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Dental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosis 3/29/11 12:27 AM Journal List J Conserv Dent v.12(3); Jul–Sep 2009 J Conserv Dent. 2009 Jul–Sep; 12(3): 87–100. doi: 10.4103/0972-0707.57631. Copyright © Journal of Conservative Dentistry PMCID: PMC2879723 Dental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosis Usha Carounanidy and R Sathyanarayanan1 Department of Dentistry, Pondicherry Institute of Medical Sciences, P
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  3/29/11 12:27 AMDental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosisPage 1 of 16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879723/?tool=pubmed Journal List>J Conserv Dent>v.12(3); Jul–Sep 2009 J Conserv Dent. 2009 Jul–Sep; 12(3): 87–100.doi:10.4103/0972-0707.57631.PMCID: PMC2879723Copyright© Journalof Conservative Dentistry Dental caries: A complete changeover (Part II)-Changeover in the diagnosis andprognosis Usha Carounanidy and R Sathyanarayanan 1 Department of Dentistry, Pondicherry Institute of Medical Sciences, Pondicherry, India 1 Department of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India Address for correspondence: Prof. Usha Carounanidy, 107, Perumal Koil Street, Pondicherry – 605 001, India. E-mail:usha.c.sathya@gmail.comReceived October 14, 2009; Accepted October 14, 2009. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the srcinal work is properly cited. This article has beencited byother articles in PMC. Abstract Realization that dental caries is a reversible, dynamic biochemical event at a micron level has changed the waythe profession recognizes the caries disease and the caries lesion. The diagnosis of dental caries poseschallenges due tothecomplex interaction of multiple endogenous causal factors. The most appropriatediagnostic aid for this purpose is the risk model of caries risk assessment. The analyses of the biologicaldeterminants provide clues to the dominant causal factor. The detection of a carious lesion has undergone arigorous revision and revolution in order to identify the earliest mineral change so that it can be controlledwithout resorting to invasive management options. Apart from detection, it became mandatory to assess theextent of the lesion (noncavitated/cavitated), assess the activity status of the lesion (active/arrested), monitor thelesion progress (progression/regression over a period of time), and finally to predict the prognosis of the lesionas well as the disease. The prognosis of the disease can be best assessed by analyzing the predictor factors incaries risk assessment. The ultimate objective of such a meticulous and methodical approach aids in devising atailor-made treatment plan, using preventing measures precisely and restorative measures minimally. Thisensuresthe best oral health outcome of the patient. Keywords: Active caries, caries activity, cavitated caries, dental caries, detection, diagnosis, inactive caries, noncavitated caries,prediction,prognosis, r isk assessment, sensitivity, specificity INTRODUCTION The preceding part of this series had focused on the changeovers in dental caries definition andetiopathogenesis.[1] They are recapitulated as follows:1. Dental caries is a disease with multiple causal factors, called as determinants and confounders,manifesting itself on the tooth structure as a carious lesion. Such manifestations may range frommicroscopic to macroscopic changes in the tooth.2. The underlying causal process has been attributed to disturbances in two oral homeostases: (a)  3/29/11 12:27 AMDental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosisPage 2 of 16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879723/?tool=pubmed disturbance in the mineral homeostasis between the tooth and the oral fluid and (b) disturbance in themicrobial homeostasis in the biofilm.3. The result is alternate cycles of mineral loss and gain in the hydroxyapatite crystal. These cycles areorchestrated by a set of factors called as the demineralizing factors and the remineralizing factors.With this knowledge in the backdrop, the ensuing text shall unfold the changeovers in dental caries diagnosisand prognosis. DIAGNOSIS OF DENTAL CARIES DIASESE – THEN AND NOW Diagnosis is “the recognition of a disease or a condition by its outward signs and symptoms”.[2] The diagnosticprocess in medical field is called as the hypothetico-deductive process, where data are collected methodically tozoom-in to the particular disease, from a list of differential diagnoses.[3] Devising a treatment to cure the patientfrom the disease and its associated symptoms is the end point of a diagnostic process in medicine.[4]If dental caries is a disease and the lesion is the sign of the disease, then even a dental clinician should followthe same. But in reality, this process of elimination does not take place in the diagnosis of dental caries. Adental clinician is instantly and intuitively aware that certain unique demineralizations and destructions observedon the tooth are tell-tale signs of none other than a dental caries disease. Therefore, diagnosis is rarely aboutfinding out what the patient has but does the tooth have caries.