1

SUBJECTIVE & OBJECTIVE

METHODS OF CARIES
DETECTION

CONTENTS

INTRODUCTION

TOOLS

VISUAL EXAMINATION
TACTILE
BASED ON RADIOGRAPHS
Conventional

IOPAR & Bitewing

Xeroradiography

CONTENTS

DIAGNOSTIC

Digital

FUTURE TRENDS IN RADIOGRAPHIC

DIAGNOSIS OF DENTAL CARIES

BASED ON VISIBLE LIGHT

BASED ON ELECTRICAL CURRENT
ULTRASOUND
ENDOSCOPY /VIDEOSCOPE
DYES Enamel & Dentin
CONCLUSION
REFERENCES

INTRODUCTION

In Greek Dia means thoroughly

Giagnoska means

to know

OBJECTIVES
To

identify lesions which require surgical treatment

(restoration).
Identify

lesions, which require non-surgical treatment.

Identify

high-risk group.

PREREQUISITES:

Accurate
Reproducible
Sensitive
Reliable
Specific
Cost effective
Not transferring infection to other
areas

Methods of caries
detection

In vivo

1.

Visual examination

2.

Tactile examination

3.

Radiographs conventional , digital and

xeroradiography

4.

Fiber optic transillumination

5.

Optical method Fluorescence, light scattering

6.

Electronic resistance measurements

7.

Ultrasonic

8.

Dyes

In Vitro

Single tooth measurement

1.

Chemical analysis

2.

Cross sectional microhardness testing

3.

Polarized light microscopy

4.

Traditional transverse microradiography

5.

Microprobe analysis

Method of sequential measurements on tooth slab

6.

Iodine absorbitometry

7.

Longitudinal microradiography

8.

Light scattering

9.

Surface microhardness

Visual
examination
The visual examination of
caries
detection of white spot,
discoloration and
frank cavitation or
suspicious pits and fissures.

White spot

Discoloration

Pits and
fissures

AIDS:

Magnification
Use

loupes

of temporary elective tooth

separation.

10
PROCEDURE:
For detailed examination, the teeth are cleaned &
dried with compressed air & illuminated with
adequate light source.
DISADVANTAGES:
Discoloration of pits & fissures may be mistaken for
caries
Not reliable for detection of secondary caries or
occult caries.

CLINICAL SEVERITY INDEX SCORES

11
Ekstrand et al, 1998
SCOR

CRITERIA

ES
0
1
2

No or slight change in enamel translucency after drying

(> 5 sec)
Opacity or discoloration hardly visible on wet surface,
but distinctly visible after air drying (> 5s)
Opacity or discoloration distinctly visible without air
drying
Localized enamel breakdown in opaque or discolored
enamel &/or grayish discoloration from the underlying
dentine
Cavitations in opaque or discolored enamel exposing
dentine

PROBING (TACTILE EXAMINATION)

12

During

the past 10 years the role of

explorers in caries detection has
become a controversial issue.

 AIDS:

-Mouth mirror

13

For direct illumination

For indirect illumination
Self illuminating

-Explorers
Right angle probe {no.6}
Back action probe {no.17}
Shepherds crook {no23}
Cow horn with curved ends {no.2}

PROCEDURE:

Determining roughness or softness of the tooth with sharp

explorer. Both penetration & resistance to removal of an
explorer tip i.e. the catch is interpreted as evidence of
demineralization.

REVIEW OF LITERATURE:

14

Black et al (1924) gave the concept of passing the explorer

into pits & noting whether or not there is softening & whether
the instrument catches at any point.
Simon et al (1956) recognized marginal changes around a
previously placed restoration.
Gilmore et al (1982) showed that a susceptible site can be
entered by the use of a small sharp explorer or if enamel is
rough , decalcified or directly opens in dentin.

15

Marzouk et al (1985) showed that by pressing a sharp

explorer tip into pit &fissure will cause it to penetrate the
enamel & or dentinal caries cone making a definitive
diagnosis of caries.

Strudvent et al (1985) were of the view that defects are

best detected when an explorer provides tug back or
resistance to removal.

16
DISADVANTAGES:
Can produce traumatic defects in lesions arrested by
plaque control alone.
Does not improve accuracy of diagnosis.
Inter-operative variables.
May transfer cariogenic bacteria from one site to another.
Study by Lussi (1991) has found that application of too
much pressure on explorer does not increase the accuracy
of caries detection.

Use of floss as an adjunct to tactile

sensation
Pickard (1961)
the use of floss for detection of
caries.

