International Journal of Dentistry
`
`Ficure3: (a) Light of certain wavelengths is led by an optic fibre from the light source to a hand piece with a micro-Charge Couple Device
`video camera. (b) The image can be captured and saved forlater analysis. Computer program: QLF 1.97e Inspector Research System BV,
`Amsterdam, The Netherlands.
`
`
`
`
`
`(b)
`
`Ficure4: (a) The LF device operates with light from a diode laser transmitted through a descendentoptic fibre to a hand held probe with a
`fibre optic eye. The emitted fluorescence is collected through the tip, passes into ascendingfibres, andis finally processed and presented on
`the display as an integer between 0 and 99. (b) In the presence ofcarious tooth substance, fluorescence increases.
`
`is a poor correlation between LF readings and the mineral
`content, but possibly better correlation with the presence of
`infected dentin.
`in vivo studies of LF for occlusal caries
`In general,
`detection indicate moderate to high sensitivity and lower
`specificity [24, 60, 66, 68]. Lack of specificity, the increased
`likelihood offalse-positive readings due to stain and plaque,
`and the absence of a single threshold are factors underlying
`the reluctance among authors to recommend the LF method
`unequivocally for caries detection. Therefore, the LF device
`should be regarded at most as a supplementary aid for
`detection of caries on coronal surfaces.
`
`3.3. Transillumination with Near-Infrared Light. The caries
`lesion may also be examined by shining white light through
`the tooth. Wavelengthsin the visible range (400-700 nm) are
`limited by stronglightscattering, makingit difficult to image
`through more than 1mm or 2mm oftooth structure [79].
`Therefore, methods employing wavelengths in the visible
`range of the electromagnetic spectra (400-700 nm) such as
`QLF [40] (A > 520nm), LF [58] (A = 655 nm), and Digital
`Imaging Fiber-Optic Transillumination (DIFOTI)
`[80]—
`which uses high intensity white light—are highly limited
`
`by scattering. Methods that use longer wavelengths, such
`as in the NIR spectra (780 to 1550 nm), can penetrate the
`tissue more deeply. This deeper penetration is crucial for
`the transillumination (TI) method. Research has shown that
`enamelis highly transparent in the NIR range (750 nm to
`1500 nm) due to the weak scattering and absorptionin dental
`hard tissue at these wavelengths [81-86]. Therefore,
`this
`region of the electromagnetic spectrum is ideally suited to
`the development of new optical diagnostic tools based on
`TI. Figure 5 illustrates the typical experimentalset-up of a TI
`system with an NIR light source, an imaging camera such as
`a charge-coupled device (CCD), and software for computer-
`controlled acquisition. The image can be captured, saved,
`andstored in digital format.
`This is a promising imaging technique for detecting
`the presence of caries and measuring its severity. The
`TI
`image is presented as a visually recognizable image,
`which is preferred by the average clinician. The method is
`nondestructive, nonionising, and reportedly more sensitive
`to detect early demineralisation than dental X-rays [83].
`Identification of dental caries by TI is based on the fact
`that increased mineral loss in an enamel lesion leads to a
`twofold increase in scattering coefficient at a wavelength of
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`IN 4
`
`Lens
`
`Lens
`
`Polarizer
`
`Polarizer
`
`%&
`
`St
`
`q
`Tooth specimen
`
`International Journal of Dentistry
`
`can indicate the relative position of a lesion on approximal
`surfaces by calculating the ratio of contrast values obtained
`by dluminating tooth from the lingual or buccal surface,
`respectively. The method uses a range of wavelengths where
`low-costlight sources are available and the transmitted image
`can be detected by an ordinary CCD camera, similar to
`the one in mobile phones. The method can therefore be
`developed at reasonable cost as a fibre optic probe for
`intraoral use, connected to an ordinary computerscreen.
`The LF method generates a simple numerical index of
`de- and remineralisation in enamel and dentin that can be
`recorded in the patient’s file and monitored over time. The
`instrumentis easy to handle and can also be purchased at a
`reasonable price. New methods should be critically appraised
`according to strict criteria. Among LF studiesthere is a wide
`variation in specific design features (the number ofteeth
`included, the threshold for LF scores, validation methods,
`the outcomes expressed, etc.). In vivo studies highlight the
`importanceof rigorous clinical studies to confirm promising
`laboratory results. Results of the LF method in vivo have been
`somewhat contradictory. Therefore, The LF device should
`be regarded at most as a supplementary aid for detection of
`caries on coronal surfaces, pending the publication of further
`clinical studies.
`
`References
`
`[1] P.E. Petersen, D. Bourgeois, H. Ogawa,S. Estupinan-Day, and
`C. Ndiaye, “The global burden of oral diseases andrisks to oral
`health,” Bulletin of the World Health Organization, vol. 83, no.
`9, pp. 661-669, 2005.
`[2] I. Mejare, H. Stenlund, and C. Zelezny-Holmlund, “Caries
`incidence and lesion progression from adolescence to young
`adulthood: a prospective 15-year cohort study in Sweden,”
`Caries Research, vol. 38, no. 2, pp. 130-141, 2004.
`J. D. B. Featherstone, “Dental caries: a dynamic disease
`process,” Australian Dental Journal, vol. 53, no. 3, pp. 286-291,
`2008.
`
`[3]
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`[4] O. Fejerskov and E. Kidd, Dental Caries: The Disease and
`Its Clinical Management, chapter 4, Blackwell Munksgaard,
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`[5] L.-P. Choo-Smith, C. C. S. Dong, B. Cleghorn, and M. Hewko,
`“Shedding new light on early caries detection,” Journal of the
`Canadian Dental Association, vol. 74, no. 10, pp. 913-918,
`2008.
