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what is diagnosis?
- ID disease from signs & symptoms
- 1. recognize SS
- 2. Hx, Phys
- 3. Diff Diag
- 4. Hypothesis
- 5. Diagnostic tests
- 6. Diagnosis
- 7. Treatment
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What is the protocol for caries diagnosis?
- 1. Detect lesions: differentiate caries-free v caries-affected
- 2. Factor RISK
- 3. Determine caries management options
- * avoid unjustified (overtreatment)
- * classifying carious lesions corresponding to the best management options for each lesion type
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Which questions should management options consider?
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What is the difference between detection and diagnosis?
detetion is part of diagnosis
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What are the caries lesion classifications?
- cavitated: RESTORATIVE management, form and function, proper OHI, NOT disease mgt
- Non-cavitated: non-restorative (control plaque, diet, Fl, CPP-ACP, monitor), cost concerns of professional application (usually if active)
- active: ongoing mineral loss (professional non-restorative or lesion specific OHI)
- arrested: no active mineral loss: professional intervention not needed
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What does cavitated lesion imply?
- Restorative: form, function, facilitate OH
- NO MGT OF DISEASE
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What are the essentials for proper visual tactile clincal caries assessment?
- light: anterior interproximals, shadows
- DRY, clean
- 3-way syringe: dry
- mirror: retract tissue, reflect light
- sharp explorer: remove plaque with side, assess roughness w/tip & gentle pressure(vibrations), do not EXPLORE STICK(NOT valid detection)
- magnification
- systematic (isolate/dry quadrants)
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Why dry teeth before clinical exam?
- Dry w/ 3 way syringe to increace refractive index between sound and carious enamel
- allows visualization of surface texture
- look for white spots, lines, shadwows beneath enamel
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What are the features of an active non-cavitated lesion?
- white (or yellow)
- opaque, chalky (neon-like)
- Rough texture
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What are the features of an arrested non-cavitated lesion?
- variable color (whitish to black)
- shiny
- smooth texture
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What are the features of an active cavitated lesion?
- soft, leathery
- dull, not shiny
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What are the features of an arrested cavitated lesion?
hard & shiny
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What are differential diagnosis of white enamel lesions?
- caries: arch, banana, kidney-shaped (plaque accululation along present of former FGM)
- fluorosis: symmetric distribution of fine horizontal stiae (perichymatal enamel pattern)
- developmental defect(non Fl): round or oval, clearly defined from adjacent enamel on single teeth
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What are the visual features of mild flurosis?
- white lesions w/ symmetric distribution & fine horizontal striae reflective of perichymatal enamel pattern
- perikyma: pits around the long prisms of tooth enamel. They indicate the places where enamel-producing cells used to make contact to neighboring cells and are the result of normal enamel apposition.
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What white lesion is round or oval and usually appears on single teeth?
developmental, non-flouride
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What are the various scores of flourosis?
- TF1: thin, white, opaque lines corresponding to perikymata, may include white areas along cusp tips, incisal edges or marginal ridges
- TF2: more pronounce lines appear as bands
- TF3: entire surface cloudy, white, opaque w accentuated perikymata
- perikymata: pits around the long prisms of tooth enamel. They indicate the places where enamel-producing cells used to make contact to neighboring cells and are the result of normal enamel apposition.
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What is CAMBRA?
Caries Management by Risk Assessment
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What is the 1st step of CAMBRA?
Risk Asessment
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What is PREVTX1?
- caries risk assessment: Preventive Dentistry Consultation Notes
- MBI/PI categories
- OHI
- Fl trays
- Prevention Plan
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What is PREVTX2 of caries risk assesment?
- High Risk categories
- Visible caries/ dentin caries radiograph
- Restorations last 3 yrs
- frequent snaacks
- saliva reducing factors (meds, radiation, systemic)
- visually inadequate saliva
- Appliances
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What is meant by high risk for caries?
- YES” on visible cavitations or dentin in radiograph or on any two of:
- Restorations last 3 yrs
- frequent snaacks
- saliva reducing factors (meds, radiation, systemic)
- visually inadequate saliva
- Appliances
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What is asssesed in PREVTX3?
- Moderate risk & Protective factors
- exposed roots
- dev defects: deep pits/fissures
- interprox lesions, radiolucenies
- enamel white spots/discoloration
- recreational drug use
- Protective: Fl H2O, Fl toothpaste, mouthwash, salivary flow, xylitol (4x/day), CHX
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What is PREVTX4 in GSD?
Treatment recommendations
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What is WREC of CAMBRA?
- Disease Indicators
- White spots
- Restorations <3yrs
- Enamel lesions
- Cavities/dentin
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What is BAD of CAMBRA?
