CARIES ACTIVITY TESTS

Dental caries is a highly dynamic process with periods of progression alternating with periods of arrest,with periods of activity varying widely in their duration and intensity between populations, between individuals, within a single patient at different ages and even throughout the day. Even though caries is a multifactorial disease,a number of tests so far are based on the microbiological aspect of dental caries. Caries activity test determines the risk of developing caries. It is a predictor of future caries activity

INTRODUCTION

DEFINITION Caries activity:

It is defined as the occurrence and rate at which teeth are destroyed by the acid produced by plaque bacteria. OR It can also be defined as the sum total of new carious lesions and the enlargement of existing carious activities during a given time. Caries susceptibility: It is defined as the inherent propensity of the host and the target tissue to be afflicted by the carious lesions. Caries experience: It is defined as total number of carious lesions at a specified age

To identify high risk groups To determine the need and extent of preventive measures To identify patient co-operation Estimation of recall of the patient i.e. *patients with low caries activity should be recalled at 6 months. *patients with high caries activity should be recalled at 3 months. *patients with very high caries activity are advised immediate measures To motivate and monitor the effect of education programs ,diet counselling and, oral hygiene procedures

USES

As a precautionary signal to orthodontists in placing bands

Aid in determination of prognosis

IDEAL CHARACTERSTICS

Validity: method of measurement must be simple to describe and be accurate. Reliability: should indicate strong correlation if test is performed on the same subject by different researchers or by same researcher on different subjects. Specificity: should be specific for a given parameter. Sensitivity: test should be efficient enough to detect minute levels of caries activity. Feasibility: It should be feasible and clear if applied to general population .It should be easy to use by both medical and non-medical personnel. Simplicity: with regard to technical procedures and skills required

CLASSIFICATION
A) Microbial test: 1) Lactobacillus count test 2) Snyder test 3) Albans test 4) Dentocult lactobacilli test 5) Mutans group of streptococci screening tests: -plaque or tooth pick method -saliva or tongue blade method -s.mutans adherence method -s.mutans replicate method -s mutans dip slide method 6) Swab method 7) Oricult method

B) Test for evaluating salivary defense: 1) Salivary reductase test 2) Dentobuff test 3) Salivary viscosity test 4) Salivary flow rate test 5) Fosdick calcium dissolution test 6) Dewar test C) Test for evaluating tooth defense: 1) Critical visual examination 2) Fluoride level as a method to tooth resistance 3) Intra oral carcinogenicity test 4) Past caries experience 5) Vanguard electronic caries detector

Caries activity test also classified as

A) Biochemical and physical properties of saliva: 1) Salivary pH 2) Salivary buffer capacity 3) Uptake of oxygen 4) Salivary oxidation-reduction potential 5) Salivary amylase activity 6) Hyaluronidase activity 7) Salivary reductase test

B) Acidogenic potential of salivary constituents: 1) Enamel dissolution test (fosdicke) 2)Salivary pH test(dewar) 3) Soluble color indicator (rickets) 4) Color indicator (snyder) 5) Modified snyder (albans) 6) Methylene blue test 7) Cariostat C) Viable count of bacteria in saliva: 1) Acidogenic bacteria 2) Lactobacilli count 3) Streptococci count

IMPORTANT CARIES ACTIVITY TESTS

1. ) Lactobacilli colony count test:

One of the earliest and most widely used test it was introduced by Hadley in 1933. Principle: this test estimates the no. of acidogenic and aciduric bacteria in the patients saliva by counting the no. of colonies on tomato peptone agar plates or Rogosa agar plates Dentocult test is commonly used now a days.(undiluted saliva over modified rogosa agar and results compared with an illustrated chart with a count of 1000 CFU/ML as high)

