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Original Article

Comparative clinical evaluation of the efficacy of a

new method for caries diagnosis and excavation
Cem Peskersoy, Murat Turkun, Banu Onal
Department of Restorative Dentistry, Faculty of Dentistry, Ege University, Izmir, Turkey

Abstract
Aim: The purpose of this study is to compare the efficiency of fluorescence-aided caries excavation (FACE) to remove carious
dentin primary teeth with that of conventional methods.
Methods and Materials: After caries excavation was carried out, dentin surfaces were conventionally inspected using visual
tactile criteria and 415 cavities which were classified as caries-free, re-inspected with Face-Light and caries detector dye
(CDD) methods. Orange-red fluorescing areas classified as carious dentin, as well as stained carious dentin. All the data were
recorded according to localization of the caries and determination efficiency of the methods. X2 test was used to compare the
mean values of both Face-Light and dye applications, while Wilcoxon test performed to evaluate the effectiveness for each
diagnostic method.
Results: A total of 273 patients with 415 Class II (OM/OD) cavities (1.65 0.52 teeth per patient) with carious lesions in
molar and premolar teeth, were examined. Out of 415 teeth, in 149 teeth (35.9%) no caries findings had been illustrated.
While FACE detected remaining carious or partially removed areas in 237 teeth (57.2%), CDD stained only 29 teeth by itself
(P <0.05).
Conclusion: In conclusion, FACE has a higher detectability compared to visual inspection and caries detector dye in diagnosis
and removal of carious dentin.
Keywords: Caries detector dye; fluorescence-aided caries excavation; visual assessment

INTRODUCTION over 60 years.[3] The diagnostic value of probing dental

structures is extremely poor, and the indiscriminate use of
In the era of minimally invasive dentistry, the common sharp hand instruments can cause extensive tooth tissue
delineator is tissue preservation preferably by preventing damage, including iatrogenic pulp injuries, in addition
disease occurrence and intercepting disease progress, as to false-positive diagnoses.[4] Moreover, caries detector
well as by removing and replacing diseased tissue with dyes (CDDs), which were released as an advancement in
as little tissue loss as possible; consequently, this goal diagnostic dentistry, have recently decreased in popularity
has changed dental diagnostic systems and dentistrys due to insufficient distinctive properties such as staining
approach to dental caries management.[1,2] The traditional the less mineralized circumpulpal and predentin areas[5]
visual assessment and probing methods for detecting which causes possible damage to pulpal tissue.[6]
caries lesions have been commonly used procedures for
Optical methods of caries diagnosis are considered as
natural and noninvasive methods for lesion detection.
Address for correspondence:
Dr. Cem Peskersoy, Department of Restorative Dentistry, These methods present possible advantages of allowing
Faculty of Dentistry, Ege University Campus, Erzene Road, better identification and recognition of the affected area
Izmir - 35040, Turkey.
E-mail: dtcempeskersoy@hotmail.com This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
Date of submission : 17.04.2015
Review completed : 08.06.2015 allows others to remix, tweak, and build upon the work non-commercially,
Date of acceptance : 22.07.2015 as long as the author is credited and the new creations are licensed under
the identical terms.
Access this article online For reprints contact: reprints@medknow.com
Quick Response Code:
Website:
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How to cite this article: Peskersoy C, Turkun M, Onal B.
Comparative clinical evaluation of the efficacy of a new
DOI: method for caries diagnosis and excavation. J Conserv Dent
10.4103/0972-0707.164032
2015;18:364-8.

364 2015 Journal of Conservative Dentistry | Published by Wolters Kluwer - Medknow

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Peskersoy, et al.: Diagnostic efficiency of light-induced fluorescence method

and ease in handling compared to the conventional visual removal and iatrogenic origin were the primary reasons for
assessment and probing methods.[7,8] excluding those teeth from participation in the study.

