Enhanced Clinical Decision-Making and Delivery of Minimally Invasive Care Using the ICCMS4D Integrated with Hands-Free Fluorescence-Based Loupes and a Chemomechanical Caries Removal Agent

Abstract

The purpose of this case report was to evaluate an approach for enhanced clinical decision-making while providing minimally invasive treatment, using the combined International Caries Classification and Management System (ICCMS 4D) with hands-free fluorescence-enhanced loupes (Reveal, Designs for Vision Inc., New York City, NY, United States) and a chemo-mechanical caries removal agent (Papacárie Duo Gel, Formula & Acao, Sao Paulo, Brazil). In recent decades, a shift towards a conservative approach to caries management has developed. The use of adequate operative techniques and correct decision-making are of paramount importance for early caries detection and tooth-preserving operative care. The use of noninvasive fluorescence-based adjuncts for enhanced diagnostic accuracy has gained popularity. Fluorescence describes the absorption of photons by a molecule, followed by its partial emission at a longer wavelength. Fluorescence detection of bacterial activity is largely based on the red/orange fluorescence emanating from bacterial metabolism, and has been shown to be found particularly in active caries and mature anaerobic plaque. The combined approach of using the standardized visual International Caries Detection and Assessment System (ICDAS) with fluorescence as an operative adjunct was shown to enhance the advantages of both systems. The approach may potentially increase detection sensitivity without compromising the specificity of the visual tactile method. A recent hands-free device is aimed to combine simultaneous diagnosis and therapy (theragnosis) using fluorescence, while overcoming possible obstacles to workflow continuity. The "Reveal" fluorescence-enhanced loupes are fitted with a dual white light/fluorescence light, and are said to allow the clinician to conduct any operational procedure with optional fluorescence guidance, from detection to caries removal, to treatment completion. Using the described method, a comprehensive pathway that emphasizes evidence-based information, correct clinical decision-making, and a minimally invasive therapeutic approach was proposed. The approach may represent a potential advancement in providing minimally invasive caries care.

Fig. 1

“Reveal” fluorescence-enhanced-magnification-loupes equipped with a ( A ) dual white light and ( B ) fluorescence 405-nm light.

Fig. 2

Initial pictures of the case. ( A ) Frontal view under white light. ( B ) High-magnification frontal view under white light. ( C ) Radiograph showing the lesions on the front teeth. ( D ) High-magnification frontal view under fluorescence light.

Fig. 3

Palatal aspect of the right upper lateral incisor. ( A ) White light initial lesion. ( B ) Fluorescence light initial lesion. ( C ) Cavity opening under white light. ( D ) Cavity opening under fluorescence light. ( E ) White light view following selective removal of infected tissue. ( F ) Fluorescence view following selective removal of infected tissue.

Fig. 4

Palatal aspects of the upper left central and lateral incisors. ( A ) White light initial lesion. ( B ) Fluorescence light initial lesion. ( C ) Cavity opening under white light. ( D ) Cavity opening under fluorescence light. ( E ) White light view following selective removal of infected tissue. ( F ) Fluorescence view following selective removal of infected tissue.

Fig. 5

Excavation and reconstruction procedure. ( A ) Selective removal of infected tissue with Papacárie Duo Gel, according to manufacturer instructions. ( B ) IRB application to the affected regions. ( C ) Composite reconstruction of the right upper lateral incisor. ( D ) Composite reconstruction of the upper left central and lateral incisors.

Fig. 6

Fluorescence identification of restorative materials on a typodont model. ( A ) White light view. ( B ) Fluorescence light view.