Procedure: 5 to 10 ml stimulated whole saliva by chewing paraffin is collected in a sterile bottle. 1:10 dilutions is prepared by pipeting lml saliva sample into 9 ml tube of sterile saliva solution. This is shaken, 1:100 dilution is made by pipeting 1 ml of 1:10 dilution into another 9 ml tube of sterile salt solution. The 1:100 dilution is mixed thoroughly and 0.4 ml of each dilution is spread on surface of tomato juice agar or rogosas lactobacillus medium (each has low pH 5 ) with a bent glass rod. The plates are then incubated at 37C for 3-4

Count of number of colonies is then made with Quebec counter

No. of organisms
0 1000

Degree of caries activity suggested

IMMUNE

1000 5000
5000 10000 More than

SLIGHT
MEDIUM HIGH

10000

Indications for use

Pre-selection of patients for yearly or half yearly check-ups in the community Sometimes a steady high count of lactobacilli indicate a medically compromised patient(eg:Diabetes mellitus) Unchnaged value of lactobacilli is a contraindication for expensive bridges,implants,orthodontic treatment

Advantages: useful for monitoring the effectiveness of restorative dentistry and care completion. simple to carry out. useful as a screening test for caries activity in large groups. Disadvantages: inaccurate for predicting the onset of caries it does not completely exclude the growth of other relatively aciduric organisms. counts involving single individuals are not as reliable results take several days to be declared. counting is a tedious procedure.

2)Snyder test:
A calorimetric test devised by Snyder in 1951. Dye used is bromocresol green. This test is a measure of acidogenic and aciduric bacteria. Principle: Based upon rate of acid production when a sample of stimulated saliva is inoculated in a glucose and agar containing media with pH 4.7 -5.0

Procedure:

Stimulated saliva sample is collected similar to the lactobacillus colony test and 0.2 cc of saliva is pipetted into the media, incubated at 37C for a period of 72 hours. This semi-solid medium contains a) Bactopeptone-2Ogm b) Dextrose-2Ogm c) Sodium chloride-5gm d)Agar 16gm e)Bromocresol green-0.O2gm ,indicates the color change in a range of pH 5.4 to 3.8, from blue green to yellow A standardized color chart is used as an aid in determining color changes At the end of 24,48,72hours color change is recorded.

Color of bromocresol changes from blue-green to yellow in the range of pH of 5.4 to 3.8 Time for Caries activity colour change (in hours) 24 hours high 48 hours 72 hours medium slight

No color change immune for more than

Advantages: relatively simple to carry out. tests are of value in assessing the oral environment. only one tube of medium and no serial dilutions are required. Disadvantages: time consumed is more. sometimes the color changes are not so clear.

3) Alban test:

It is a modification of the snyder test. It uses less agar i.e. 5ml per tube. The saliva is drooled directly into the tube and the tubes are incubated for 4 days at 37C. The colour changes from bluish green to yellow and the depth to which the change has occurred is noted.

4) S. Mutans level in saliva :

Principle: this test measures the no. of s. mutans colony formed per unit volume of saliva. However a number of people may have mutans infection in the oral cavity without any signs of developing caries Procedure: Saliva or plaque samples are obtained by using tongue blades or tooth picks and are incubated in selective mitis salivarius bacitracin agar (MSB agar) .The agar plates are incubated at 37 degrees Celsius for 48 hrs in 95% at 5% CO2 gas mixture.

Interpretation: no. of s. mutans colonies more than 10 colonies per ml of saliva is indicative of high caries activity. Advantages: since the frequency of isolation of s. mutans is high prior to initiation of lesions as contrasted to lactobacilli, so, the clinician utilizes this count as an adjacent in caries management. Disadvantages: difficulty in distinguishing between a carrier state and cariogenic infection.

s.mutans may constitute less than 1%

5)Salivary buffer capacity test : (dentobuff strip test) Principle:10ml of saliva is collected atleast 1 hour after eating and stored under paraffin oil to prevent loss of bicarbonate ions.4 ml of this is measured in a beaker. After correcting the pH meter to room temperature the pH of the saliva is adjusted to 7 by additin of an acid or a base.the level of lactic acid is noted and then the pH is reduced till 6 by addition of a measured amount of lactic acid.This amount is a measure of the buffer capacity

