- Email: [email protected]
The Detection of Carious Lesions on the Proximal Surfaces of Teeth
198 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
The detection of carious lesions on the proximal surfaces of teeth John Haddin B arr* D.D.S., Boston, and A. Hallam Gresham, f B.D.S., Dunedin, N. Z.
Physical and roentgenographic examina tions o f the teeth of 416 patients were made concurrently in order to evaluate the two technics in the detection of cari ous lesions on proximal surfaces. The survey disclosed 3,389 cavities in patients ranging from 5 years of age to young adulthood (Table 1 ). The validity of the data obtained was checked by inde pendent duplication of the physical ex aminations in over 200 of the cases, with almost exact correspondence in total findings. The mouth examinations were performed by several experienced oper ators participating at different times dur ing the course o f the survey, individual variations in efficiency o f physical ex amination thereby being absorbed into grouped data. W e believe the physical and roentgenographic findings represent the same level of efficiency in mouth ex amination as would prevail under very favorable operating conditions in clinics or private dental offices. An evaluation o f examination technics is properly con cerned with data assembled on that basis if it is to find application in practice. Results are considered under three headings: (1) Comparative evaluation of physical and roentgenographic tech nics; (2) variability of the level o f ef ficiency of the physical examination; and (3) influence of some specific factors on
the efficiency of examinations for proxi mal caries. COMPARATIVE EVALU ATIO N OF P H Y S IC A L AN D R O EN TG EN O GRAPHIC T E C H N IC S
The total numbers o f cavities disclosed by physical and roentgenographic exami nations are shown in Table 1. W ith the exception o f maxillary anterior teeth in the group o f young adults, the efficiency of the roentgenographic examination was found to be substantially superior to the physical examination, and relatively more stable. When expressed in a form which reveals the additional number of proxi mal lesions disclosed per patient on com plementing physical examination with roentgenographic study, the results were as follows: Group I : 2.99 additional proximal lesions per patient in posterior teeth; Group I I : 1.08 additional cavi ties per patient in anterior teeth, 4.37 additional cavities per patient in poste rior teeth; and Group I I I : 0.77 addi tional lesions per patient in upper an terior teeth and 4.72 in posterior teeth.
*Tufts College Dental School, Boston. Formerly In the Department of Medicine, University of Texas School of Dentistry. fUniversity of Otago Dental School, New Zealand.
BARR-GRESHAM . . . VOLUME 41, AUGUST 1950 • 199
In the interpretation of results, the superiority of one or the other form of examination is not so important as the number or percentage of lesions which would have been overlooked if either method of examination had been omitted or not fully utilized. Even a single cavity, needlessly overlooked in its early stages, may prove sufficient to initiate disinte gration of an intact dentition. It seems clear that physical and roentgenographic technics together provide thé best and only adequate answer to the problem o f thorough examination for detection of proximal caries. W e have found that an adequate roentgenographic examination of proxi mal surfaces calls for a minimum o f ( 1 ) three small size no. 0 films to cover the upper anterior teeth and (2) four pos terior bi tewing films, two on each side of the mouth. The bitewing roentgenogram has not proved satisfactory for examina tion of anterior teeth because of the in evitable image distortion. This explains the recommendation for the use of small periapical films (Fig. 1 ). In the exami nation of posterior teeth, one film is used to cover the upper and lower bicuspid areas primarily, taking care to include
the distal surfaces of the cuspid teeth (Fig. 4 , below ). Another film is used primarily for the molar area (not illus trated), for it has been shown repeatedly that all proximal surfaces of the poste rior teeth cannot be shown satisfactorily on a single film on each side. This is partly due to limitations in the use of di vergent radiation between approximately parallel surfaces some distance apart, and partly because exposure requirements cannot be satisfied at the same time for teeth of such widely varying buccolingual dimensions as bicuspids and molars. VARIABILITY OF E F FICIEN C Y OF P H Y S IC A L E X A M IN A T IO N
A wide variation in the findings by physical examination from one operator to another prompted an illuminating ex periment which could be duplicated in many individual cases. Tw o experienced dentists independently made careful phys ical examinations for proximal lesions in an adult dentition; subsequently a final diagnosis o f proximal defects was arrived at by mutual consultation and agreement after roentgenograms had also been stud ied. The result depicted in Figure 2 illus-
Ta b le 1 • Findings by physical and roentgenographic examination of proximal surfaces for caries Number o f proximal cavities disclosed by each technic Case groups and region of mouth
Age range
Upper anterior teeth (Permanent dentition) II. Early adolescence 13-14 III. Young adults, median a g e 20.0 years 18-30 All posterior teeth M ixed dentition I Children, 194 cases, /5 -8 median age 7.5 years \9 -1 3 Permanent dentition II. Early adolescence 13-14 III. Young adults, med ian age 20.0 years 18-30
N o . of cases Roent genogram
Both exams
Per cent of total proximal cavities disclosed by each technic Findings Physical Roent common exam genogram to both exams
Total
Physical exam
60
182
127
174
119
69.8
95.6
65.4
162
352
221
229
98
62.8
65.0
27.8
T56 38
1073 206
587 104
991 190
oyo
54.7 50.5
92.4 92.3
I AA Ï /
60
453
191
441
179
42.4
97.3
39.5
162
1123
322
1057
256
28.6
94.2
22.8
Ì /
200 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
trates considerable variation between in dependent physical examinations, and also a possibility that sound proximal surfaces may be conscientiously but er roneously interpreted as carious. A single example cannot, of course, justify generalization; but it serves well to dramatize other findings based on ade quately large groups of cases. Through several unselected component sections of a homogeneous group of cases, the num bers of lesions discovered by physical ex amination, expressed as percentages of the total numbers disclosed by physical and rocntgenographic methods together, were reported in as follows: Examiner Examiner Examiner Examiner
C ........................... 46.8 D ........................... 56.2 A ............................56.4 E ............................62.7
per per per per
cent cent cent cent
In making a necessary correction for sound surfaces agreed to have been er roneously reported as carious, double the
error was deducted on the assumption that for each such instance, some other surface happened to be correctly re ported carious on no better evidence. This procedure placed the findings of the four examiners in a new perspective, confusing the order of their apparent efficiency as shown below: Examiner C ......................... 45.2 per (46.8 per cent less 1 .6 ) Examiner A ................. .41.9 per (56.4 per cent less 14.5) Examiner D ......................... 38.2 per (56.2 per cent less 18.0) Examiner E ......................... 37.8 per (62.7 per cent less 24.9)
cent cent cent cent
These figures suggest that there may be some optimum level of apparent effi ciency in physical examination, beyond which there tends to be a dispropor tionately large and undesirable error in cluded.
