new technologies in caries diagnosis: the canary...

NEW TECHNOLOGIES IN CARIES

DIAGNOSIS

The Canary System in

Pediatric Practice

Dr. Ian McConnachie AAPD Annual Session May 24-27, 2012

New Technologies in Caries Diagnosis

• Diagnodent by Kavo • Caries ID by Dentsply • Spectra by Air Techniques • CarieScan by CarieScan Ltd • The Canary System by Quantum Dental

Technologies

A Micro Review of Cariology

Measuring and Recording Decay - The Current Reality

The Shift in Dealing with Decay

Newer Technologies Detecting Decay

The Canary System

Use of the Canary in Pediatric Dentistry – The 9 Month Story

Canary-Ready for Prime Time?

Outline of the presentation

• No Commercial Interest or Reimbursement from Quantum Dental Technologies

• Member of Unpaid Dentist Advisory Panel to Quantum Dental Technologies

Disclosures

Physical Changes and interactions with the Biofilm

A micro review of cariology

Caries Progression

Early Carious Lesion in Enamel

ENAMEL SALIVA PLAQUE PLAQUE

Pathogenesis of Dental Caries (biological balances)

SUGARS

Polysaccharides

Bacterial Enzymes

Salivary buffers

Plaque buffers

Calcium Salts

Calcium Salts

ACID

mouth inside of tooth

Demineralization Re-mineralization

ENAMEL

• Visual Exam

• Mirror and Explorer

• Dental Radiographs

• Transillumination

• Dmfs/dmft

Measuring and recording decay – the current reality

Methods for Caries Detection

Conventional methods

• Visual examination: + non-destructive + safe - poor resolution - unable to detect incipient demineralization - unable to detect subsurface caries

• X-rays: + non-destructive + can detect subsurface caries - limited safety - unable to detect incipient demineralization - low resolution

Public Perception

In other words – NO BIG DEAL

Our Reality

A VERY BIG DEAL

Lower body weight

Psychological impact

TOOTH DECAY is PREVENTABLE

• Don’t treat underlying disease

• Don’t address plaque biofilm issues

• Don’t change risk level

We need to from a surgical approach to a RISK management & preventive

approach.

Caries is a transmissible bacterial infection and a multifactorial disease that reflects

change in one or more significant factors in the total oral environment. (NIH Consensus Conference 2001)

D i a g n o s i s i n v o l v e s r e c o g n i t i o n o f t h e s e c h a n g e s rather than simply no t i ng cav i t i es

• Growing awareness of social determinants

• Newer recording of caries levels-ICDAS

• Risk-based care

• A myriad of new products

• New diagnostic devices

The shift in dealing with decay

Copyright ©2007 American Academy of Pediatrics

Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520

FIGURE 1 Child, family, and community influences on oral health outcomes of children

“ It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be” Isaac Asimov

UNDERLYING DARK

SHADOW +/-

SURFACE INTEGRITY

LOSS

Score 4

Score 5

DISTINCT CAVITY

WITH VISIBLE

DENTINE

EXTENSIVE DISTINCT CAVITY

WITH VISIBLE

DENTINE

Score 6

OPACITY Distinct Visible Change

without air-

drying: WHITE, BROWN

Score 2

Score 0

LOCALISED ENAMEL

BREAKDOWN

SURFACE INTEGRITY

LOSS

Score 3

OPACITY First Visible

Change

only after airdrying: WHITE, BROWN

Score 1

SOUND ICDAS-II detection criteria, 2005

Enamel Caries Dentin Caries

UNDERLYING DARK

SHADOW +/-

SURFACE INTEGRITY

LOSS

Score 4

Score 5

DISTINCT CAVITY

WITH VISIBLE

DENTINE

EXTENSIVE DISTINCT CAVITY

WITH VISIBLE

DENTINE

Score 6

OPACITY Distinct Visible Change

without air-

drying: WHITE, BROWN

Score 2

Score 0

LOCALISED ENAMEL

BREAKDOWN

SURFACE INTEGRITY

LOSS

Score 3

OPACITY First Visible

Change

only after airdrying: WHITE, BROWN

Score 1

SOUND ICDAS-II detection criteria, 2005

ICDAS II (International Caries Detection & Assessment System) scores Enamel Caries Dentin Caries

Product Decisions?