VISUAL TACTILE
METHOD
EUROPEAN
SYSTEM
Visual method
examination
requires 10
minutes /
subject.

AMERICAN
DENTAL
ASSOCIATION
CRITERIA (USA)
Visual tactile
3 min per
subject

18

19

RECENT ADVANCES
(Visual, tactile assessment)

CLINICAL SEVERITY INDEX

- Ekstrand et al, 1998

Scor INTERNATIONAL CARIES

e

DETECTION & ASSESSMENT

SYSTEM (ICDAS)

No/slight change in enamel translucency

after drying (> 5 sec)

- Ismail et al, 2007

No/slight change in enamel
translucency after drying (> 5
sec)

Opacity/ discoloration hardly visible on

wet surface, but distinctly visible after air
drying (> 5s)
Opacity/discoloration visible without air
drying
Localized enamel breakdown in opaque/
discoloured

enamel

&/or

greyish

discoloration from the underlying dentine

Cavitations in opaque or discoloured
enamel exposing dentine
-

1st visual change in enamel

Distinct visual changes in enamel

Localized enamel breakdown in

opaque/ discolored enamel

4
5
6

Underlying dark shadow from

dentin
Distinct cavity with visible dentin
Extensive Distinct cavity with
visible dentin (>1/2 surface)

SCORE 1

SCORE 2

SCORE 4

SCORE 5

SCORE 3

SCORE 6

Description and clinical examples of

ADVANTAGES :

ICDAS has presented CONTENT VALIDITY

ICDAS has presented CRITERION VALIDITY
Significant correlation with lesion depth in the histologic
examination has been shown.
Braga et al, 2009

The specificity has been high, even when considering

the non-cavitated threshold.
- Novaes et al , 2009

LIMITATIONS :

In primary teeth, ICDAS cannot distinguish accurately

between lesions related to the outer or inner half of the
enamel.
Braga et al, 2009

Its sensitivity has been low for proximal caries in vivo

- Novaes et al 2009

ACTIVITY ASSESSMENT OF
NONCAVITATED
AND CAVITATED CARIES
LESIONS
- Nyvad
et al, 1998
ADVANTAGES :

This system has presented construct & predictive

Validity concerning caries lesion activity status.

Worked well in assessing the depth of lesions on

PRIMARY TEETH.
Braga et al, 2009

SCO
RE

CATEGORY

0
1

Sound
Active caries
(intact
surface)

Active caries
(surface
discontinuity)
Active caries
(cavity)
Inactive caries
(intact
surface)
Inactive caries
(surface
discontinuity)
Inactive caries
(cavity)
Filling (sound
surface)
Filling 1 active
caries
Filling 1
inactive caries

6
7
8
9

Description of scores in NYVADS SYSTEM

Normal enamel translucency and texture
Enamel surface whitish/yellowish, opaque with loss of
luster; feels rough on explorer examination. Intact
fissure morphology; lesion extending along the walls
of the Fissure
Same as 1.

Surface of cavity feels soft/ leathery on gentle

probing.
Enamel surface whitish/ brownish/black. Lesion
extending along the walls of the fissure
Same as 4. Localized surface defect. No undermined
enamel or softened floor detectable with the explorer
Surface of the cavity feels shiny and feels hard on
gentle probing.
Cavitated/Non-Cavitated Lesion
Cavitated/Non-Cavitated Lesion

26

RADIOGRAPHS

Conventional IOPAR & Bitewing

Xeroradiography

Digital :

1.

Enhancement

2.

Subtraction

3.

Tuned Aperture Computed Tomography (TACT)

I. CONVENTIONAL
RADIOGRAPHY

It involves two techniques:

IOPA radiographs

Bitewing radiographs

27

Other techniques are:

28

- Occlusal radiograph
- Panoramic radiograph

29
LIMITATIONS:
Overlapping of approximal contacts.
False diagnosis due to over estimation of lesion depth due to
change in angulations
Occlusal lesions, at times are imperceptible due to bulk of
buccal & lingual cusps.
Radiolucency can be due to resorption or other defects like
wear etc.

30

It gives 2 dimensional image of a 3 dimensional

object.

Superficial demineralization on buccal & lingual

surfaces may be misinterpreted as a proximal lesion

Fracture of one lingual cusp may also appear as

radiolucent proximal caries.

Tilted maxillary lateral too, gives carious appearance

Cervical burn out also mimics cervical caries.

