New Technologies in Caries Diagnosis: The Canary System in Pediatric Practice

NEW TECHNOLOGIES IN

CARIES DIAGNOSIS

The Canary System in

Pediatric Practice

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

A couple of Gifts from the North

• No Commercial Interest or Reimbursement

from Quantum Dental Technologies

• Member of Unpaid Dentist Advisory Panel to

Quantum Dental Technologies

• Some slides provided by QDT

Disclosures

Acknowledgements

• DR. STEPHEN ABRAMS President and CEO of Quantum Dental Technologies • DR. MARIELLE PARISEAU Creator of www.ShapingTheFutureofDentistry.org Note: The current final version of this presentation will be available on the Shaping the Future of Dentistry website later this week. Look in Menu under Resources

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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

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

THE CURRENT REALITY

• Visual Exam • Mirror and Explorer • Dental Radiographs • Transillumination • Dmfs/dmft

Measuring and recording decay

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

Radiographs • Radiographic imaging of pits and fissures is of minimal

diagnostic value because of the large amounts of surrounding enamel .

• Literature review by Dove: • “overall the strength of the evidence for radiographic

methods for the detection of dental caries is poor for all types of lesions on proximal and occlusal surfaces”.

• “it is beneficial only if the intervention is the surgical removal of tooth structure and detrimental if it is used for non-invasive remineralization methods.”

McKnight-Hanes C, Myers DR, Dushku JC, Thompson WO, Durham LC. Radiographic recommendations for the primary dentition: comparison of general dentists and pediatric dentists. Pediatr Dent. 1990 Jul-Aug;12(4):212-216 Flaitz CM, Hicks MJ, Silverston LM. Radiographic, histologic, and electronic comparison of basic mode videoprints with bitewing radiography. Caries Res. 1993; 27(1): 65-70. Lussi A, Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 27:409-16, 1993 Dove,  S.  B.,  “Radiographic  Diagnosis  of  Dental  Caries  in  Consensus  Conference  on  Dental Caries Management Throughout Life, March 2001, Journal of Dental Education, 2001; 65 (10): 985 – 990

NO BIG DEAL

A VERY BIG DEAL

Lower body weight

Psychological impact

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)

A TRANSMISSIBLE BACTERIAL INFECTION

Diagnosis involves recogn i t i on o f t h e s e c h a n g e s rather than simply n o t i n g c a v i t i e s

TOOTH DECAY PREVENTABLE is

BECAUSE FILLINGS

D o n ’ t t r e a t u n d e r l y i n g d i s e a s e

D o n ’ t a d d r e s s p l a q u e b i o f i l m i s s u e s

D o n ’ t c h a n g e r i s k l e v e l

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

• 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

“ 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

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

The Value of Early Detection

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

1. To contain, arrest or remineralize lesions, in

order

2. 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

New Technology Methods For Caries Detection

Fluorescence-based Technology • Diagnodent • Caries ID • Quantitative Light-Induced Fluorescence • Spectra (QLF Technology) Digital Fibreoptic Transillumination (DIFOTI) Electrical Impedance Measurement • Caries Scan

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 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 Characteristics of an Ideal Caries Detection System

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

Therefore, an experimental test aims to achieve 100% sensitivity (no false positives) and 100% specificity (no false negatives)

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

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

THE 9 MONTH STORY 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 Canary in Pediatric Practice –

THE 9 MONTH STORY Lesions evaluated clinically Pit and fissure Interproximal Facial Under sealants ICON Under and around restorations

Pit and Fissure Caries

Pit and Fissure Caries

Pit and Fissure Caries

Pit and Fissure Caries

Interproximal lesions

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 ICDAS # Canary # Permanent Occlusal 2 13-19 3 17-34 4 24-53 Interproximal (Pre-Adjustment) 2 24-26 4 21-29 (Post Adjustment) 3,4 32-40 (small sample size)

Interproximal lesions

The key is to understand what the device is measuring

• Canary number will under report lesion size

• Intervention decisions

remain based on CAMBRA

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

Issues With ICON

• Newer technology with limited in-vivo

data

• Caries development around and within

material unknown

• Longevity of material unknown

• Potentially a very useful material

• How to monitor for early change

Detection Around ICON

Detection Around ICON

Anomalous Lesion

Anomalous Lesion

Characteristics

• No surface breakdown (ICDAS 1 or 2)