Fluoride CPP-ACP (Recaldent) NovaMin ProArgin Xylitol products Antibacterial rinses Salivary products Neutralizing agents Silver Diamine Fluoride Povidone Iodine CHX varnish (Prevora) Sealants ICON

• RISK Demand? • Age and Ability? • Buffering? • Fluoride Uptake? • Contact time needed? • Desensitization? • Antibacterial Activity? • Salivary Stimulant? • Compliance?

Newer technologies detecting decay

1. isis the ability to control the disease process in order

2. to contain, arrest, or remineralize lesions in order

3. to avoid or delay the burdens and costs associated with a spiral of restoration and re-restoration

4. s the ability to control the disease process in order

5. to contain, arrest, or remineralize lesions in order

6. to avoid or delay the burdens and costs associated with a spiral of restoration and re-restoration

• If the lesion is left to extend until a filling is needed, the clinical opportunity for effective prevention is lost

The Value of early detection:

1. Is the ability to control the disease process in order 2. To contain, arrest or remineralize lesions, in order 3.

The Value of Early Detection

1. Is the ability to control the disease process in order 2. To contain, arrest or remineralize lesions, in order 3. To avoid or delay the burdens or costs associated with a spiral of restoration and re-restoration If a lesion is left to extend until a filling is needed, the clinical opportunity for effective prevention is lost

Page 25

Methods for Caries Detection Fluorescence-based methods

• DIAGNODent (Kavo Danaher): detects fluorescence light emitted by porphyrins present in carious tissue following absorption of laser light + non-invasive - low resolution - risk of false diagnosis (porphyrins are present in stained healthy enamel, and not in the primary bacteria that cause tooth decay) - unable to quantify the level of demineralization •Caries ID (MidWest Dentsply) •Detection similar to DIAGNODent –Looks at fluorescence and reflection +Not repeatable –Low resolution

Methods for Caries Detection Fluorescence-based methods

• Quantitative Light-Induced Fluorescence (QLF):

+ non-invasive + quantifies mineral gain & loss + repeatable measurements - low resolution - expensive - unable to quantify lesion depth - unable to detect interproximal lesions

Spectra QLF based Technology •May be issues with accuracy and sensitivity of the technology •Software may not be as accurate •Camera may not capture pixels as accurately •Need more clinical information including comparison to original QLF

Methods for Caries Detection

Methods of Caries Detection DIFOTI (Digital Fibreoptic

Transillumination) + non-invasive - Low resolution - Tooth decay scatters & absorbs

more light than healthy tissue. + DIFOTI is 2x, more sensitive than bite-

wing radiography for detection of decay * (Caries Research, 1997)

Methods of Caries Detection Caries Scan (Electrical Impedance

Measurement) Tooth decay delays or changes the conduction

of an electric current. - Only detects surface defects +Repeatable +Non-invasive - May be able to monitor and quantify mineral

loss - Can not detect caries at restoration margins - Low resolution

The Characteristics of an Ideal Caries Detection System

Primary - High sensitivity & specificity for caries detection - Detects & monitors de & re-mineralization - Detects smooth surface, root surface, occlusal surface & interproximal lesions - Detects caries around restoration margins - Non-invasive & safe - Repeatable measurements

The key is to understand what the device is measuring.

The Characteristics of an Ideal Caries Detection System

Secondary - Imaging and or image capture - System for recording & storing measurements - Patient Education and Motivation - In-vitro and in-vivo data & publications - Minimal or no preparation of the tooth surface prior to taking a reading - Ability to detect and monitor erosion lesions

The key is to understand what the device is measuring.

Sensitivity and Specificity

Sensitivity • The proportion of true positives correctly identified

by the test Specificity • The proportion of true negatives correctly identified

by the test Because these are proportions, can calculate confidence intervals Closer the C.I. is to 1.0 the better

The Canary System

by Quantum Dental Technologies

Canary interactive software and printed patient reports

The Canary Console

Science Behind The Canary System

•Pulses of laser light hit the tooth surface.

•Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).

•PTR can provide a depth profile by varying the frequency of the laser beam.

Temperature increase < 1oC not harmful

•Detected signals reflect the tooth’s condition.

•Detects 50 micron lesion up to 5 mm below the surface.

