4.2 Caries Diagnosis

Rate of Progression of Lesions

In addition to estimating lesion depth, assessing carious lesions’ rate of progression is critical in developing a treatment plan. Reviewing findings from previous examinations and X-ray history is essential. A new patient’s initial examination will not include an X-ray history to help the dentist determine the rate of progression of any caries that is found. The dentist should ask new patients how long it has been since their last dental visits and if any decay was found and/or restored at that time.

On average, it takes 12 to 24 months for incipient lesions to develop into clinical cavitation in primary dentition. Incipient lesions usually progress more slowly in the permanent dentition, taking about 4 years to travel through the enamel. In patients at high or very high risk for caries, lesions may progress faster, and cavitation may occur sooner.

This means that for most patients, the dentist can treat white spot lesions and small, non-cavitated radiographic lesions with topical fluoride and safely monitor them for 6 to 12 months to determine activity level before deciding whether to restore.33 A non-progressive or arrested lesion can be left alone. If needed, a slowly progressing lesion can be restored later with a restoration no larger than the one that would have been placed had restoration taken place at the initial encounter.

Most caries in the primary dentition progress quickly, and some patients have rapidly progressing disease in their permanent dentition. Rapidly progressing lesions should be treated aggressively to limit damage and potential pulpal involvement. Patients with rapidly progressive caries in their permanent teeth may need to be moved to a higher risk category and their recall interval shortened until the infection and its destructive sequellae are controlled.

Recurrent Caries

During the examination, the dentist assesses for the presence of recurrent caries, which must be viewed at a restoration margin or on an X-ray. Because of treatment implications, dentists must be careful to distinguish recurrent caries from otherwise defective restorations. “DF” (for “defective filling”) should be written in the chart beside the tooth with the defective restoration with no caries to distinguish it from teeth with recurrent caries.

Lesions classified as “recurrent caries” can be assumed to harbor odontopathic bacteria. Such lesions need interventions such as improved oral hygiene, improved diet, and use of fluorides. Patients with active recurrent caries may need to be moved to a higher risk category, and their recall interval may need to be shortened; neither of these applies to patients with defective restorations.

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