International Medical Journal Vol. 20, No. 3, pp.

395 - 398 , June 2013

395

DENTAL SCIENCES

Radiographic Diagnosis of Approximal Caries and Restorative

Treatment in Patients Attending Hospital Universiti Sains
Malaysia (HUSM)
Tan Ying Yin1), Mon Mon Tin-Oo2), Mohammad Khursheed Alam1)

ABSTRACT
Background: Bitewing examination is helpful for detecting hidden lesions in the approximal surface and is an essential aid
for clinical diagnosis.
Objective: This study aim to assess the prevalence of approximal carious lesions from radiograph and treatment given.
Methods: A retrospective record review study was carried out on 239 clinical records of patients age 14 and above who
attended in dental clinic of HUSM from January 2008 to December 20011. Readable bitewings of second molar to first premolar
were assessed for the absence or presence and depth of caries. Caries prevalence, distribution of caries and treatment given
were calculated by frequency (%).
Results: A total of 4538 surfaces were examined. Lesions confined to the outer half of the enamel and inner half of enamel
were found in 7.1% and 3.5% of surfaces respectively. Lesions in outer half of dentine were 2.8% and lesions beyond the outer
part of the dentine were 3.8%. No treatment was given for most of the surfaces with radiolucency in the enamel. Topical fluoride was given in the 4% of outer and 8.8% of inner half of the enamel. While surface with caries extend into dentine (59.7%)
and more than half of dentine (58.6%) were replaced with restoration. The more extensive treatment such as RCT and extraction were found in 22.7% of dentinal caries surface.
Conclusion: Both enamel and dentine caries prevalence was low. Most enamel caries were not intervened. Preventive intervention was given more in enamel caries. Dentinal caries were restored according to the depth.

KEY WORDS
bitewing, approximal caries, treatment

INTRODUCTION

Bitewing as an aid to clinical diagnosis is essential if much

approximal caries not to be missed. Bitewing radiographs are widely
used in dentistry, both to detect the presence of approximal caries and
to monitor the progression of previously detected lesions. The evaluation of the size of approximal carious lesion, through interpretation
of bitewing radiographs is the main tool in reaching a decision to
treat approximal caries (Weiss et al. 1996).
Enamel caries with intact surface and small detectable carious
lesions limited to enamel at approximal surfaces can be detected by
bitewing X-rays however, mistaken diagnosis is common. There can
be considerable variation in the interpretation of radiographs and
treatment decisions make by dentists (Purmal et al. 2012). The clini-

cian is the predominant factor in determining the extent of carious

lesions. Decisions of giving treatment or not giving appear to be
influenced by a number of factors including the ability to detect the
presence or and the dentist's belief in the likely progression and eventual outcome of the lesion. Over diagnoses became evident at the
treatment planning stage where many surfaces were incorrectly
planned for restoration (Maupome and Sheiham 1993). On the other
hand underestimation of approximal caries tends to miss preventive
care and fail to precede restorative treatment.
The management of approximal caries varies according to the
state of disease of surface and the presence or absence of a cavity is
very relevant. Caries confined to enamel surface on bitewing radiograph where there is unlikely to be a cavity, should be encouraged
to arrest. Dietary advice and proper oral hygiene instruction should
be given to patient, and in some cases, where patient cooperation is
doubtful, chair side application of fluoride by the dentist may be indicated. In contrast, when a cavity is present, operative treatment is
usually indicated (Kidd and Nyvad, 2003).

Received on June 12, 2012 and accepted on September 20, 2012

1) School of Dental Sciences, Universiti Sains Malaysia
16150, Kubang Kerian, Kota Bharu, Kelantan, Malaysia
2) Dental Public Health Unit, School of Dental Sciences, Universiti Sains Malaysia
Correspondence to: Mon Mon Tin-Oo
(e-mail: monmonto@kb.usm.my)

C 2013 Japan International Cultural Exchange Foundation

& Japan Health Sciences University

396

Tan Y. Y. et al.
Table 1. The depth of interproximal caries found at distal surface (D) and mesial surface (M) of each tooth at maxilla and
mandible
Depth of caries

Tooth number and number of surfaces

14

15

16

17

24

Total

25

26

27

surfaces

n%

R0

163

163

148

151

176

199

138

149

138

142

161

191

1926 (84.0)

R1

10

17

10

11

17

16

10

127 (5.5)