• Evident radiographically, often for a year or

longer

• Once  through  enamel  you  “drop”  into  defect

• Lesion tends to be reddish-brown  and  “mushy”

• Does not exhibit typical carious texture

• Suspicion is the histological picture is distinct

from traditional caries picture

Anomalous Lesion

Anomalous Lesion – Preliminary Observations

• Canary does not accurately measure defect • Lesion appears to have a different

pathology and suspected different

histological picture • More information required

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Preliminary Observations on Canary Overall

Occlusal Surface • Highest ease of measurement and

predictability Facial surface • Highest ease of measurement and

predictability Interproximal Permanent Teeth • Significant learning curve • Lesion will be at least as deep as

measurement indicates

Preliminary Observations on Canary (cont’d)

Interproximal Primary Teeth • Greater accuracy of Canary number

compared to permanent teeth Under Sealants • Very good indicator of what lies beneath ICON • Likely good indicator of change with

repeat scans Under and Around Restorations • Good indicator of restoration failure

Orthodontic Treatment – A Unique Opportunity

Facts on Orthodontic-Related Decalcification and

Caries

• Approximately 50% of ortho cases  end  with  “white  

spot  lesions”

• Lesions can commence within 1 month of bracketing

• Braces can preclude bitewing radiographs for 3

years or longer

• Risk-based preventive strategies exist

• Canary System an excellent diagnostic tool

Orthodontic decalcifications and caries

Slide courtesy of Reliance Orthodontics

Orthodontic Treatment – Recommended Canary Protocol

• Collaboration and communication triad established

pre-orthodontics

• Baseline risk assessment

• Baseline bitewing radiographs

• If moderate or high risk then full Canary scan at

baseline

• Rescan of interproximal and facial surfaces at 3-6

months based on risk

• Customized preventive strategy for home, primary

care office and orthodontic office

Dear Dr. Re: Patient Our mutual patient was in recently for regular care. You will recall that he/she demonstrates a higher risk for dental caries. As a result, we have initiated a customized preventive programme for him/her while undergoing the orthodontic care under your supervision. Specific components of this preventive programme include: ___ Higher fluoride toothpaste used at bedtime ___ More frequent dental hygiene visits for scaling, prophylaxis ___ More frequent dental hygiene visits for additional fluoride varnish application ___ Review of home hygiene techniques including use of floss and proxybrush ___ Scanning of at risk sites on teeth with the Canary System The  current  review  of  ________’s  oral  hygiene  and  caries  status  reveals: ___ Oral hygiene is under control ___ Adjustments to the preventive programme are required and involve the following: ___ A rescan of the at risk sites is planned for ___ months We appreciate your collaboration in the oral care for _______. Please contact our office if you have concerns about anything for him/her. Sincerely yours, Ian McConnachie B.Sc., D.D.S., M.S., F.R.C.D.(C )

The Canary: Clinical Indications

• Complementary to bitewing radiographs – may

reduce frequency need

• Monitor of remineralization therapy

• Monitor of margins of existing restorations

• Monitor of pre-cavitated lesions on all surfaces

• Complement to Caries Management by Risk

Assessment

• Part of collaboration triad in orthodontic care

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

The Characteristics of an Ideal Caries Detection System - How Does Canary Rate?

Primary

? - High sensitivity & specificity for caries detection

YES - Detects & monitors de & re-mineralization YES BUT- Detects smooth surface, root surface, occlusal surface & interproximal lesions YES - Detects caries around restoration margins YES - Non-invasive & safe YES BUT - Repeatable measurements

The key is to understand what the device is measuring.

The Characteristics of an Ideal Caries Detection System

Secondary YES - Imaging and or image capture YES - System for recording & storing measurements YES - Patient Education and Motivation YES but More Needed - In-vitro and in-vivo data & publications YES BUT - 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 WORTH CONSIDERING

Is This the Motherlode In Caries Diagnosis?