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`[6] B. Angmar-Mansson, “How to measure the effects of fluoride
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`pp. 30-33, 2001.
`[7] I. A. Pretty, “Caries detection and diagnosis: novel technolo-
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`
`Figure 5: Transillumination (TI) with Near-Infrared (NIR)light.
`experimental set-up of the TI system. The tooth is illuminated
`with NIR light. Polarizers are used to experimentally block out the
`ambient light from saturating the detector, a Charge Couple Device
`(CCD).
`
`1.3m [82, 83]. Caries thus appear as dark regions, since
`less light reaches the detector. Most research to date has used
`this wavelength, where low-cost light sources are available.
`Whenlight Wluminates the tooth the strong scattering effect
`in the enamel caries lesion results in less transparency. The
`decreased light transmission associated with the lesion can
`be detected when comparedto that of the surrounding sound
`tissue.
`The use of dental radiography should always be limited,
`even thoughit is the most often employed concept of routine
`examination. Dental radiographsalso lack the sufficient abil-
`ity for early caries detection [13, 16]. An initial caries lesion
`may be missed or underestimated in size in radiographs due
`to low attenuation of radiation in lesion, particular physical
`properties of the tooth structure, and imperfect technique
`such as overlapping. In contrast, the TI method offers the
`advantage of allowing for repeated projection to overcome
`someofthese limitations.
`The importance of the location of the caries lesion and
`how the resolution differs when the resultant image has to
`traverse a thick part versus a thinner part of the tooth to
`reach the detector is also of interest. Contrast calculation of
`the signal generated by a single lesion located near versus far
`from the CCD camera can be estimated. The ratio between
`the contrasts of images captured from bothsides of the tooth
`can estimate the more precise location of the caries lesion on
`the approximal surface.
`
`4. Summary
`
`Both QLF and the TI methods enable imaging detection
`of enamel caries that can be digitally stored and viewed
`later. The QLF method also includes image analysis software
`which measures the difference in fluorescence between sound.
`and demineralised enamel. Changes in fluorescent radiance
`and lesion area can be followed over time,
`to measure
`lesion development. The method seemsto have been rapidly
`adopted as a standard reference measure in clinical tests of
`the efficacy of preventive measures.
`Transillumination of enamel with NIR light is a promis-
`ing technique for the detection and imaging of occlusal
`and approximal
`lesions. Application of repeatable, non-
`ionising radiation of the tooth allows the TI method to
`be used without restriction to monitor the caries process.
`The method overcomes some of the limitations of dental
`radiography such as overlapping. Moreover,
`the method
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`

`SCIENTIFIC REVIEW
`
`
`Near-Infrared Imaging of
`Dental Decay at 1310 nm
`
`Daniel Fried, PhD*, Michal Staninec, DDS, Cynthia L. Darling, PhD
`
`University of California San Francisco (UCSF) School of Dentistry, San Francisco, California
`* Principal and corresponding author
`
`
`
`__ Inthis review paper wepresentan__
`overview. of our research which
`has shown: that dental enamel
`manifests high transparencyin the
`3
`near-infrared: (NIR) and suggests
`"that NIR light at 1310 nmis ideally 3
`suited for the imaging of catious
`3
`lesions on proximal and occlusal
`tooth surfaces. NIR-sensitive
`
`imaging systems with broadband
`light sources centered at 1310 nm
`were used to acquire NIR images
`of lesions in extracted teeth and
`
`proximal lesions in vivo. Stains
`and noncalcitied plaque are not
`visible in the NIR, enabling better
`discrimination of defects, cracks,
`and demineralized areas. Carious
`lesions were visible in the NIR
`
`with high contrast and can be
`viewed from multiple surfaces to
`aid in diagnosis. These studies
`indicate that NIR imaging may
`offer significant advantages over
`the conventional visual, tactile,
`and radiographic caries-detection
`methods.
`
`been reported between the wave-
`length range of 200-1550 nm. For
`enamel, absorption is very weak in
`the visible range (u, < lem!,A =
`400-700 nm).’ For dentin in the
`400-700 nm wavelength range, the
`absorptioncoefficient is essentially
`wavelength-independent with a
`value of p, ~ 4 cm'l.§ Scattering in
`enamelis strong in the visible (ys
`= 60 cm:! at 632 nm) and decreases
`~ 3 with increasing wavelength to
`a value of only 2-3 cm! at 1810 nm
`and 1550 nm in the NIR.O”
`
`Therefore, enamel is virtually
`transparent in the NIR with optical
`attenuation 1-2 orders of magni-
`tude less than in the visible range.
`
`J Laser Dent 2010;18(1):8-16
`
`
`
`Editor’s note: Dr. Daniel Fried is the Academy of Laser Dentistry’s 2009
`T.-H. Maiman award winnerfor dental research. His article gives a
`summary of his work at the University of California San Francisco School
`of Dentistry on using a 13810-nm laser for imaging dental carious lesions.
`
`CARIES DETECTION
`AND NEW OPTICAL
`DIAGNOSTIC
`TECHNOLOGIES
`During the past century, the nature
`of dental decay or dental caries in
`the United States has changed
`markedly due to the introduction of
`fluoride to drinking water, the use
`of fluoride dentifrices and rinses,
`application of topical fluoride in the
`dental office, and improved dental
`hygiene. In spite of these advances,
`dental decay continuesto be the
`leading cause of tooth loss in the
`United St