Risk Factors: Bacteria, absent saliva, diet(poor)
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What is SAFE of CAMBRA?
Protective: sealants, antibacterials, Fl, Effective diet
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Steps of CAMBRA?
- Hx & clinical exam
- enter notes
- assign category
- treatment reccomendations
- explain
- instruct (writing)
- provide test results
- reassess in 3-6 months
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CAMBRA low risk clinical guidlines?
- Radio: BW 24-36 months
- Recall: 6-12 month
- Fl:
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What was the 1st caries detection dye?
- fuschin: Fusayama (1972) histologic stain for protein, discovered 2 layers(affected, infected) of carious dentin
- partially carcinogenic: replaced by 1% acid red
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What product replaced fuschin?
1% acid red in propylene glycol or polypropylene glycol
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What is the difference between affected and infected dentin?
- infected w/bacteria, affected by acid
- infected (outer): highly-decalcified, fuschin stainable, irreversibly denatured collagen, unrecalcifiable
- affected (inner): partially-decalcified and recalifiable, no fuschin stain, sound collagen
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What are the features of caries detection dyes?
stain only infected dentin to enhance removal, prevent over-excavation, improve accuracy
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What was the traditional tactile and visual criteria for dentin?
- sound: Rock hard, not discolored
- Low specificity= High FP rate
- often over-removed
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How do CDDs work?
- stain organic matrix (collagen) of less-mineralized dentin(not enamel), more stained, more disease
- don't stain bacteria (NOT RELATED TO PENETRATION OR ELIMINATION)
- must know limitations
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What are the statistical features of CDD?
- Low specificity = high FP
- especially in DEJ, near pulp because higher organic matrix comp
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What are common sites of CDD FP(false positives)?
DEJ, near pulp where more organics(collagen)
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Do CDDs work on enamel?
NO, nonspecific protein, will stain food, pellicle and other organics trapped in pits & fissures
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What is FO Transillumination
- Non ionizing, EARLY caries detection (3D-view) via scattering light principles
- Sound tissue: more light transmission
- Demineralized tissue:more scattering, more absorption
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What does sound tissue do to light?
transmits (no shadows, scattering)
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What do enamel and dentin lesions look like when transilluminated?
- enamel: gray shadow
- dentin: orange-brown or bluish
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What are the stats on FOTI?
- High specificity for both FOTI and BW
- Lower sensitivity for FOTI vs BW
- another study showed high specificity and no sensitivity vs BW
- High Spec = Low FP
- Low sensitivity = misses a lot (High FN)
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How well does FOTI work on occlusal?
better than visual but steep learning curve, low performance w/stains
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What is DIFOTI?
FOTI w/CCD intraoral
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How does DIFOTI perform on proximal lesions?
- Higher sensitivity in detection of early lesions not apparent in conventional radiography
- use of DIFOTI in conjunction with radiographs improves diagnostic accuracy
- NOT for depth
- Adjuntive(not replacement) diagnostic tool
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What are the main strenths of (DI)FOTI?
- EARLY lesions
- visualizing suspicious fissures and confirming enamel or dentin cracks
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How is a crack visuallized with FOTI?
light transmission is blocked at crack planes
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What is fluoresence and how is it used in dentistry?
- phenomenon where absorption of light of a given wavelength by a molecule is followed by
- the emission of light at longer (visible) wavelengths.
- Direct relationship between fluorescence and mineral content (distinguish sound and demineralized enamel)
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What is Quantitative Light-induced Fluorescence(QLF)?
- arc lamp to analyze sound vs demin enamel via 370nm (blue) wavelength
- lesion area(mm2), depth(% fluoresence loss), volume (area*depth)
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What are the stats for QLF?
- good corr btwn % fluoresence loss and lesion depth in vitro (0.85)
- smooth surfaces: sensitivity: .76 specificity .85
- occlusal: sensitivity .68 specificity .7
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What are the QLF advantages?
- early lesion detection & quantification
- storable/tranmittable data
- over time comparisons of remin & preventive tx
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What is laser fluorescence(diagnodent)?
- IR light and has a 655 nm wavelength (red) reades moment(real time)/peak(max)
- probe uses 2-way FO system
- must be used on CLEAN DRY to reduce FP
- rotate & pivot to improve accuracy
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How is diagnodent technique improved?
- CLEAN/DRY (stains/plaque->FP)
- rotate & pivot tip
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What do moment peak values of diagnodent(laser) mean?
- 0-10 sound enamel
- 10-20 outer enamel caries
- 20-30 lower enamel caries
- >30 dentinal caries
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What are the stats for Diagnodent(laser)?