R2

11

13

10

74 (3.2)

R3

11

10

11

70 (3.0)

R4

20

13

18

101 (4.3)

34

37

44

35
D

36
D

45
D

46
D

47
M

R0

178

181

143

124

106

159

187

192

146

152

108

147

1823 (81.0)

R1

11

21

16

18

21

10

19

12

23

32

199 (8.8)

R2

18

12

11

86 (3.8)

R3

13

59 (2.6)

R4

10

16

12

16

73 (3.2)

Table 2. Frequency distribution of interproximal caries and treatment given (N = 4538)

n% of surfaces given various treatment

Radiographic reading of interproximal caries

Total surfaces

No treatment

n%

given

Restoration

RCT

Extraction

Topical

R1: Radiolucency in 1/2 outer enamel

326 (7.1)

303 (93.0)

10 (3.0)

0 (0.0)

0 (0.0)

13 (4.0)

R2: Radiolucency in 1/2 inner enamel

160 (3.5)

118 (73.8)

27 (16.9)

0 (0.0)

0 (0.0)

14 (8.8)

fluoride

R3: Radiolucency in >1/3 of outer dentin

129 (2.8)

45 (34.9)

78 (61.2)

2 (1.5)

1 (0.8)

4 (3.1)

R4: Radiolucency in >2/3 of outer dentin

174 (3.8)

30 (17.2)

102 (58.6)

12 (6.9)

29 (16.7)

1 (0.6)

In the study by Poorterman et al. (2002) on Dutch adolescents

found, of all enamel lesions 20% were not performed restorations. A
Swedish study showed 50% of the lesions in the outer half of the
dentin were restored when they were first detected (Lith et al. 2002).
Stenlund et al. 2003 found the caries rate of an approximal tooth surface was 1.6-32.3 times higher if the adjacent surface was in a caries
state compared to when the latter was sound.
There are different intervention taken by different practitioners
toward approximal caries detected on bitewing X-rays. This study
aims to explore the distribution of approximal caries presence and
intervention undertake among patient attending Dental Clinic,
HUSM.

MATERIALS AND METHODS

This retrospective record review study was carried on randomly

selected 239 folders of patients who had attended in dental clinic of
HUSM from Jan 2008 to Dec 20011. Inclusion criteria were folders
of patients who were minimal age 14 years and above with completed
treatment cases, bitewing radiograph with optimal density and with
teeth images that have no overlap contacts. Patient's folder will be
excluded if bitewing present with more than two missing teeth in two
quadrants, surface with restoration and fixed prosthesis and surface
unreadable radiograph.
Folders that selected were requested from Record Unit for

review. Patient's age and gender were recorded. Bitewing radiographs

from each folder were extracted and viewed in the dark environment
on the viewing light box. The bitewing radiographs were inspected
for approximal caries present from mesial surface of second molars
to distal surface of first premolar in both maxilla and mandible.
Dental caries criteria adopted for radiographic analysis were similar
to that proposed in previous study (Lunder and Fehr FR von der
1996): R0: no visible radiolucency; R1: Radiolucency in 1/2 outer
enamel; R2: Radiolucency in 1/2 inner enamel up to the dentinoenamel junction (DEJ); R3: Radiolucency in > 1/3 of outer dentin; R4:
Radiolucency in > 2/3 of outer dentin; R5: Radiolucency throughout
dentin. Interexaminer agreement was obtained by viewing of second
examiner on 20% of bitewings. Cohen's Kappa test was employed to
check the inter-examiner reproducibility.
Consequently, patient's record was reviewed carefully whether
any intervention was carried out on the approximal surface and material used for restoration was also recorded. In addition information of
patients' age and gender were recorded.
The data were entered in SPSS version 12.0 soft ware. A descriptive analysis was used to describe the percentage distribution of
enamel caries and dentine caries. The percentage distribution of radiographic scores assigned to proximal surfaces and frequency of treatments given on proximal molar surfaces were calculated.

Ethical consideration
Ethical approval was obtained from the Human Ethics Committee
of Universiti Sains Malaysia. All patients' identification and data
were kept confidential.