The optical methods that have been introduced recently
include the following: Light scattering, fibre-optic
transillumination, and fluorescence-aided caries excavation
(FACE) by light or laser. During the process of caries formation,
bacteria in affected dentine leave metabolic products
(porphyrins) behind. Fluorescence light devices generally
illuminate blue-violet light; however, when an exposed cavity
is illuminated with this type of light, porphyrins display red
fluorescence, thereby indicating the significant areas for
caries detection and excavation.[9] Owing to the novelty of
this study, investigating the caries detection performance
of the FACE, which was introduced as a noninvasive new
approach, seemed to be interesting. While it is claimed
that, visualization of the remaining infected dentin and
evaluation of the caries excavation can be performed without
any specialization, clinical applicability and diagnostic
performance of the method should be investigated.
The aim of this study was to evaluate the clinical applicability
and efficiency of FACE by light and CDD methods in cavity
preparation after caries excavation using conventional
methods to evaluate the null hypothesis that FACE is an
advanced diagnostic method compared to CDDs and visual
inspection.
MATERIALS AND METHODS
Two hundred and seventy-three patients who were treated
at the Restorative Dentistry Clinic at Ege University,
Turkey, were selected for this study. The procedure and
aims of this study were explained to these patients, and
informed consent was obtained from all patients before
their participation in this study. This study was conducted
in accordance with the Declaration of Helsinki, and Ethics
Committee approval was obtained. The following inclusion
criteria were used to determine entry into the study: The
included teeth must be permanent maxillary or mandibular
molar and premolar teeth, caries must represent a primary
lesion that could been diagnosed clinically, caries lesions
must extend to one of the proximal surfaces (OM/OD),
and the teeth must be free of any existing restorations,
and any pulpitis symptoms. Pulp exposure due to caries
Access cavities were prepared using a high-speed handpiece
(NSK, Nakanishi International, Japan) with diamond burs
under continuous water cooling, followed by caries
excavation using a low-speed handpiece (NSK, Nakanishi
International, Japan) with stainless steel round burs and
excavators. After the caries excavation during an initial
examination using the classical probe and visual assessment,
all 415 cavities were classified as caries-free [Figure 1a].
Fluorescence-aided caries excavation stage
After initial cavity preparation, fluorescence violet light (405
nm) was generated using a 100-130-watt xenon discharge
lamp (FaceLight, W&H Dentalwerk, Brmoos GmbH, Austria)
to evaluate caries removal. The operator inspected the
cavity through a 500 nm red long-pass glass filter, which is
compatible with standard corrective goggles, to recognize
the orange-red fluorescing areas representing the bacteria-
infected dentin surfaces [Figure 1b]. Before CDD application,
the results regarding the presence or absence of caries were
collected from the FACE by light stage and recorded.
Caries detector dye stage
Subsequently, the teeth were dried briefly by using
compressed air and evaluated using a CDD method without
performing any operative procedures. Caries detection dye
(Caries Detector, Kuraray, Osaka, Japan) was applied to the
cavities for 10 s each, and then the cavities were rinsed
with water for 10 s, and dried again using compressed air
[Figure 1c]. Dentin surfaces that retained stain and stainless
areas were recorded [Table 1].
Finally, all the remaining carious areas that were diagnosed
using both methods were removed before the final
restoration procedure and re-checked [Figure 1d]. All the
acquired data were descriptively analyzed. The mean,
standard deviation, and 95% confidence intervals were
calculated for quantitative variables, and the frequencies
were calculated for qualitative variables. Descriptive and
explorative statistical analyses were performed using
SPSS 17.0 (IBM SPSS Statistics, Chicago, IL, USA). While
the Chi-square test was used to compare the mean values
of both FACE and dye applications, the evaluation of the

Table 1: Visual assessment scale for diagnosing caries excavation efficiency

Rank Description of each rank
0 No carious dentin detected
(Caries-free)
1 Caries detected (Visual)
2 Caries detected (Tactile)
3 Caries detected (Visual &
Tatile)
Definiton of each rank
Sound dentin observed (Visual)
Tactile hard
Dark stained dentin observed (Visual)
Tactile hard
Sound dentin observed (Visual)
Tactile softened
Carious dentin observed (Visual)
Tactile softened
Performed action
Excavation was terminated when the dentine remaining in the cavity
was not sticky to probing and did not exert any tug-back
Excavation was continued because the dentine remaining in the
cavity was hard in tactiling, but colorization existed due to the
chromogenic bacteria
Excavation was continued because the dentine remaining in the cavity
was not hard, but leathery, sticky to probing, or exerted tug-back
Excavation was continued until hard and unstained dentine has been
reached

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Peskersoy, et al.: Diagnostic efficiency of light-induced fluorescence method