DENTOBUFF STRIP TEST: Procedure: One drop of stimulated saliva is placed on a test strip containing acid and pH indicator After 5 minutes when reaction between saliva has taken place, the color of the test pad is compared to color chart of the pH indicator.
Interpretation: High buffer capacity - resistant to carious process Low buffer capacity - susceptible to caries

Sample collection

Sample application

Interpretation in 5 minutes

6) Salivary reductase test / susceptibility test:

Principle: this test measures the rate at which an indicator molecule diazoresorcinol,changes from blue to reed to colorless or leukoform on reduction by mixed salivary flora. Procedure: saliva is collected in a plastic container by chewing paraffin and expectorated directly into collection tube and is mixed with the dye Diazo-resorcinol. The colour changes reading is taken after30 seconds and 15mins.

EVALUATION OF CARIES CONDUCIVENESS

COLOUR TIME (min) SCORE CARIES ACTIVITY COLORLESS 30 SEC 5 Extremely conducive Red Red 30 SEC 15min 4 3 Highly conducive Moderately conducive Orchid 15min 2 Slightly conducive Blue 15min 1 Non conducive

7)Fosdick calcium dissolution test: Principle: this test measures the mg. of powdered enamel dissolved in 4hrs by acid formed when the patients saliva is mixed with glucose and powdered enamel. Procedure: 25 ml of gum stimulated saliva is collected. Part of this is analyzed for calcium content. The rest is placed in an 8 inch sterile test tube with about 0.1 gram of powdered human enamel. The tube is sealed and shaken for 4 hours at body temperature, after which it is again analyzed for calcium content. Interpretation : the amount of dissolution increases as the caries activity increases.

8)Dewar test:

This test is similar to the Fosdick calcium dissolution test except that: the final pH after 4 hours is measured instead of the calcium dissolved.

9)Swab test:
Developed by GRAINGER etal in 1965 Valuable for evaluating caries activity in very young children Principle: Measures the aciduric-acidogenic component of oral flora after suitable incubation period. Procedure: Oral flora is sampled by swabbing buccal surface of the teeth with cotton applicator subsequently incubated in medium. Change in pH or color change following 48hours incubation is read on pH meter or colour comparator respectively.

Interpretation: pH
pH4.1 and <4.1

Caries activity
marked caries activity active slightly active

pH4.2 4.4 pH 4.5 4.6 -

pH > 4.6

caries active

10) Salivary defense factors: Salivary flow rate,salivary quality and constituents have been studied along with other systemic and oral parameters that are related to caries A : Salivary flow rate: a) Collection of unstimulated saliva: patient sits upright with head bent forward and lets saliva drip into graduated tube without chewing. resting flow rate averages about 0.3 0.4 ml/min in adults while stimulated by paraffin wax averages 1-2 ml/min less than 0.1 ml/min is considered high

b) Collection of stimulated saliva:

patient is upright in position with head bent forward flow rate is determine by collecting paraffin stimulated saliva in a calibrated cylinder or a test tube over a 5 min period of time average 10.1 ml/min in males 8.6 ml/min in females values less than 0.7 ml/min is consider high risk

B: Viscosity of saliva: As flow rate decreases viscosity increases. Saliva with more viscosity is less effective in cleaning mouth. Viscosity of saliva is determined by comparing it with that of water. A special ostwald pipette with a caliberated bore Is used

Relative viscosity = time required for saliva time required for water Which is about 1.5

11) Cariostat test was formulated by professor Tsutomu Shimono in 1974 Principle: it measures the pH decrease caused by streptococci mutans in plaque sample. Medium used is semi-synthetic liquid containing indicator like Bromocresol green and Bromocresol purple

Procedure:The plaque sample are inoculated on cariostat medium and incubated at 37C for 48 hours.

Methods: 1. The buccal swab the maxillary molars, wiped a few times, and collecting the plaque. 2. To put the swab into ampoules. 3. 37 ( 2 ) and cultured for 48 hours. 4. To determine and compare the color swatch.