Radiographic Diagnosis of Approximal Caries

RESULTS

The inter-examiner reproducibility value regarding the radiographic reading was 0.74 (Kappa's value). The folders of 239
patients [126 (52.7%) female and 113 (47.3%) males] were reviewed.
Their age ranged from 14 to 60 years with the mean (SD) age of 27.6
(10.51) years. Total 4538 tooth surfaces from bitewings were studied.
Readable maxilla posterior teeth surfaces in bitewings were 2240 and
2298 surfaces of mandibular posterior teeth. Table 1 describes the
depth of approximal caries found at distal surface (D) and mesial surface (M) of each tooth in bitewings. Percentage of surfaces involved
approximal caries of R1, R2 and R3 categories were higher in
mandibular teeth than maxilla teeth. Tooth surfaces where radiolucencies with obvious spread in outer half of dentine were higher in
maxillary teeth (4.3%) than mandibular teeth (3.2%). Radiolucency
in 1/2 outer enamel (R1) was most common in mandibular second
molars, distal surfaces of mandibular first molars and distal surfaces
of second premolars. Among maxillary molars, R1 was commonly
seen in distal surfaces of maxillary second premolars. As for dentinal
caries highest rate was found in maxillary teeth.
Out of total 4538 surfaces inspected, 82.0% were caries free with
no radiolucencies (R0) detected. Among all tooth surfaces readable
bitewings 10.7% were detected to have enamel caries (R1 and R2).
Caries that had been broken into enamel-dentinal junction without
obvious was 129 (2.8%) and spread to outer half of dentine was
found to be 3.8% (Table 2).
Subsequent to the radiographic reading folders were reviewed
whether the approximal surfaces were given treatment or were not
given. Frequency distribution of approximal caries and treatment
given were shown in Table 2. Approximal surfaces that radiolucency
in outer half of enamel were 326 and 93% of them were not been
treated. Four percent were applied with topical fluoride and only 3%
had been restored. Radiolucency in the inner half of enamel was
found on 160 approximal surfaces. Among them 73.8% were not
given any treatment. Restoration was done on 27 % of them and 8.8%
were applied with topical fluoride. 61.2 % of caries that bitewings
show radiolucency in dentine broken e-d border had been restored
and 34.9% were not given any intervention. More than half of
approximal caries (58.6%) that have radiolucency with obvious
spread in outer half of dentine were being restored; 17.2 % of them
were not given any treatment and 16.7% were extracted. There were
only 6.9 % of caries that extend into outer half of dentine were given
root canal treatment.

DISCUSSION

Among all readable 4538 surfaces the total of enamel caries was
10.7%. Similarly, the study of bitewings of 120 Dutch persons an
enamel lesion was found to be 12 to 15% of the unfilled surfaces
(Poorterman et al. 2001). A study in New Zealand examined the 2710
surfaces on bitewings of 123 subjects. Carious lesions were found in
173 (6.38%) surfaces. Among all the carious lesions 79% were enamel caries (R1 and R2) and 21% were dentine caries (Chandler et al.
2005).
Prevalence of caries in enamel is higher compare to dentinal
caries in most of the study. Hintze, (2001) reported that enamel and
dentine caries was found in 9% and 6% of the approximal surfaces
respectively. In this study distal surface of mandibular first molar
was found to have highest number of surface with radiolucency in 1/2
outer enamel surfaces caries and dentinal caries. This result is comparable with Hintze et al. (2001) study whereby the highest caries
experience surface was in distal surface of first permanent molars in
mandible and mesial surface of first permanent molar in maxilla.
Hopcraft and Morgan (2006) stated that first molar was the most susceptible to dental caries.
Stenlund et al. (2003) reported that distal surfaces of the first
molars were more prone to caries than the mesial surfaces of second
molars. In this study enamel caries was more common on mesial sur-