[5]Generally, it is a common practice that on dental examination, if demineralizations or destructions are observed,at whatever stage, they are immediately labeled as “dental caries.” Probably, the labeling may extend a littlefurther, to include the nature and extent of the lesion (e.g., DC class II MO). Once the lesion is labeled, atreatment plan is devised for that lesion (e.g., silver amalgam class II MO). Thus diagnosis and treatment of thedisease shrink down to just labeling and treating the lesion. Due to the absence of important steps such asdifferential diagnosis and diagnosis, probably, the carious lesion takes the center stage eclipsing the importanceof the caries disease. An inevitable query rises with this practice of using the “sixth sense” in caries diagnosis;has the dental profession ever bothered to diagnose and treat dental caries disease? The answer to this can beelucidated by revisiting the dental caries causal process. DENTAL CARIES – PROCESS OR PATHOLOGY? In the presence of the biofilm, every sucrose attack creates an acidic environ in the immediate vicinity of thetooth. This initiates a sequence of random biochemical reactions of mineral loss and mineral gain. As long asthe dynamic equilibrium of the mineral content of the tooth-oral fluid and the microbial content of the biofilm ismaintained, the entire sequence remains within the boundary of a physiological process, where loss and gainare equalized[6] [Figure 1]. Given the fact that the tooth is always cloaked under a blanket of the biofilm, this concept of dental caries being a physiological process is further reinforced. Thus dental caries is also thought tobe a ubiquitous physiological process, ever present in the oral cavity.[7] Figure 1 Illustration depicting the micro biochemical events occurring on the tooth- biofilm interface over time. (a) The mineral loss and gain balanced and lesion not visible (b) The mineral loss andgain not balanced and lesion is visible as white spot[6] However, if the factor disturbing the homeostasis is strong, intense, and long lasting, then the demineralizationpersists and prevails. The mineral loss is now more than the gain, which becomes evident as structural changesin the tooth structure. Along a timeline, this shift in the balance leads to more changes in the tooth structure,  3/29/11 12:27 AMDental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosisPage 3 of 16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879723/?tool=pubmed which cannot be accepted as healthy, but should be considered as pathological. Thus the physiological dentalcaries process becomes a pathological dental caries disease. PROCESS TO PATHOLOGY CONTINUUM - A PROBLEM IN DENTAL CARIES The transformation of dental caries from a physiological process to pathology is not a sudden cross-over, but acontinuum over a period of time, affected by numerous variables. There is a lack of a definite boundary linebetween health and disease. This becomes the raison d'être for the inextricable confusion in the diagnosis of dental caries and even in the detection of its manifestation. The profession is perpetually burdened by thequestion “when is caries, caries.”[8] Extensive research is being spent to pinpoint the starting point of thedisease process and the ending point of the physiological process, but in vain. Different studies choose differentcut-off points in the continuum as a baseline. The criteria used by the epidemiological surveys are different fromthose used in clinical settings. Lucid frame lack in differentiating “sound” or “diseased” tooth results invagueness of diagnosis and confusions in treatment decisions as well. Indecisions such as “to treat or not totreat,” and “to do less or to do more” hover the treatment plan, resulting in either overtreatment or undertreatment. The ultimate objective of an accurate diagnosis is to provide a wholesome treatment, and to err in this objective is indubitably undesirable.Therefore, in order to achieve this goal of best management options for the patients, a shift in disease paradigmhas been suggested.[9] The concept of understanding caries as the disease and lesion as the manifestation isbased on a philosophy called as essentialism. This concept seems to fail in bringing out a definite baseline or gold standard, “caries truth.” It is clearly evident from the above discussion that the lacuna is simply due to acomplex caries process. Nominalism, a philosophy that is directly opposite to essentialism, is beingrecommended as the need of the hour, to circumvent this problem. In the nominalistic concept, the ultimateobjective is to arrive at the best treatment outcome for the patient, not wasting time in finding out the invisibledisease or the indefinable caries truth. According to this concept, the disease name is just a convenient way of labeling a set characteristics defined as the lesion. Here it is implied that “the disease and the signs are thesame; in other words, the disease does not exist; only a causal process exists that results in clinical signs andsymptoms”[10] [Figure 2]. Thus a dental clinician uses a method of pattern recognition through a nonanalytical thinking and match the signs present on the tooth with the previously stored caries scripts.