CRITERIA FOR RADIOGRAPHIC ASSESSMENT

- Mejare et al, 31
1999
R0 = no radiolucency
R1 = Radiolucency confined to outer half of
enamel
R2 = Radiolucency
extending upto but

in inner half of enamel +

not beyond DEJ.

R3 = Radiolucency in dentin, broken DEJ, but

with no obvious
spread in dentin
R4 = Radiolucency with obvious spread in outer
half of dentin.
R5 = Radiolucency with obvious spread in inner
half of dentin

FIVE POINT SCALE FOR OCCLUSAL CARIES BASED ON

VISUAL EXAMINATION + RADIOGRAPHS 32
-Espelidel et al, 1994
Grade 1: Non cavitated white spot / slightly discolored caries lesion in
enamel not detected on the radiograph.
Grade 2: Some superficial cavitation in the fissure entrance, some non
cavitated mineral loss in the surface of the enamel. Surrounding the fissure /
and a caries lesion in enamel detected on the radiograph.
Grade 3: Moderate mineral loss with limited cavitation in the extreme of
fissure / lesion in the outer third of dentin, detected on radiograph.
Grade 4: Considerable mineral loss with cavitation / or lesion into the
middle third of the dentin, detected on the radiograph.
Grade 5: Advanced cavitation / or lesion into the inner thirds of dentin,
detected on radiograph.

(II) XERORADIOGRAPHY

33

-Chester Carlson, 1937

It is also called as EDGE ENHANCEMENT
RADIOGRAPHY which means differentiating areas of
different densities at the margins or edges.
This technique simulates a Xerox machine.
The image is recorded on an aluminium plate coated with
a layer of selenium.
These selenium particles are given a uniform electrostatic
charge & are stored in a unit called conditioner.

ADVANTAGES :

34

The characteristic feature of this technique is to capture both

positive & negative prints.
Better contrast
It is twice as sensitive than D speed film but comparable to E
speed film.
Edge Enhancement
No need of any developer unit

LIMITATIONS:

35

The electric charge over the film causes discomfort to the

patient as oral cavity provides humid environment which acts
as medium for flow of current.
Exposure time varies as exact thickness of plate is not
decided.
Processing has to be completed in 15 minutes.

(III) DIGITAL IMAGING

36

A digital imaging is an image formed and represented by a

spatially distributed in rows and columns known as pixels.

37
These are of 2 types:
Direct- the direct image receptor that collects the xrays directly e.g. RVG

Indirect- E.g. Video camera is used for forming digital

images of a radiograph.

38
Digital image is a simple means where image is recorded in
non film receptors.
There are three types of digital detectors available, namely:
- Charged Couple Device (CCD)
- Complementary metal oxide semi conductor (CMOS)
- Phosphostimulable phosphorous plates

39
Certain examples of Direct Digital Radiography include:
SYSTEM

MANUFACTURER

PROBE SIZE

RVG

Trophy, Japan

19 x 28 mm

Flash dent

Villa, Italy

20 x 24 mm

Sens-a-Ray

Regan, Sweden

17 x 26 mm

Vixa

Gendex, Italy

18 x 24 mm

ADVANTAGES:
Dark room is not required
Image is viewed instantly

40

Image quality is consistent

Radiation dose is reduced
Elimination of the hazards of film development
Contrast can be enhanced 70% by digital mode
Digital method is 50% more sensitive in detecting occlusal
caries
DISADVANTAGES :
High cost of system
Life expectancy of CCD in not certain

1) DIGITAL IMAGE ENHANCEMENT41

It was shown that the resolution of digital image is lower
than radiographs and the range of grey shades is limited to
256, whereas in a radiographic film, over one million
shades of grey appear.
The diagnostic performance of unenhanced digital image
does not exceed radiographs. Therefore, the contrast can
be digitally enhanced.

2) DIGITAL SUBTRACTION RADIOGRAPHY

42

- B.G.Zeides des Plantes, 1920

Two standardized radiographs produced with identical

exposure geometry are used.
The first one is called reference image & the next ones are
for comparison. The reference image is displayed on screen &
the comparison images are super imposed on it.
The difference between the original & the subsequent images
shows dark bright areas.

43

Nummikoski et al (1992) & Minah et al (1998) have regarded

it as a powerful tool in detecting primary & secondary caries.

ADVANTAGES :
Detecting progress of re-mineralization & de-mineralization
pattern.
Alveolar bone height in periodontal diseases
It is 90% accurate & can detect even up to 5% of mineral
loss as compared to 30- 60% by conventional radiographs.

