Introducing Diagnodent published in The Grapevine Jan 1999 by Dipak Joshi

Practitioners I suspect, have always been aware, but somewhat detached, to the possibility of “hidden carries” lesions in our patients. A sudden traumatic encounter with a collapsed occlusal surface of a permanent first molar prompted our practice to review our diagnostic procedures. We started using the Diagnodent in the summer of this year and since then there has been a significant change in our approach to the treatment of children. We have had to purchase a new range of materials. This article summarises the changes that resulted from the introduction of Diagnodent into our general practice.

Examination
After a little initial practice, we found the Diagnodent easy and very quick to use. After drying the teeth and explaining the “new toy” to both the parents and patients, we were able to scan the fissure patterns quickly. We were amazed at the number of positive readings that we encountered. (I would estimate that the detection rate of Diagnodent was over double the normal scoring). Initially we would cross check the readings by displaying the tooth on the intraoral camera. Only then, at x40 magnification, a characteristic “halo” of decalcified enamel around a stained fissure, was quite often revealed.

Charting
Since it is quite common to find more than one lesion within a single fissure pattern, it soon became apparent that we would need to change our charting method. We now note both the numerical value and the precise location within each tooth’s fissure pattern. The system has been shown to generate a quantitatively reproducible measurement and can detect undermining caries up to a depth of 1mm. Because the Diagnodent can detect early lesions and the readings are reproducible, the following options for treatment are possible.

Treatment
With experience it is possible to guage the depth of the problem (no pun intended) from the numerical scale. KaVo are producing guidelines based on these numeric values.
From 00 to 20 probably very early enamel decalcification present (just visible with the magnification of an intraoral camera, at the high numbers).

Treatment regimes would be concentrated on preventive therapy, to include oral hygiene dietary instruction and the use of fluoride-based mouth rinse gels and, recently introduced foams to encourage re-mineralisation. It is now possible to monitor the lesions, as the mearsurement is reproducible. This significant advance removes the guesswork and allows us to apply preventive therapy with a degree of confidence and a considerable reduction of risk.

From 20 to 40 enamel lesions are probably sufficiently advanced to warrant minimal invasive treatment i.e. micropreparations using “sealant restorations”. We use “Ultraseal”, Optident Ltd. Their well-designed application system is particularly suited for this type of treatment. The other materials include Fuji II LC Glass lonomer and “Revolution” flowable composite with “Optibond FL” from SDS-Kerr. As these lesions are often located in the enamel only, treatment can be provided without the use of a local anaesthetic. A fact appreciated by both the child patient and their dentist! Sometimes, a much greater dentinal spread is present.

A check radiograph is advised. I must stress that these are personal observations. However, I am encouraged to note that KaVo is currently working on a clinical guideline for distribution. They also intend to support the practitioners by designing and producing supporting literature for patients.

The other clinical uses are:

• Checking teeth prior to fissure sealing
  
  
• Hypocalcific spots that mimic decalcification present in early carious lesions, can be differentiated
  
  
• Checking at risk areas e.g. palatal fissures of upper anterior teeth

Diagnodent is however not without it’s limitations. False positive readings do occur. Fissures that are filled with calculus and stained, as well as “fissure sealed” teeth can register positively. It is therefore important to check all readings. This is probably its most limiting factor for adult use.

Conclusion
Diagnodent is poised to change the way early occlusal caries is detected and managed. Our previous best just got better. A change that may herald a new chapter in modern preventive treatment.