Hide and Seek

In support of minimally invasive dentistry, new technologies and other strategies that can facilitate early diagnoses have never been more important. We zero in on ways your clients can intercept little problems before they become big ones.

The cause of dental pain is not always obvious during an exam. Its source may not show up in X-rays, and sometimes not even the patient can pinpoint it. To complicate matters further, tooth pain can stem from myriad conditions, ranging from endodontic issues and sinusitis to bruxism and caries. For this reason, dentists should know about the latest in dental screening and detection devices to help find the culprit and areas of concern.

Trouble brewing may be signaled by sudden, sharp or dull, throbbing, lingering pain. Triggers can include exposure to hot and/or cold, sweets, pressure and percussion. On the other hand, a tooth may become compromised, but lack any real pain. There is also the possibility that pain is being transferred from one area to another.

With so many possible sources of dental discomfort, you don’t need to be a member of Mensa to see the challenges involved in the tooth pain detection game. But, armed with seasoned know-how, and the latest in digital screening and detection devices, clinicians have a better shot than ever at solving these kinds of dental whodunits.


LEXICON

D1/D2; E2/D1 lesions: The American Dental Association Caries Classification System’s designation of a mild to moderate cavitation involving dentin; and the designation of the earliest detectable lesion with mild demineralization involving enamel and dentin.
Incipient decay: Early-stage carious lesions.
Interproximal: Surfaces between teeth.
Periodontium: Supporting tissues that surround a tooth.
Sjögren syndrome: An autoimmune disease that can cause dry mouth.


STRATEGIES TO FIND SOURCE OF PAIN

So what are the best strategies to determine the cause of tooth pain when there is no clear etiology? “When someone has tooth pain we go back to diagnostic basics to determine the cause,” explains Hewlett, New York-based practitioner and educator Ron Kaminer, DDS. “Listening to the patients’ chief complaint is always the initial step, typically followed by a radiograph. Palpating and percussing the area of concern can determine if there is an endodontic problem. Temperature testing, using heat and cold, can also help give us some indication of where and what kind of pain the patient is in.”

Albany, Oregon-based practitioner V. Kim Kutsch, DMD, a recognized expert in caries prevention and minimally invasive dentistry, adds, “I think we too often look for the usual cause of tooth pain, get focused on that and don’t really hear what our patients are telling us. Is the pain part of the normal dentin-pulp complex or periodontium, or is it caused by localized nondental-related factors such as maxillary sinusitis, or related to systemic factors like diabetic nerve pain, or angina? Can it be caused by medications, dry mouth or Sjögren syndrome? There are many nonobvious causes of tooth pain. These can each be tested individually and ruled out, but nothing replaces a good interview about the symptoms. An experienced clinician years ago told me that if I listened carefully enough to my patients they would tell me what is wrong with them. That’s been really great advice.”

Marty Jablow, DMD, who practices general dentistry in Woodbridge, New Jersey, lectures and writes prolifically about dental technologies agrees with his colleagues that clinicians can’t simply rely on technology. “But,” he advises, “you need to use everything at your disposal, including radiography, white light with magnification and transillumination with and without fluorescence.”

TECHNOLOGICAL AIDS

Of the various types of radiographies available, cone beam computed tomography (CBCT), basically a smaller version of the CT scan, offers perhaps the most comprehensive view of dental structures in that images are rendered in three dimension (3D). Many clinicians say that their diagnostic efforts have been enhanced by the use of CBCT.

“When we talk about detection and diagnostics what we are really talking about is seeing better,” says Kaminer. “When we can see better, we can diagnose quicker, earlier and easier. CBCTs allow the dentist to see issues such as endodontic problems in 3D, allowing for better diagnostics.”

In addition to CBCT, other kinds of radiography, and the obvious benefits of using good lighting and magnification, transillumination allows clinicians to actually see inside a tooth — without radiation. In fact, Jablow notes that the ability to actually see caries with transillumination may lead to more accurate detection and diagnosis of incipient interproximal caries lesions than the use of radiography.

Transillumination involves the shining of a light through the tooth. The light will travel through healthy dental structure until it encounters a variation such as a crack or carious tissue. At that point those tissues will appear darker as they don’t transmit as much light as healthy tissue.