Figure 1: View of a molar, (a) after conventional caries Figure 2: Intraoral camera (with 500 nm red-filter) view of
excavation, (b) observed with fluorescence-aided caries a molar, (a) after excavation, (b) false-stained circumpulpal
excavation, (c) stained with caries detector dye, (d) final areas, (c and d) diagnosed with fluorescence-aided caries
cavity excavation

effectiveness of each diagnostic method was performed Table 2: Percentage and difference (95% confidence
using the Wilcoxon 2 related sample test. interval) in sensitivity and specificity for each
diagnostic method
FACE CDD FACE vs. CDD
RESULTS
Sensitivity 89.1 % 65.1 % 31 (93/29)*
Specificity 80.5 % 37.6 % 47 (56/120)*
The results of the FACE method and caries detection dye * P < 0.05
method were compared with the conventional visual
assessment and tactile probing method to calculate the
Table 3: Number of patients and cases caries detected
sensitivity, specificity, and accuracy of the various caries in each diagnostic method
diagnostic techniques. Furthermore, the obtained values Groups Definition of Each Group Patients Cases p value
for different caries diagnostic techniques were compared
N % N %
with each other [Table 2].
GR-1 No caries detected 84 30.7 149 35.9 P < 0.05
GR-2 Caries detected by only Face Light 66 24.2 93 22.4 P < 0.05
In total, 273 patients with 451 Black II (OM/OD) cavities GR-3 Caries detected by only CDD 22 8.1 29 6.9 P > 0.05*
(1.65 0.52 teeth per patient) with caries lesions in molar GR-4 Caries detected with both methods 101 37.0 144 34.8 P < 0.05
Total 273 100 415 100
and premolar teeth that were scored according to the
*Number of cases detected by CDD is statistically insignificant
International Caries Assessment and Detection System
were examined. Of the 451 teeth, 36 teeth were excluded
from the study due to pulpal exposure. Although the visual Table 4: Common localizations diagnosed with
diagnostic methods where caries removal uncompleted
assessment yielded no caries lesions after cavity preparation
Only Only caries Both methods Total
and excavation, the FACE by the light method and the CDD
face-light detector dye
method found no caries in 149 teeth (35.9%) [Table 3]. In 237
Gingival step 48 3 63 116
cases (57.2%), the FACE by light method detected remaining Axial wall 18 9 39 66
carious areas or partially removed caries, while CCD could not Occlusal step 14 7 21 35
stain the carious areas (P <0.05) of 94 cases (22.6%) that the Buccal wall 12 0 12 24
Cuspal undercut 0 5 4 13
FACE by light method diagnosed as partially excavated caries. Dentino-enamel junction 2 4 5 12
In addition, CDD stained demineralized dentin areas close to Total 94 28 144 266
the pulp chamber [Figure 2] in 28 cavities (6.7%) that had been
diagnosed as sound using the FACE by the light method.
step, cuspal undercuts, and dentino-enamel junction (DEJ)
The locations of unexcavated and still affected areas were statistically insignificant (P > 0.05) (Tables 3 and 4).
are displayed in Table 4. The most common areas left
insufficiently excavated during the cavity preparation stage DISCUSSION
that were detected by one of the two above-mentioned
methods were gingival steps (27.8%) and axial walls (14.7%) Most clinicians still rely on radiographs, exploration, and
(P < 0.05). The differences between the buccal wall, occlusal visual examination for caries detection. The development

