American Uental ~ducation AssocIation: NtH L;onsensus
Development Conference on Diagnosis and Management
of Dental Caries Throughout Life, J Dent Educ 65,
2001.
MandellD: Caries prevention: current strategies, new directions,JAm Dent Assoc 127:1477,1996.
Newbrun E: Cariology, ed 3, Baltimore, 1989, Williams &
Wilkins.
'lanzer JM: Understanding dental caries: an infectious
disease,not a lesion, Int] Oral BioI 22:205, 1997.
Thylstrup A, Fejerskov0: Textbook of Clinical Cariology, ed
2, Copenhagen, 1994, Munksgaard.
RADIOGRAPHIC CARIES DETECTION
De Araujo F et al: Diagnosis of approximal caries: radiographic versus clinical examination using tooth separation, Am] Dent 5:245,1992.
Hintze H, Wenzel A: A two-film versus a four-film bite-wing
examination for caries diagnosis in adults, Caries Res
33:380, 1999.
Hintze H, Wenzel A, Danielsen B: Behayiour ofapproximal
carious lesions assessedby clinical ex!llIlination after tooth
separation and radiography: a 2.5-yearlongitudinal study in
young adults, Caries Res 33:415, 1999.
Mejare I, Kallestal C, Stenlund H: Incidence and progression
of approximal caries from 1 I to 22 years of age in Sweden:
a prospective radiographic study,Caries Res 33:93, 1999.
Mjor lA, Toffenetti F: Secondary caries: a literature review
with casereports, Quintessence Int 31:165,2000.
CHAPTER 16
313
DENTAL CARIES
Simpo PDF Merge and Split Unregistered Version - http://www.simpopdf.com
Nielsen LL, Hoernoe M; Wenzel A: Radiographic detection
of cavitation in approximal surfaces of primary teeth using
a digital storage phosphor systemand conventional film,
and the relationship between cavitation and radiographic
lesion depth: an in vitro study, Int] Paediatr Dent 6:167,
1996.
Nyvad B, Fejerskov0: Assessingthe stage of caries lesion ac~v::
ity on the basisof clinical and microbiological examination,
Comm Dent Oral Epidemiol 25:69, 1997.
Petersson GH, Bratthall D: The caries decline: a review of
reviews,Eur] Oral Sci 104:436, 1996.
Qvist V, Johannesen L, Bruun M: Progre~sion of approximal
caries in relatio"nto iatrogenic preparation damage,] Dent
Res 71:1370,1992.
Ratledge DK, Kidd EAM, Beighton D: A clinical and microbiological study of approximal carious 1esions. Part 1: the
relationship between cavitation, radiographic lesion depth,
the site specific gingival index and the level of infection of
the dentine, Caries Res 35:3, 2001.
Wenzel A, Pitts N, Verdonschot EM, Kalsbeek H: Developments in radiographic caries diagnosis,] Dent 21:131,1993.
Wenzel A: Current trends in radiographic caries imaging,
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:527,
1995.
Wenzel A: Digital radiography and caries diagnosis, Dentomaxillofac Radiol 27:3, 1998.
Wenzel A, Anthonisen PN, ]uul MB: Reproducibility in the
assessment of caries lesion behaviour: a comparison
between conventional film and subtraction radiography,
Caries Res 34:214,2000.
White SC,Yoon DC: Comparative performance of digital and
conventional images for detecting proximal surface caries,
Dentomaxillofac Radiol 26:32, 1997.
TREATMENT DECISIONS
Bader ]D, Shugars DA: What do we know about how dentists
make caries-related treatment decisions?Comm Dent Oral
Epidemiol 25:97, 1997.
de Vries H et al: Radiographic versus clinical diagnosis of
approximal carious lesions, Caries Res 24:364, 1990.
Kidd EAM, Pitts NB: A reappraisal of the value of the bitewing radiograph in the diagnosis of posterior proximal
caries, Br Dent] 1689:195,1990.
Pitts NB: The use of bitewing radiographs in the management
of dental caries: scientific and practical considerations,
Dentomaxillofac Radiol 25:5, 1996.
Pitts NB: Diagnostic tools and measurements-cimpact on
appropriate care, Comm Dent Oral Epidemiol 25:24,
1997.
Verdonschot EH et al: Developments in caries diagnosis and
their relationship to treatment decisions and quality of
care, Caries Res 33:32, 1999.
Woodward GL, Leake ]L: The use of dental radiographs to
estimate the probability of cavitation of carious interproximal lesions. Part I: evidence from the literature,] Can Dent
Assoc 62:731, 1996.