LATEST THINKING ON ORAL CANCER DETECTION TECHNOLOGIES

The Oral Cancer Foundation estimates that nearly 50,000 Americans will receive their first diagnosis of oral or oropharyngeal cancer this year, with just 57% surviving five years.2 The alarming death rate associated with these cancers is said to be high due to late diagnosis. Though it is not particularly difficult to discover and diagnose in a screening, oral cancer is frequently symptomless until it is in advanced stages.2

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Dentists are typically on the front lines of screening for oral/oropharyngeal cancer, and routine screenings have become the standard of care in American dental offices.

But while emphasis was placed on the use of several detection aids a few years ago, including light-based fluorescence and reflective technologies, toluidine blue staining, and brush cytology, inconclusive evidence on their efficacy and the risk of false positives have led clinicians to emphasize the traditional gathering of patient history along with visual and tactile inspection of the head and neck, and facial and oral structures.3

And while clinicians seem to be in agreement on the importance of using traditional methods, many, nonetheless, continue to value, as adjuncts, the use of anything that ups the odds of finding anything that might be suspicious.

“Nothing substitutes for clinical knowledge and the ability to see,‘‘ says Ron Kaminer, DDS, who practices in Hewlett, New York. “But oral cancer detection devices assist us in our diagnostics by using fluorescence to help illuminate potential areas of concern.‘‘

Kaminer notes that newer testing, using salivary markers may also be in process, and that brush biopsy and smear cytology may be helpful as well. He stresses, however, that adjuncts should be used as extra measures, not for definitive diagnostics.

Marty Jablow, DMD, who practices in Woodbridge, New Jersey, concurs. “You still need to do a good white light exam, but fluorescence adds another degree of looking a second time,‘‘ he says, predicting that genetic testing will be the way of the future, though it needs to become more cost effective.

Likewise, Albany, Oregon-based practitioner V. Kim Kutsch, DMD, says that in addition to visual and tactile exams, he’s been using a fluorescence-based device for years. Says Kutsch, “These new technologies should help us improve early diagnosis, which should provide better outcomes from treatment and survival rates.‘‘

“In the end it is up to the knowledge and judgment of the examiner to decide whether to biopsy something or not,‘‘ says Kaminer. “Early detection is critical because it can be the difference between someone surviving or not from oral cancer.‘‘


A variety of transilluminators are commercially available. Some use fiber optic (FOTI) or digital fiber optic (DIFOTI) lights for transillumination, while others rely on infrared light or fluorescence. As an added bonus, digital devices are commonly paired with cameras, which allow real-time viewing of the process on a monitor. In fact, such combinations are being seen as potential revenue enhancers as they offer one device that does the work of two or more devices.

Says Kaminer, “Transillumination ultimately is another form of seeing better. If we can see better in between teeth we can diagnose better. We have technology out there today that acts as electronic transillumination, and we can snap images and store them in our patients’ records. We can also do it the old fashioned way with a small transillumination light that we can shine in between teeth to see incipient decay.”

But, while Kutsch agrees on the benefits of technologies such as transillumination, which, he says, is very good at identifying cracks in the enamel and activity beneath the enamel, particularly in interproximal sites, he cautions that because of its efficacy in identifying changes in hard tissue, the challenge then becomes deciding on when to treat.

For instance, Kutsch explains, “We now know that an interproximal lesion that demonstrates penetration radiographically as an E2/D1 lesion most of the time does not have surface cavitation. This means that it can be remineralized instead of restored. So the technologies may lead to some invasive overtreatment unless the dentist understands the science. Depending on the patient’s individual caries risk assessment, a dentist should decide to restore the lesion somewhere between the D1/D2 stage, when there is cavitation and the lesion is still progressing after attempts at remineralization have failed.”


POINT OF SALE | DIAGNOSTIC AIDS

  • A number of adjunctive devices can help clinician arrive at accurate diagnoses after a patient history has been gathered.
  • Cone beam computed tomography is seen as an important player in detection of oral disease, and as costs drop may become available to more dental offices.
  • Electronic pulp testing devices can help to ascertain pulp sensibility, though other up and coming measures that measure things like blood flow and oxygen saturation may prove more reliable.
  • Transillumination devices can help to secure accurate diagnoses without radiation, and are increasingly available in configurations that allow them to double as intraoral cameras, curing lights, oral cancer screening devices and more.
  • Oral cancer screening devices, though strictly used as diagnostic adjuncts, are nonetheless still seen by many clinicians as important aids in oral cancer mitigation.

