Shifting from a surgical approach in Dentistry to one of risk management and meaningful prevention because we know that when a lesion is left to extend until a filling is needed, the clinical opportunity for effective prevention is lost.

1. NEW TECHNOLOGIES IN
CARIES DIAGNOSIS
The Canary System in
Pediatric Practice
Dr. Ian McConnachie
AAPD Annual Session May 24-27, 2012

2. A couple of Gifts from the North

3. Disclosures
• No Commercial Interest or Reimbursement
from Quantum Dental Technologies
• Member of Unpaid Dentist Advisory Panel to
Quantum Dental Technologies
• Some slides provided by QDT

4. Acknowledgements Page 4
• 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

5. 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

6. Outline of the presentation
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?

8. Early Carious Lesion in Enamel

9. Pathogenesis of Dental Caries
(biological balances)
SALIVA PLAQUE
PLAQUE ENAMEL
ENAMEL
Polysaccharides
Calcium
Salts
Plaque
buffers
mouth inside of tooth
SUGARS ACID
Calcium
Salts
Bacterial
Enzymes
Salivary
buffers
Demineralization Re-mineralization

10. Measuring and recording decay
THE CURRENT REALITY
• Visual Exam
• Mirror and Explorer
• Dental Radiographs
• Transillumination
• Dmfs/dmft

11. 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

12. 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

13. NO BIG DEAL

14. A VERY BIG DEAL
Psychological impact
Lower body weight

15. A TRANSMISSIBLE BACTERIAL INFECTION
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)
Diagnosis involves
recognition of
these changes
rather than simply
noting cavities

16. TOOTH DECAY
is PREVENTABLE

17. BECAUSE FILLINGS
Don’t treat underlying disease
Don’t address plaque biofilm issues
Don’t change risk level
We need to from a surgical approach to a RISK management & preventive approach.

18. The SHIFT in Dealing with Decay
• Growing awareness of social
determinants
• Newer recording of caries levels-
ICDAS
• Risk-based care
• A myriad of new products
• New diagnostic devices

19. “ 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

22. Product Decisions?
 Fluoride • RISK Demand?
 CPP-ACP (Recaldent) • Age and Ability?
 NovaMin • Buffering?
 ProArgin
• Fluoride Uptake?
 Xylitol products
 Antibacterial rinses • Contact time needed?
 Salivary products • Desensitization?
 Neutralizing agents • Antibacterial Activity?
 Silver Diamine Fluoride • Salivary Stimulant?
 Povidone Iodine • Compliance?
 CHX varnish (Prevora)
 Sealants
 ICON

23. Newer Technologies
Detecting
Decay

24. 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

25. 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

26. 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

27. 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

28. The Characteristics of an Ideal
Caries Detection System
The key is to understand
what the device is measuring

29. 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

30. The Canary System

31. by Quantum Dental Technologies
Canary interactive software
and printed patient reports
The Canary Console

32. 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.

33. What it is - Screenshot
Odontogram
Menu
Options
Camera
Image
Canary Number

34. Caries Mapping
Camera
Image with
Grid
Canary Number

36. 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

37. 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

38. 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

39. The Life Cycle of Tooth Decay
Healthy Early Advanced
Tooth Enamel Decay Enamel Decay
Demineralization
Remineralization
Remineralization Therapies The Canary System Scan X-Ray, Drill Fill & Bill

40. Caries Detection on ALL Surfaces
• Between teeth
(interproximal areas)
• Around the edges of fillings
• Enamel and root surfaces
Canary detects small lesions • Biting Surfaces
from 50 microns in depth and (occlusal pits and fissures)
up to 5 mm below the tooth
surface.

41. Sensitivity and Specificity
Sensitivity
• Overall measurement in vitro 97%
Specificity
• Overall measurement in vitro 82%
*Bench study Dr. B Amaechi UTSA

42. 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

43. The Canary in Pediatric Practice –
THE 9 MONTH STORY
Our questions at the start
• How easy to measure
• How reproducible
• How accurate
• Canary Scale 21-70
• Specificity and Sensitivity

44. The Canary in Pediatric Practice –
THE 9 MONTH STORY
Lesions evaluated clinically
Pit and fissure
Interproximal
Facial
Under sealants
ICON
Under and around restorations

45. Pit and Fissure Caries

46. Pit and Fissure Caries

47. Pit and Fissure Caries

48. Pit and Fissure Caries

49. Interproximal lesions
Issues at Outset
• How easy to learn
• How reproducible the numbers
• Canary Scale 21-70
• Sensitivity and specificity

50. Houston, We Had a Problem

65. 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)

66. 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

67. Detecting Caries under a Sealant

68. Detecting Caries under a Sealant

69. 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

70. 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

71. Detection Around ICON

72. Detection Around ICON

73. Anomalous Lesion

74. 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

75. Anomalous Lesion

76. Anomalous Lesion – Preliminary Page
76
Observations
• Canary does not accurately measure
defect
• Lesion appears to have a different
pathology and suspected different
histological picture
• More information required

77. 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

78. 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

79. 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

80. Orthodontic decalcifications
and caries
Slide courtesy of Reliance Orthodontics

81. 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

82. 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,

83. 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

84. Office Integration
Recall or Specific Exam
Reassess 6 Months •Identify White Spots
•Assess Lesion •ICDAS or Measure
•ICDAS or Measure •Risk Assessment
•Apply Remineralization
•Apply
Therapy
Remineralization •Oral Hygiene
Therapy Instruction
•Dispense Home- •Provide Home-based
Based Therapy Therapy
Reassess 3 Months
•Assess lesion
•ICDAS or Measure
•Apply
Remineralization
therapy
•Dispense Home-
based therapy

85. 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.

86. 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.

87. Is This the Motherlode In Caries Diagnosis?
MAYBE – BUT DEFINITELY WORTH CONSIDERING