- high sensitivity for dentinal caries but wide range
- higher sensitivity, lower specificity than visual (more FP)
- adjunct
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How does LED reflectance/refraction used in dentistry?
- Δ in optical signature of healthy vs.demineralized tooth structure
- healthy(green) ->more translucent than decalicied(red)
- used on WET tooth surface
- tool must be calibrated (ceramic)
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How is Midwest ID (LED) used interproximally?
directed down long axis
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What are the Midwest ID (LED) stats?
- 80% sensitivity IP
- 92% occlusal
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What causes FPs in LED(MW) and lasers(diagnodent)?
- atypical enamel morph
- restorations or sealants
- Calculus or plaque
- Stains (thick, dark brown)
- Food debris
- Contaminants on probe tip
- Probe not being in contact with tooth surface
- Tooth is dry (Midwest Caries I.D.) or tooth iswet (DIAGNOdent)
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How does Spectra Fluoresence work?
Six LEDs emitting blue light @ 405nm
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How does CarieScan work?
- AC impedance spectroscopy
- Sound enamel =high electrical resistance.
- Demineralization = ↑enamel permeability = ↓electrical resistance
- By the time caries has reached dentin the resistance has dropped by a factor of 30.
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What is the efficacy of Fl?
- only drug proven to prevent
- dental caries lesions
- higher conc (5000 vs 1500) enhanced remineralization and inhibited demineralization
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What is the ACP mechanism?
- Amorphous Calcium Phosphate Free & available for incorporation into tooth structure
- Best for pts. w/mild remin probs and high motivation
- Two-phase delivery system
- Prevents the calcium and phosphate from reacting
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What is the drawback of ACP?
- low substantivity
- acid challenge (pH<5.5) breaks down ACP and not available after
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What is CPP?
- Casein Phosphopeptides (CPP)
- tooth-protective activity
- bind calcium and phosphate and keep them in a soluble, amorphous state
- provides SUBSTANTIVITY to ACP
- penetrate into the tooth enamel, work synergistically with fluoride and repair demineralized areas
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What is enamelon?
insoluble calcium phosphate crystals
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How is MI paste applied?
- pea-sized on finger
- smear on teeth
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What are the indications for MI paste?
- High caries risk
- Infants & Children
- Expectant Mothers
- Orthodontics
- Whitening sensitivity
- Root exposure
- Chemotherapy, radiation
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What is the composition/chemical features of MI Paste?
- CPP-ACP: 10%
- •NaF: 900 ppm* (OTC toothpaste: 1000 ppm*)
- •ph: 7.2
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Why is Fl added to CPP-ACP?
- superior anti-caries effect than Fluoride alone
- high risk for dental caries and dental erosion
- Remineralized(thickened) through the body vs surface only of Fl alone
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What is the forumulation of MI Paste Plus?
- 5 :3 :1
- 5 / Calcium
- 3 / Phosphate
- 1 / Fluoride
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What do studies say about CPP-ACP?
- CT evidence insufficient to make conclusions regarding the longterm effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth
- not yet been substantiated
- Topically applied fluoride remains the standard for anti-caries effectiveness
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What is Tri-calcium phosphate?
- anticavity toothpaste 1.1 (5000ppm F-) blended/milled with organic materials
- • Calcium – phosphate bonds are broken
- • Calcium oxides become ‘protected’ by the organic materials
- • TCP ingredient can coexist with fluoride ions in an aqueous dentifrice base High fluoride availability
- • Organic carry the calcium to the tooth surface, protected from fluoride ion High fluoride bioavailability during application
- • Saliva activates the calcium compound degrading the protective coating, releasing calcium at the tooth surface Calcium bioavailability during application
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What activates tri-calcium phosphate?
saliva at tooth surface increase bioavailability
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What is Novamin?
- Particulate “bioactive glass” material
- attach to tooth surface,
- → react with water
- → release Ca2+ and PO43- ions
- → new HA forms on tooth surface
- Found in NUPRO Sensodyne Prophylaxis Paste with NovaMin (5000ppm F- too)
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How do HA nanocrystals(pHluorigel) work?
- Foundational Principles
- • Resting saliva pH = 6.75
- • Stimulated saliva pH = 7.8
- • HA dissociates into Ca2+ and PO4 3- ions at pH < 5.5
- • Fluorapatite (FA) dissociates at pH < 4.5
- ∴ Saliva environment favors presence of HA and FA nanocrystals over ions
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How properties of O3 make it good for the mouth?
- Powerful oxidant, disinfectant (CONFLICTING)
- unstable releases nascent oxygen
- Disinfection of endodontic systems (CONFLICTING)
- Promote soft tissue healing (e.g. apthous ulcers)
- Tooth whitening (oxidation)
- HALT/REVERSAL OF CARIES LESIONS (NO EVIDENCE)
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what are Ozone medical uses?