What it is - Screenshot

Odontogram

Menu Options

Canary Number

Camera Image

Caries Mapping

Canary Number

Camera Image with

Grid

38

Canary Scale

Canary Patient Report

• Customized patient report on dental practice letterhead

• Clear simple indication of problem areas

• Patient can track their progress

• Engages patient in their oral health care

Internet Connectivity

• The Canary System equipped with wireless connect to

the ‘Canary Cloud’. • Benefits for internet connectivity include:

– Back-up and storage of data – Seamless software updates – Data and risk analysis for report generation – Online access of patient reports via Canary Web Portal – Access to data even when the system is being serviced or

upgraded – Enables dentists to access all patient data among all dental

operatories – HIPPA and PIPEDA Compliant

Value Proposition

Value to the Dentist

• Attract new patients: with state of the art technology and a minimally invasive approach

• More patient visits: more frequent visits for patients enrolled in remineralization programs

• Reduce costs: scans can be performed by lower cost staff (hygienists, assistants)

• Affordable: flexible leasing options provide immediate profitability

Value to Patients & Insurers

• Reduce costly & painful restorations

Healthy Tooth

Early Enamel Decay

Advanced Enamel Decay

Demineralization

The Life Cycle of Tooth Decay

Remineralization

Remineralization Therapies The Canary System Scan X-Ray, Drill Fill & BIll

• Between teeth (interproximal areas)

• Around the edges of fillings

• Enamel and root surfaces

Canary detects small lesions from 50 microns in depth and up to 5 mm below the tooth surface.

• Biting Surfaces (occlusal pits and fissures)

Caries Detection on ALL Surfaces

Sensitivity and Specificity

Sensitivity • Overall measurement in vitro 97% Specificity • Overall measurement In vitro 82%

*Bench study Dr. B Amaechi UTSA

Integrating into Dental Practice

• Scanning done by lower cost staff (dental assistant)

• Applying remineralizing therapies

• Return for repeat monitoring of suspect lesions

• Good practice management tool

Our questions at the start

• How easy to measure

• How reproducible

• How accurate

• Canary Scale 21-70

• Specificity and Sensitivity

The canary in pediatric practice – the 9 month story

The canary in pediatric practice – the 9 month story

Issues at Outset

• How easy to learn

• How reproducible the numbers

• Canary Scale 21-70

• Sensitivity and specificity

Houston, We Had a Problem

Range of Measurements Verified by Treatment

Surface Canary # ICDAS #

Facial

Occlusal

Interproximal

Pit and Fissure Caries

Pit and Fissure Caries

Pit and Fissure Caries

Pit and Fissure Caries

Detecting Caries under a sealant

Detecting Caries under a sealant

Detecting Caries under a sealant

Lab study on extracted teeth comparing Canary and Diagnodent Sensitivity • Canary 0.83 • Diagnodent 0.64 Specificity • Canary 0.79 • Diagnodent 0.46

• ORCA Abstract from QDT 2012

Detection Around ICON

Detection Around ICON

Anomalous Lesion

Anomalous Lesion

The Canary – ready for prime time?

The Characteristics of an Ideal Caries Detection System

Primary - High sensitivity & specificity for caries detection - Detects & monitors de & re-mineralization - Detects smooth surface, root surface, occlusal surface & interproximal lesions - Detects caries around restoration margins - Non-invasive & safe - Repeatable measurements

The key is to understand what the device is measuring.

The Characteristics of an Ideal Caries Detection System

Secondary - Imaging and or image capture - System for recording & storing measurements - Patient Education and Motivation - In-vitro and in-vivo data & publications - Minimal or no preparation of the tooth surface prior to taking a reading - Ability to detect and monitor erosion lesions

The key is to understand what the device is measuring.

MAYBE – BUT DEFINITELY THE BEST YET

Is This the Motherlode In Caries Diagnosis?

Integration into Clinical Practice

Office Integration Recall or Specific Exam •Identify White Spots •ICDAS or Measure •Risk Assessment •Apply Remineralization Therapy •Oral Hygiene Instruction •Provide Home-based Therapy

Reassess 3 Months •Assess lesion •ICDAS or Measure •Apply Remineralization therapy •Dispense Home-based therapy

Reassess 6 Months •Assess Lesion •ICDAS or Measure •Apply Remineralization Therapy •Dispense Home-Based Therapy

Summary

• Healing Dental Caries – the medical model for management of dental caries

• Dental Caries is reversible • Watch & Wait is really supervised neglect • Remineralization Therapy does work but you need

the following elements: – Ability to detect, monitor and record lesions – Office Therapy – Home Therapy – Patient Engagement

• An Additional Group of Services provided by Hygienists or Dental Assistants