397

faces of second molars than distal surface of first molar in both maxilla and mandible. As for dentine caries distal surface of first molars
were more affected than mesial surface of second molars. Study of
Stenlund et al. (2003) have shown that the more recently erupted
approximal surface the more being caries resistance than neighbouring surface with more mature enamel. Furthermore, older enamel is
less penetrable to different agents, including fluoride, than newly
erupted teeth (Brunn et al. 1973, Mellberg and Nicholson, 1968) and
mature enamel is more caries susceptible (Burchell et al. 1984). This
might helps to explain the higher caries susceptibility of the older
approximal surface when it reaches contact with its neighbor.
However, Nordblad and Larmas (1986) observed no differences in
caries susceptibility between distal surface of first molar and mesial
surface of second molar.
In this study approximal caries R1, R2 and R4 were highly susceptible in distal surface of maxillary and mandibular second premolars. In Hopcraft and Morgan (2006) study caries experience in premolars was low, although distal and occlusal surfaces were more than
twice as susceptible as mesial surfaces. Likewise our study Hopcraft
and Morgan (2006) documented that mesial and distal surfaces of
second premolars were more susceptible to caries. In fact the risk of
developing caries on an approximal surface would also increase when
caries is detected on the adjacent approximal surface. A sound surface next to sound surface had a relatively small risk of developing
caries while the risk increased 1.6-32.3 times if the neighboring surface was in a caries states as judged radiographically (Stenlund et al.
2003).
In present study, mesial surface of first molar in maxilla was
detected to have the second highest caries rate's surface. This finding
may therefore be reasonable to assume that the caries rate of an
approximal surfaces may also depended on the caries status of the
adjacent tooth.
Rate of caries progression has an influence towards caries prevalence and caries depth (Arrow, 2007). The authors reported that the
median time to occurrence of enamel caries was 6.1 months; while
median time to dentine caries was 77.7 months. Their study showed
that time to occurrence of enamel lesions in approximal surfaces is
relatively rapid while progression into dentine is relatively slow.
On the contrary, Shwartz et al. (1984) found that about 10 per
cent of new lesions will progress through the enamel in one year and
25 per cent in two years. However, over 40 per cent of the lesions
will not have progressed in 4 years. Therefore, most of the lesions
detected from bitewing were still confined to enamel rather than proceed to dentine. Generally, caries progression rate is slow but continuous. Since there are patients with enamel caries in our study these
patients should be recalled for posterior bitewing examination at 18 36 months intervals and very firm preventive measures must be formulated.
The implicit valuation which dentists place on the outcomes of
their treatment decisions may be a major contributory factor in dentists' decisions about when to restore teeth (Kay and Nuttal, 1994).
Regarding the treatment given for caries detected in this study, no
treatment was given for most of the surface with radiolucency in the
outer half of enamel (93%) however restoration was given on 3%.
Furthermore, caries involvements at inner half of enamel surfaces
73.8 % were not treated and 16.9% were given treatment. Shwartz et
al. (1984) stated that large proportions of carious lesions confined to
the inner or outer half of the enamel up to, but not beyond the amelodentinal junction do often progress for many years. Thus, such
lesions should also be kept under observation and the preventive
regime initiated. Restoration done on enamel surfaces found in this
study might be due to other causes that indicated for filling.
Preventive intervention such as topical fluoride application was given
more in enamel (12.8%). However, applying topical fluoride in dentine caries 3% was arguable for its effectiveness.
In this study the surfaces with caries extend into dentine (61.1%)
and more than half of dentine (58.6%) was replaced with restoration.
The more extensive treatment such as RCT and extraction were
increased in dentinal caries. Enamel caries are difficult to detect and
it is equally as difficult to decide how to treat them. One treatment
option is to not treat the lesion surgically but to treat the factors that
caused the lesion and to observe its progression or reversal. Many
dentists are reluctant to only monitor the lesion over time
(Anusavice, 1997). Most of the dentists would choose to restore
lesions that were within the enamel surface for a patient who is high
risk. The survey on dentists' decision of treatment for a high risk
caries patient, 66% of dentists indicated that they would restore proximal enamel lesion. While 24 % would do once the lesion had

398

Tan Y. Y. et al.

reached into outer third of dentine. For a low risk patient, only 39%
of respondents reported they would restore an enamel lesion, and
54% would do once the lesion reached into outer third of the dentine
(Valeria et al. 2009). Likewise, in the study of Lith et al. (2002) also
found out that the dentists in Scandinavia chose not to restore lesions
those were limited to enamel; restorative treatment was predominantly recommended for surface that involved dentine. Moreover the
practitioners may approach a carious lesion as a separate entity and
not as part of a disease. In addition, the cure of caries should not only
just rely on treatment given but also on individual assessment of
caries risk and patient education (Normastura et al. 2009).

CONCLUSION

In this study we revealed, enamel caries prevalence was higher

compare to dentinal caries as it progress slowly. The treatments given
for caries are mostly related to caries depth. Most of the enamel
caries were not intervened with treatment; however preventive intervention was given more in enamel caries compare to other treatment.
Besides, Dentine caries were restored accordingly. Extensive treatment such as root canal treatment and extraction were mostly done on
the dentine caries.

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