- • Wound healing – long history
- • Gangrene, infection, burns
- • Ocular diseases
- • Kills microorganisms, safe for human tissue cells (GOOD EVIDENCE)
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What were the original uses of O3 in dentistry?
- promote haemostasis
- • enhance local oxygen supply,
- • inhibit bacterial proliferation
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What is the intraoral mechanism of O3?
- • Oxidizing action drives O2 beneath surface of lesion to
- kill bacteria
- • Neutralization of acids creates hostile environment for
- cariogenic bacteria
- • Lesion is populated with non-cariogenic bacteria
- (probiotic effect)
- • Remineralization from salivary or topically-applied
- sources of F, Ca, and PO is facilitated
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What was really the only good evidence for O3 dentistry?
prophy for restorative prior to etching
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What is Icon (DMG)?
- Diffusion barrier for proximal lesion infiltration of NON-CAVITATED, smooth surface lesions
- Interproximal
- White spot lesions
- Infiltrate the porous body of lesion with low-viscosity resin
- Block diffusion pathways INSIDE vs surface sealant for cariogenic acids
- Procedure: Acid-etch, rinse, dry Drying solution (ethanol) Infiltrate with resin Light-cure
- Stats: higher penetration coefficient
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How was infiltration methods evaluated?
digital subration images of radiographs
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Is complete removal of all infected and affected dentin necessary?
- strong evidence for the advisability of leaving behind infected dentin…”
- cariogenic bacteria isolated by a restoration pose no risk…”
- removing all vestiges of infected dentin from lesions approaching
- the pulp is not required for caries management
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What was the historical evidence for AgF?
- black surfaces of amalgam-restored teeth
- had no caries progression
- • Knew of silver nitrate use for sensitive teeth
- • Showed 61% decay inhibition at 3 years w/silver nitrate
- Arrest of active lesions
- • Prevention of new lesions
- • May be more effective than fluoride varnish!*
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What is the mechanism of AgF?
- AgF: HA->FA (hydroxy apatite to fluoroapetite(less acid soluble)
- in infected area AgPO4s go into Thiols of AA and nucleic acids that aren't metabollically active for bacteria
- also only darkens infected areas
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What chemical can reduce discoloration of AgF?
KI (potassium Iodide)
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What is main advangtage of radiography?
preclinically evident detection of demineralization
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What is an acceple range of overlap for bitewings?
less than 1/3rd of enamel
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What is sensitivity?
- TP/(TP+FN)
- correct test result for all with disease
- ability to detect presence of disease when it’s actually present
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What is specificity?
- TN/(TN+FP)
- ability to rule out disease when it’s not present
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What are stats of radiographs?
- low sensitivity & high specificity
- False negatives more likely than false positive
- miss more than incorrect diagnos
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What factors contribute to radiographic accuracy?
- size: low accuracty for small proximal lesions, increases w/ lesion depth
- must be combined with clinical exam (visual/tactile)
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Do digital radiograph receptors (CCD/CMOS/PSP) perform as well as film?
yes
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Where do proximal caries usually appear?
- between contact and gingival margin
- therefore do not superimpose teeth
- must be at least 30-40% to be radiographically visible
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What are the false positives of radiographs causes?
- cervical burnout: illusion of radiolucency of a radiopaque object as a radiolucent area or band between two extremely radiopaque areas.
- hypoplastic enamel
- morhological variation: lingual concavity, enamel hypoplasia (look like erosion)
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What are reasons for false negatives in radiographs?
- needs to be 30-40% demineralized
- overlap: less than 1/3rd ideal
- about 50% of proximal caries aren't detected
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What are the stats for early enamel lesions of radiographs?
- DEPENDS ON RISK!!
- incidence = 10%, (50% sensitive, 95% specific, PPV = 53%)
- incidence = 50%, (PPV = 90%)
- Therefore PPV is better for high risk groups
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What are radiographic reccomendations for high risk pts?
- 6-12 months (children,adolescents)
- 6-18 adults
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What are radiographic reccomendations for low risk?
- 12-24 months children
- 18-36 adolescents
- 24-36 adults
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What are the radiographic false positives of occlusal?
- Deep buccal pits
- minimize by correlating w/ clinical exam
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What are the radiographic false negatives of occlusal?
- superimposition of tooth structure
- insufficient radiographically detectable demineralization
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What are limits of CBT with caries diagnosis?
- Beam hardening "scatter" artifacts from metallic restorations
- artifacts interfere w/ caries diagnosis
- typically only used for high risk
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