44
Minimal thickness - detected is 0.012 mm of bone.
Overall density & contrast are good.
By increasing spatial resolution the amount of detail displayed
can be increased.

DISADVANTAGES :
Correct projection geometry is mandatory.

3) TUNED APERTURE COMPUTED

45
TOMOGRAPHY (TACT)
This method contracts radiographic section through teeth.
The slices can be viewed for presence of radiolucencies.
Slices can be brought together in 3-D computer model called
a psedohologram.
TACT slices and pseudohologram adequately detect primary
and secondary caries.

46
FILM

DIGITAL

TACT

Significant differences between film,

digital radiography, TACT slices in the
detection of caries.

47
FUTURE TRENDS IN RADIOGRAPHIC

DIAGNOSIS OF DENTAL CARIES

(A) Terahertz Imaging

(B) Multi-photon Imaging
(C) Optical coherence tomography

(A) TERAHERTZ IMAGING

48

(-) Arnone et al (1980)

(It uses waves with terahertz frequency (15 m to 1
mm). This wavelength forms short enough to provide a
reasonable resolution.
(SOURCE OF TERAHERTZ RADIATION
Photoconductive emitters of certain crystals
(Zinc
telluride) exposed to short pulses (<10-12) seconds of
visible infra red light would emit electromagnetic waves
with the frequency in the terahertz range.

 ADVANTAGES:

49

- Low power used for imaging.

- Use of Non-ionizing radiation.
DISADVANTAGES :
1) Low spatial resolution due to long wave length of the
source.
2) Alterations in image interpretation since terahertz
waves are strongly absorbed by water, a potential
complication in the mouth.

(B) MULTIPHOTON IMAGING

50

- Vinerot et al, 2010

ADVANTAGES :
Non invasive method.
Low average level of laser power. Therefore lower risk of
photo toxicity to the pulp.
Longer incident wave
length results in increased
penetration.
Can collect information
from caries lesion up to 500 m.

51
DISADVANTAGES :
- The Micron assay involves movements required to produce
serial tomographic images over a period of 1 min or so is
well beyond the capabilities of most dentists.
- Currently the technique is performed only on extracted
teeth and large laser equipment is required.

52
(C) OPTICAL COHERENCE TOMOGRAPHY
(OCT)
Developed
and

for

semi

transparent
transparent

structures.
Wave length of light 840-1310
nm with a depth of 0.6-2 mm
is used

 PRINCIPLE:
Based on interference of light.

53

OCT uses Super Luminescent Diodes (SLD) as light

source. Which produces light with the broad range of
wave length.
ADVANTAGES:
Non-invasive diagnosis of secondary caries.
Development of prototype hand pieces for intra-oral OCT.

BASED ON VISIBLE LIGHT

Optical
FOTI

54

caries monitor (OCM)

and DIFOTI (Electro-Optical Sciences, Irvington,

N.Y.)
QLF

(Inspektor Pro, OMNII Oral Pharmaceuticals,

West Palm Beach, Fla.)

DIAGNOdent

(KaVo, Lake Zurich, Ill.; Midwest Caries

I.D., Dentsply, York, Penn),

DELF(DYE-ENHANCED
Ultraviolet

LASER FLUORESCENCE)

(I) OPTICAL CARIES MONITOR (OCM)

55
This comprises of
light source
measuring and reference units
a detection part.
The light is transported through a fiber bundle to the tip of
hand piece.
The tip is placed against the tooth surface and the
reflected light is collected by different fibers of the same
tip.

(II)

FIBER

OPTIC

( FOTI )

TRANSILLUMINATION
56

-Friedman & Marcus (1970)

PRINCIPLE:
There is different index of light transmission for decayed and
sound tooth. Tooth decay has a lower index of light
transmission than the sound tooth structure, an area of decay
shows up as a darkened

METHOD:

57

A 150 watt halogen lamp and rheostat is used to produce a light

of variable intensity. A fiber optic probe of 0.5 mm diameter is
used to place in embrasure area. The marginal ridge is viewed
from occlusal surface.

ADVANTAGE :

58

No hazards , lesion not easily diagnosed by radiographs

can be diagnosed.
Initial results indicate that both specificity and sensitivity
are high.
DISADVANTAGE :
Subject to inter and intra observer variation. The major
problem remains low sensitivity.

Digital imaging fiber-optic59

transillumination
(DIFOTI)

Schneidermanalt
al 1997
Visible light fiber-optic
transillumination andet
digital
CCD
camera.