Scoring is done according to color changes observed

score pH 6.1 0.3 5.4 0.3 4.7 0.3 4.0 0.3 Colour Caries

activity
0 Blue Caries inactive 1 2 Green Yellow Slight caries Moderate

green
3 Yellow

caries
Marked caries

A number of researchers have reported that the cariostat test is superior to the radiographic examinationfor ddetection of initial proximal caries Cariostat test also significantly corelates with the mutans count in children

SALIVA-CHECK MUTANS

Very specific immunochromatograp hy process Test strip contains 2 monoclonal antibodies that selectively detect only the S. mutans species, meaning no other bacteria contaminates the results.

Saliva-Check BUFFER Kit

Test Procedures Hydration testing measures salivary production. Salivary Consistency testing visually assesses the viscosity of unstimulated saliva. Resting Saliva pH testing measures the pH of unstimulated saliva. Stimulated Saliva Flow testing measures the quantity of saliva produced in 5 minutes while chewing an unflavored piece of wax. Stimulated Saliva pH testing measures the pH of saliva produced under masticatory stimulus. Saliva Buffering Capacity testing measures the ability of saliva to minimize an acid challenge. All 6 tests take less than 10 minutes total per patient. In most cases, tests can be performed by trained auxiliaries. Saliva-Check makes it easier to initiate change in patient hygiene

CRT bacteria accurate diagnostic reading *two in one: records the mutans streptococci and lactobacilli count *high selectivity *hygienically sealed Agars CRT bacteria easy handling *quick and easy to use * results after just 2 days

CRT

CRT buffer easy handling * quick and easy Procedure * results after just 5 minutes

CARISCREEN TEST

Using a Caries Activity Test to Predict Caries Risk in Early Childhood Michiko Nishimura, DDS, PhD, Takashi Oda, DDS, Naoyuki Kariya, DDS, PhD, Seishi Matsumura, DDS, PhD and Tsutomu Shimono, DDS, PhD

ABSTRACT Background. The authors conducted a two-year longitudinal study to show the predictive abilities of a caries activity test (Cariostat, Dentsply-Sankin, Tokyo), and to include the predicted screening indexes that were based on previous caries activity test results and lifestyle factors that influence caries activity. Methods. The subjects were 1,206 children born in 2000. These children participated in health examinations at 18 months, 2 years and 3years of age at Kurashiki-City Public Health Center in Kurashiki-City, Japan. Two of the authors performed caries activity tests at 18-month and 2-year examinations.

Questionnaires regarding the patients lifestyle were mailed to each participants parents or guardians. The authors analyzed these questionnaires to evaluate lifestyle factors that made participants susceptible to caries.
Results. A caries activity test score at 18 months of age not only reflected caries incidence but also predicted caries incidence and screening results in 2- and 3-year-old children. A caries activity test score at 2 years of age both reflected and predicted childrens caries incidence and screening results at 3years of age. Breast-feeding and use of the bottle to intake liquids other than water produced significant caries susceptibility in 18-month-old children. Additionally, increased frequency and total time of sucrose intake put 2-year-old children at high risk of developing caries and failure of parental brushing produced a high risk in 3-year-old children. Conclusions. A caries activity test could predict 3-year-old childrens caries risk based on 18-month and 2-year-old test results. Early weaning, less sucrose intake and toothbrushing by parents were effective in reducing a childs caries risk. Clinical Implications. The caries activity test is more useful than oral examination because it can indicate the need for caries-preventive treatment before a carious lesion actually is manifest.

References

Textbook of pediatric. dentistry : DrS.G.DAMLE Textbook of pedodontics : SHOBHA TENDON Preventive and Community Dentistry : SOBEN PETER Dentistry for the child and adolescent : McDONALD,AVERY,DEAN. Journal of Pedodontics & Preventive

Using a Caries Activity Test to Predict Caries Risk in Early Childhood JADA January 1, 2008 139(1): 63-71