ADDITIONAL DIAGNOSTIC MEASURES

Other kinds of light-based technologies — some currently available and some still in the testing stages — offer avenues toward early diagnosis. With fluorescence technologies, tooth structure is exposed to certain wavelengths via blue LEDs or laser light. This will differentiate healthy tissue from carious tissue through fluorescence characteristics.

For evaluating pulp vitality, electronic pulp testers (EPT) can be used to check the sensibility of teeth via a mild electrical current. A nonpainful sensory response would indicate that the tooth is still vital. The problem with this is that an injured tooth may temporarily lack sensibility. So a lack of response to stimuli might lead to a misdiagnosis.

Because of this, other methods may prove more reliable. One, laser doppler flowmetry (LDF), measures blood flow noninvasively, using a diode laser light transmitted by a fiber optic probe. It has shown reliability in assessing both pulpal and gingival circulation. And its noninvasive nature would make it a boon to pediatric dentistry in particular. However, opinions are divided on the use of LDF in dental applications due to technique and environmental sensitivity.

Pulse oximetry is a noninvasive way of measuring oxygen saturation in blood. Widely used in medical settings, it is potentially useful in the field of endodontics for evaluating pulp vitality by measuring the vascular blood perfusion through the use of a diode laser that emits both red and infrared light. The problem is that to date, no suitable sensor has yet become commercially available for dental applications.

MOVING FORWARD

Radiologcially speaking, for viewing dental structures, it doesn’t get much better than a 3D view. Yet, many practices have not been able to afford an in-house CBCT unit. But according to Kaminer, that is changing. “The reduced cost of CBCT machines have made them a staple in more offices,” he notes.

But dropping price points are not the only thing clinicians can anticipate in the diagnostic field. Jablow adds, “The push now is for less radiation, so we are looking at devices that can assist our diagnosis without the potential harmful effects of radiation.”

In fact, optical coherence tomography (OCT) that uses near-infrared light is becoming available in a hand-held scanner that produces radiological-type images sans radiation. Jablow further predicts that genetic screening may ultimately make many dental conditions easier to diagnose. But he admits this technology still has a way to go to.

Kaminer reports the pending release of a new type of dental mirror. “It will allow us to see better in an illuminated field while at the same time magnifying and wirelessly projecting an image onto a screen,” he notes. “This will allow for better and clearer diagnostics in the areas of incipient decay, cracks and other problems that can be seen early on.”

But Kutsch sees diagnostic advances from a different angle. “Technologies typically identify signs of disease once an event has already occurred,” he says. “Our focus on technology perpetuates the paradigm of dental disease being tooth- or tooth-surface based, when in fact dental diseases are person-level diseases. So when I think about screening, detection and diagnosis, certainly the most significant development is CAMBRA, risk assessment-based diagnosis for dental caries.”

CAMBRA, or Caries Management By Risk Assessment, is a methodology designed to identify individual risk factors for developing caries through gathering dental, medical and lifestyle histories. Its aim is to prevent and manage caries in its early stages.1

“Identifying the root cause of the disease gives us the opportunity to help patients mitigate their risk factors and achieve and maintain health,” says Kutsch. “Dental professionals can then target the causes and coach the patient appropriately. This treats dental caries as a person-level disease, rather than a tooth-surface or tooth-level disease.”

New inventions are always on the horizon in diagnostics and detection. Especially in today’s climate of minimally invasive dentistry, the earlier trouble can be headed off, the better chance clinicians — and their patients — have at winning this high stakes game of hide and seek. 

BONUS WEB CONTENT

References

  1. University of California School of Dentistry. CAMBRA: Proven method for preventing and protecting teeth. Available at: dentistry.ucsf.edu/research/cambra. Accessed February 22, 2018.
  2. The Oral Cancer Foundation. Oral Cancer Facts: Rates of occurrence in the United States. Available at: oralcancerfoundation.org/facts/. Accessed February 22, 2018.
  3. American Dental Association. Oral health topics. Available at: ada.org/en/member-center/oral-health-topics/oral-cancer. Accessed February 22, 2018.

Featured Image by SIPHOTOGRAPHY/ISTOCK/GETTY IMAGES PLUS

From MENTOR. April 2018;9(4): 30-34.

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