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Peskersoy, et al.: Diagnostic efficiency of light-induced fluorescence method
of noninvasive techniques and instruments that can detect
early demineralization on or beneath the enamel surface
is one of the desirable aims of dental researchers.[10-12]
Although promoting the detection of noncavitated carious
lesions has become an increasing focus, the irony is that
these lesions could be detected only at the cavitation stage
in most clinical settings.[13] While making dentinal cavities,
clinicians frequently do not know where to stop the caries
excavation process.
Various methods that have been used previously to guide the
checkpoint for stopping caries excavation include the following:
The use of CDDs and the use of laser fluorescence light.[14]
In a review article, Ganter et al. emphasized that although
CDDs are produced to aid the dentist in the differentiation
of infected/affected dentin, these dyes are not specific or
reliable for infected dentin detection.[15] The literature has
also revealed that these dyes frequently stain the circumpulpal
dentin or DEJ, leading to the unnecessary removal of sound
tooth structures.[16] Although the use of chemo-mechanical
methods for the removal of the caries is increasing, these
systems are much more time consuming and misguiding than
conventional systems.[17]
FACE has also been used previously[7,10,17] Lennon et al.
examined FACE, CDDs, and conventional caries excavation
in primary teeth and concluded that excavation using FACE
is more effective than conventional excavation and dye
usage in the removal of the infected primary dentin.[11]
In another study by Lennon et al., the excavation results
using FACE were found to be similar to conventional
excavation and superior to CDDs and chemo-mechanical
excavation; however, these FACE procedures required a
significantly shorter excavation time compared to the time
required for conventional excavation.[18] FACE by light is
a fluorescence-aided diagnosing system that is based on
illustrating the metabolic products that bacteria (porphyrins)
left behind in caries-infected dentine with different
fluorescent colors. This system employs the principle that
the fluorescence signals from the dental tissues can be
used for caries detection and excavation by differentiating
between infected and affected dentin. da Silva et al.
demonstrated that caries removal using the FACE method
is significantly less painful compared to the conventional
method and reduces the risk of pulpal exposure due to
unnecessary removal of sound dentin tissues.[19]
Literature analyses also revealed that manual excavation
could not succeed in removing all carious dentin from
cavities, particularly at specific localization such as gingival
margins and axial walls.[20,21] Determining the complete
removal of carious dentin via color (visual criteria) and
hardness (tactile criteria) could lead to the unnecessary
excavation of sound dentin tissues or to insufficient
cavity excavation.[22] In addition, caries excavation
with conventional methods using steel, tungsten or
Journal of Conservative Dentistry | Sep-Oct 2015 | Vol 18 | Issue 5
polymeric burs leads to smear layer formation, and by this
means, nonspecific detector dyes could possibly cause
unintentional staining of the smear layer.[23]
Significant differences were observed between the results
of the tactile examination and CDD and between the
results of the tactile examination and the FACE method.
Regardless, CDD stained the axial and pulpal surfaces of
the carious dentin located by the FACE method. The high
frequency of staining on such dentin surfaces close to the
pulpal chamber found in this study may be related to the
inherent disadvantages of CDDs in differentiating the less
mineralized but sound circumpulpal dentin and enamel-
dentin junction, which is consistent with the results of
a study by Gugnani et al.[24] In addition, FACE is based on
detecting fluorescence caused by bacterial products in
carious tooth tissues and does not rely on measuring the
mineral content of the tooth, thus discriminating carious
dentin during or after cavity preparation.[24] Therefore,
FACE method analysis indicated that the challenging
areas where the caries are hard to access and remove
such as gingival steps were the most common surfaces
misevaluated as caries-free using conventional and dye
application methods; this finding correlated with those
results of the study conducted by Neves Ade et al.[25]
CONCLUSION
This study results showed that the incidence of residual
caries after evaluation with FACE was significantly less than
those for conventional visual assessment and detector dye
application. Therefore, the hypothesis could be accepted
for the comparison of FACE with conventional excavation