Mini D caries

60

D-Carie Mini is a new caries detection portable device

which is based on Fiber-optic principle.

It is easy to use and requires no calibration.

(III) QUANTITATIVE LASER OR LIGHT

INDUCED FLUORESCENCE
61
Sundstrom et al. (1981)
Normal Teeth fluoresce under UV light
-Benedict et al (1929)
There is a difference in the Fluorescence of sound and caries
teeth.
Loss of fluorescence is due to:
i.

Light scattered and thus the absorption per unit volume is small.

ii. Light scattering in the lesion that prevents the light from reaching the
fluorescing dentin.
iii. Protenic chromophores are removed by caries process.

METHOD:
Blue-green visible light emitted from a argon ion laser of
wavelength 488 nm is used.
Demineralization appears as dark spots.

Clinical example of a lesion on the

mesial surface of the canine
associated with partial denture

The QLF image showing

enhanced contrast between
sound and demineralized

examination alone
or radiographic
examination 63
alone.

ADVANTAGES

Diagnosis of early
lesion of enamel

High diagnostic
validity

Detection of carious
lesions in deciduous
is more accurate than
in permanent teeth.

Cannot
discriminate
between lesions
restricted to the
enamel and those
extending into the
dentine.

(IV) DIAGNOdent

64

Lucci et al (1998)
A variant of QLF system, a DIAGNOdent was based on
research by Hibst and Gal.
Light source diode laser red light 655 nm.

METHOD:

65

The DIAGNOdent unit (KaVo)

Comprises a pen like device with detachable tips of

different diameter.
A reading is provided on a digital display accompanied
by an audible tone.

Close-up of the tip and

the knob for turning it
around.

LF device (DIAGNOdentpen) with

the tip for fluorescence
measurements on approximal
surfaces
Light direction of the tip of
DIAGNOdent pen for approximal
caries detection.

Guidelines for the clinical use of DIAGNOdent

Values

Guidelines

0 to 13

No active care is advised (NCA)

14 to 20

Preventive care is advised (PCA )

21 to 30 (approx)

Preventive or operative care is advised,

depending on the patient's caries risk,
the recall interval, etc (PCA or OCA)

Over 30 (approx)

Operative (and preventive) care is

advised . (OCA and PCA)

Bader and ShugarS (2004) recently reviewed the literature

concerning studies of DIAGNOdent and concluded that

69

DIAGNOdent is more sensitive than conventional methods of

caries detection but that the risk of over diagnosis or false
positive raises concern that detection might imply diagnosis.
Attrill & Ashley (2001) compared the accuracy and repeatability of
three diagnostic systems (DIAGNOdent, visual and radiographic) for
occlusal caries diagnosis in primary molars. The DIAGNOdent was
the most accurate system tested for the detection of occlusal
dentine caries in primary molars.
.

70
DISADVANTAGES:

It cannot differentiate between decay, hypoplasia, or

unusual anatomic features.

It cant differentiate between enamel & dentine

caries.

It cant differentiate between active & inactive lesions.

It can give false results due to stain, deposits or

calculus

(V) DYE-ENHANCED LASER

LUORESCENCE

71

It had higher sensitivity than laser auto Fluorescence alone.

ADVANTAGES:
It is convenient & fast method.
Carious lesion can be detected with less than 1mm diameter
& depth of 5-10.
DYES USED ARE:
- Pyro methane 556
- Sodium Fluorescin

(VI) ULTRAVIOLET

72

UV light is used to increase the optical contrast between caries

region and surrounding sound teeth.
ADVANTAGE :
Sensitive than visual tactile method
DISADVANTAGE:
Specificity is a problem as it cannot detect between caries
lesion and developmental defect.

BASED ON ELECTRIC CURRENT

73
-Magitot et al (1878)

PRINCIPLE:
It is based on the principle of electric conductance which is
measuring the electrical conductivity through the pores.
The electric conductance & tooth resistance are inversely
proportional.
The increased conductance &/or decreased resistance are
indicative of hypo- or demineralized surface.

Two techniques have been devised:

74

1. Electroconductivity measurements
(Electronic Caries Monitor, Lode Diagnostics,
Groningen, The Netherlands)

2. Impedance spectroscopy (CarieScan,

IDMoS, Dundee, Scotland)

ELECTRONIC CARIES DETECTOR

75
It is the instrument used to measure electric conductivity of
tooth.
When potential of less than 1 volt is applied, the resistance
above 600,000 ohms -caries free tooth surface,
below 250,000 ohms - caries involving dentin are present.
0-9 scale indicating from sound to degree of
demineralization.