[5] Caries scripts area mental inventory created in the clinician's mind based on the experience of numerous previous presentationsof the carious lesion. The signs contained in the script are usually visual and less frequently tactile. Once aclinician observes a particular sign on the tooth, automatically a mental matching is done with the caries scripts.These scripts are inseparably linked to the treatment. Thus, an intervention ensues immediately. The length andspectrum of this inventory are influenced by the knowledge, experience, and attitude of the clinician, andcontinue to be updated with the changing presentation of carious lesions. Stripped off the scientific details,caries scripts are similar to the data stored in a computer. This concept apparently is no more different fromyesteryear's “labeling” of the lesion. The science of cariology might be making an about turn in the concept of diagnosis, from then to now! Evidence to support his new thinking is much awaited. Figure 2 Illustration depicting a new concept on Dental caries (a) Essentialistic concept: The causesresult in a disease that manifest as signs and symptoms. (b) Nominalistic concept: The diseasename is no more than a label given to certain characteristics of (more ...) However, diagnosis has another meaning: “the analysis of the underlying physiological/biochemical cause(s) of adisease or condition.”[2] Instead of asking when and where a process ends and a disease starts, or asking if itis possible to identify such a line of control, it might be prudent as well as imperative to ask why the disease  3/29/11 12:27 AMDental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosisPage 4 of 16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879723/?tool=pubmed started. Simply stated, identifying the cause for such a pathological shift is also a part of the diagnostic processof a complex disease like dental caries. Generally, once the cause is identified, the treatment includes a strategyfor its elimination. However, dental caries is a product of interaction of multiple causative factors that are notexogenous, but endogenous, so it is not possible to eliminate them in a true sense. Nevertheless, any or all of these endogenous factors can gain a pathogenic status due to differing reasons. They can exert an unfavorableeffect on the oral homeostasis, thus tipping the balance toward disease. If such factor/s can be identified andrectified, not eliminated, then the caries machinery can be shifted to the reverse gear, from pathology tophysiology. This particular dimension of the diagnostic process in dental caries is best accomplished by cariesrisk assessment (CRA). Caries risk assessment Risk assessment primarily intends to identify the individuals who are prone to the disease. But caries riskassessment can be comprehended as two models, namely, risk model and prediction model. A risk modelidentifies one or more causative factors of the dental caries disease. The prediction model identifies the patientwho is at high risk for the disease. Generally, three approaches have been proposed for risk assessment, suchas past caries experience, socioeconomic factors, and biological factors. The past caries experience and thesocioeconomic factors form part of the predictor model and the biological factors, such as diet, saliva, and themicrobes, are used both in risk and predictor models.[11] In other words, the confounders at the periphery of the causal model are of prognostic value and the determinants in the center are of diagnostic as well asprognostic value.In the following text, only the risk model associated with diagnosis will be discussed. The predictor model of CRA will be dealt under the section of prognosis of dental caries. CRA: The diagnostic aspect The causal factors, in the Key's circle, are depicted in the form of four intersecting circles of a uniformdimension. At a glance, it might be interpreted that all the four factors have to be of equal strength and severityto cause dental caries, which is not true always. Assuming that all the causal parameters are responsible for theprecipitation of the disease and then developing a treatment strategy that is all-inclusive is obviously a waste of resource. If two caries-inducing factors have different magnitudes, the end product is the same, i.e., dentalcaries. For instance 2 sucrose factors × 10 microbial factors = 10 sucrose factor  × 2 microbial factors = dentalcaries.[12] The pathogenicity of even an isolated factor can tip the balance toward disease. For instance, in athick, long-standing biofilm (a poor oral hygiene), acidity is retained for a long time, as the buffering capacity of the oral fluid might not be able to diffuse through such tenacity. In the same way, a sucrose attack that ispersistent (a sweet tooth!) does not provide enough time for effective buffering. Once such dominant factor(s) isspotted through risk analysis, then a treatment plan can be tailor-made specifically, targeting the specific cause.Such a target-oriented treatment plan optimizes the patient compliance and his or her health outcome, with well-spent resources. In a situation where the biofilm factor is dominant, there oral hygiene measures take the toppriority in the treatment strategy and in the situation where the sugar factor is dominant, and then the dietarycounseling is the main frame of action. The other preventive measures trail as secondary strategies.The robust literature is available on the methodology for CRA.[13 –17] The data that are obtained through risk assessment can be qualitative or quantitative. The qualitative data are obtained from history, clinicalexamination, and dietary analysis, whereas the quantitative data are obtained from the salivary and the microbialanalysis. Most of the details obtained from history and clinical examination relate to the status and prognosis of caries. Therefore only the dietary, salivary, and microbial analyses that are essential for the diagnostic processshall be dealt here.Dietary analysis is the most subjective of all, as it involves patients' attitude, motivation, cooperation, and
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