but could not be proven for the comparison with CDD.
The findings in this study reveal that FACE is an efficient,
clinically applicable, and uncomplicated method for
diagnosing sound and carious dentin.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Gimenez T, Braga MM, Raggio DP, Deery C, Ricketts DN, Mendes FM.
Fluorescence-based methods for detecting caries lesions: Systematic
review, meta-analysis and sources of heterogeneity. PLoS One
2013;8:e60421.
2. Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E.
Minimal intervention dentistry for managing dental caries A review:
Report of a FDI task group. Int Dent J 2012;62:223-43.
3. Ismail AI. Visual and visuo-tactile detection of dental caries. J Dent Res
2004;83:C56-66.
4. Neuhaus KW, Ellwood R, Lussi A, Pitts NB. Traditional lesion detection
aids. Monogr Oral Sci 2009;21:42-51.
5. Thomas CC, Land MF, Albin-Wilson SM, Stewart GP. Caries detection
accuracy by multiple clinicians and techniques. Gen Dent 2000;48:334-8.
367
[Downloaded free from http://www.jcd.org.in on Thursday, July 14, 2016, IP: 111.125.209.21]
Peskersoy, et al.: Diagnostic efficiency of light-induced fluorescence method
6. Tak O, Usumez A. Diffusion of HEMA through human carious and
non-carious dentin in vitro. J Prosthodont 2013;22:184-9.
7. Rechmann P, Rechmann BM, Featherstone JD. Caries detection
using light-based diagnostic tools. Compend Contin Educ Dent
2012;33:582-4, 586, 588.
8. Diniz MB, Boldieri T, Rodrigues JA, Santos-Pinto L, Lussi A, CordeiroRC.
The performance of conventional and fluorescence-based methods for
occlusal caries detection: An in vivo study with histologic validation.
JAm Dent Assoc 2012;143:339-50.
9. Lennon AM, Buchalla W, Brune L, Zimmermann O, Gross U, Attin T. The
ability of selected oral microorganisms to emit red fluorescence. Caries
Res 2006;40:2-5.
10. Terrer E, Koubi S, Dionne A, Weisrock G, Sarraquigne C, Mazuir A,
etal. A new concept in restorative dentistry: Light-induced fluorescence
evaluator for diagnosis and treatment. Part 1: Diagnosis and treatment
of initial occlusal caries. J Contemp Dent Pract 2009;10:E086-94.
11. Lennon AM, Attin T, Buchalla W. Quantity of remaining bacteria and cavity
size after excavation with FACE, caries detector dye and conventional
excavation in vitro. Oper Dent 2007;32:236-41.
12. Javaheri M, Maleki-Kambakhsh S, Etemad-Moghadam SH. Efficacy
of two caries detector dyes in the diagnosis of dental caries. J Dent
(Tehran) 2010;7:71-6.
13. Matos R, Novaes TF, Braga MM, Siqueira WL, Duarte DA, Mendes FM.
Clinical performance of two fluorescence-based methods in detecting
occlusal caries lesions in primary teeth. Caries Res 2011;45:294-302.
14. Meller C, Heyduck C, Tranaeus S, Splieth C. A new in vivo method for
measuring caries activity using quantitative light-induced fluorescence.
Caries Res 2006;40:90-6.
15. Ganter P, Al-Ahmad A, Wrbas KT, Hellwig E, Altenburger MJ. The use
368 Journal of Conservative Dentistry | Sep-Oct 2015 | Vol 18 | Issue 5
of computer-assisted FACE for minimal-invasive caries excavation.
Clin Oral Investig 2014;18:745-51.
16. Celiberti P, Leamari VM, Imparato JC, Braga MM, Mendes FM. In vitro
ability of a laser fluorescence device in quantifying approximal caries
lesions in primary molars. J Dent 2010;38:666-70.
17. de Almeida Neves A, Coutinho E, Cardoso MV, Lambrechts P,
VanMeerbeek B. Current concepts and techniques for caries excavation
and adhesion to residual dentin. J Adhes Dent 2011;13:7-22.
18. Lennon AM, Attin T, Martens S, Buchalla W. Fluorescence-aided caries
excavation (FACE), caries detector, and conventional caries excavation
in primary teeth. Pediatr Dent 2009;31:316-9.
19. da Silva RP, Assaf AV, Pereira SM, Mialhe FL, Ambrosano GM,
MeneghimMde C, et al. Validity of caries-detection methods under
epidemiological setting. Am J Dent 2011;24:363-6.
20. Nordb H, Leirskar J, von der Fehr FR. Saucer-shaped cavity
preparations for posterior approximal resin composite restorations:
Observations up to 10 years. Quintessence Int 1998;29:5-11.
21. Snchez CC. Diagnosing incipient caries lesions. Is this the future for
dentistry? Rev ADM 2010;67:13-20.
22. Gurbuz T, Yilmaz Y, Sengul F. Performance of laser fluorescence for
residual caries detection in primary teeth. Eur J Dent 2008;2:176-84.
23. Otake S. The influence of the difference of caries detective methods on
the bond strength for caries affected root canal dentin. Kokubyo Gakkai
Zasshi 2010;77:20-6.
24. Gugnani N, Pandit I, Srivastava N, Gupta M, Gugnani S. Light induced
fluorescence evaluation: A novel concept for caries diagnosis and
excavation. J Conserv Dent 2011;14:418-22.
25. Neves Ade A, Coutinho E, De Munck J, Van Meerbeek B. Caries-removal
effectiveness and minimal-invasiveness potential of caries-excavation
techniques: A micro-CT investigation. J Dent 2011;39:154-62.