ADVANTAGES:

76

It is site & surface specific measurement.

It is useful in detecting caries at pre-cavitation stage.
Useful in monitoring progress of caries during caries control
program.

DISADVANTAGES:
It can only recognize demineralization & not caries
specifically.
Developmental defects also give similar effect.
Enamel cracks may give false positive result.

77

(i) Van Guard Electronic Caries

Detector
()Massachusetts Manufacturing Corp. in 1980.
()The measure scale ranges from 0-9.
()The tooth is dried to prevent conductance.

(ii) Caries Meter L

It was given by GE International Corp., Belgium.
It gives indication by glowing lights.
There are 4 light sequences denoting caries:
Green

Yellow Orange Red

No caries
Enamel caries
Dentine caries
Pulp involvement

78

BASED ON ULTRASOUND

79

MEASUREMENTS
)Ultrasound makes use of sound waves (by application of an
alternating voltage applied to a piezoelectric crystal) with a
frequency ranging from 1.6 to 10 MHz.
)Ultrasound interacts differently with different tissues.

80
METHOD:
To reach the target tissue, a coupling agent namely water/
glycerin is used. A flexible probe tip is fit into wedge shaped
inter proximal contours to conform to the shape of the
tooth.
DISADVANTAGE :
Useful only for superficial enamel lesions.

ENDOSCOPE/ VIDEOSCOPE81

A blue light (400-500 nm) is used to excite fluorescence within

the tooth.
ADVANTAGE: 5-10 fold magnification possible.
DISADVANTAGES:
- Requires meticulous drying and isolation.
- Takes 5-10 minutes compared to 3-5 minutes for conventional
technique.
Additionally a camera can be used to store the image.

 DYE-PENENTRATION METHODS 82

Dyes can help visualize a subject from its routine

background or from objects that appears similar.
It gives qualitative as well as quantitative values.
For caries detection qualitative examination is done.

 FOR ENAMEL CARIES:

83

- Procion: disadvantage - irreversible as dye reacts with nitrogen

and hydroxyl groups of enamel.
- Calcein : Complexes with calcium
- Fluorescent Dye: i) Brilliant blue ii) Zyglo ZX 22
FOR DENTINAL CARIES:
-

0.5% basic fuschin in propylene glycol

1% acid red in propylene glycol

MODIFIED DYE PENETRATION METHOD Iodine penetration

method for measuring enamel porosity of incipient carious region was
developed by Balnos et al (1977).

According to Fusayama et al. (1979), basic fuschin

stains the outer layer of carious dentine but not the inner.
This outer layer is infected, highly degraded and
unremineralizable and therefore must be removed prior
to restoration. In contrast the inner layer is not infected
and has been invaded only by bacterial products.

85

Fusayama & Terachima (1972) also separated lesions

into acute and chronic in terms of stainability. They
postulated that in an acute lesion, heavier staining
occurred because of the lower dentine hardness,
whereas in a chronic lesion, lighter staining is observed
because of the harder dentine in the level below.

SUMMARY &
CONCLUSION

86

Inspite of all new discoveries there is a truth

in the
past which is not and cannot be ignored or
brushed aside
-Dr R.A.Millikan.

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nd

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Paras Medical Pub : 2008

Vimal K Sikri. Textbook of Operative dentistry .2nd
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Fejerskov . Dental caries disease & management ;
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Soben Peter. Essentials of Preventive &
Community Dentistry. 3nd edition, Arya Publishing
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Pinkham . Pediatric Dentistry ; 4th Edition, 2005 .
Mc Donald . Dentistry for Child & Adolescent ; 8th
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Stewart R E . Pediatric Dentistry; 1st Edition, 1985.

Newborn E. Cariology. 3rd ed. Chicago: Quintessence

publishing co, Inc, 1989
Axelsson . Diagnosis of Caries .Quintessence Pub. Co., 2000.
Nikiforuk G .Understanding Dental caries: Vol 1 , 1985.
Hidden and incipient carious lesions : DCNA 2005 ; 49.
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Thomas CC. Caries detector dye is useful and in diagnosis of
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D C Attrill & P F Ashley .Occlusal caries detection in primary
teeth: a comparison of DIAGNOdent with conventional
methods British Dental Journal 2001; 190: 440 443.

89
K.R. Ekstrand , L.E. Luna , L. Promisiero , A. Cortes ,
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