Fig. 1 • A b o v e : U pper anterior interproxim al exam ination, using three small-size ( # 0 ) films. Be low : Posterior interproximal ex amination should include the distal surfaces of the cuspid teeth. Four films ( tw o on each side) are re quired, of which only two are shown here
BARR-GRÈSHAM . . . VOLUME 41, AUGUST 1950 • 201
Surfaces Reported Carious
§] 6) 6] 5] 4j 4 j £ [4 M 0 M M 0 M 0 M 0
•
•
Examiner I
®
<§>
Examiner H
<§> X <§> <§>
Roen fenography
<§>
Final Diagnosis
%=
•
71 61 61 14 [5 [6
D 0 M 0 •
•
• X X X
®
Final diagnosis of caries.
•
0
M
•
•
®
<§>
<§> <§> X
X ®
<§> <§>
® ®
® = Correctly reported as carious.
X = Sound surfaces reported as carious. Fig. 2 • Findings from two independent physical examinations and from roentgenographic examination for proxim al caries in an adult perm anent dentition, related to a final diagnosis arrived at by consultation with the original examiners
be enhanced in cases characterized by some teeth being lost or missing from the dentition. Figure 4, left, shows the physical examination to have become more efficient as the number of lost or missing teeth increased; the efficiency of roentgenographic examination re mained stable at a constantly high level. At certain age levels, many interdental spaces normally exist in the dentition, notably during transition from the de ciduous to the permanent teeth, but study of the data by age groupings (T a ble 1) fails to indicate any age level at which either form of examination was completely adequate by itself. 2. The presence of restorative work in teeth could be expected to reduce the potential value of roentgenographic ex amination by obscuring proximal caries IN F L U E N C E OF SO M E SPECIFIC in some locations. This, view is supported FACTORS ON T H E EFFICIENCY by reference to Figure 4, right (posterior O F E X A M IN A T IO N S teeth ); and also by data for upper an Further analyses of the data were made terior teeth, in which for dentitions .to study specific circumstances in which grouped according to increased numbers either examination might present un of restorations present, the physical ex amination increased in efficiency from a usual advantage. 1. Possibilities for thorough physical minimum of 46.3 per cent to a maximum examination of proximal surfaces should of 65.9 per cent. Roentgenographic efThe constancy of the efficiency of given examiners, through two groups of cases whose dentitions were characteristically different, is shown in Figure 3. The re sults not only confirm variation in ef ficiency between operators as already discussed, but also reveal considerable (and in this instance opposite) variations in the level of efficiency of each operator on encountering a different type of case. Applied in terms of practice, roentgenographic and physical examinations — each technic of acknowledged value for its own primary role in the disclosure of carious lesions— are seen to acquire new values as mutual checks for the validity of diagnoses originated by the other technic.
202 • THE JOURNAL OF THE AM ER IC AN DENTAL ASSOCIATION
Fig. 3 • Comparison of findings by tw o e x aminers from physical exam inations fo r prox imal caries in anterior teeth o f unselected cases from G roup I I and from G roup I I I , shown as percentages o f total cavities dis closed by physical and roentgenographic tech nics used together. In the one instance more cavities w ere disclosed by exam iner B than by exam iner A ; in the other case the situation is reversed, illustrating the variability in effi ciency o f individual physical examinations. G roup 11: Exam iner A (3 0 ca ses), 6 3 .4 % ; exam iner B (3 0 ca ses), 7 6 .4 % . G rou p I I I ; Exam iner A (4 8 ca ses), 7 4 .3 % ; exam iner B (1 2 2 cases), 5 8 .6 %
ficiency decreased concurrently from 80.0 per cent to 56.3 per cent. 3. Untreated proximal caries as com pared with carious defects associated with proximal restorations were studied (see Table 2 ). The roentgenographic examination is seen to reach a higher level of efficiency in disclosing virgin lesions ; the physical examination is, how ever, far from adequate for sole reliance in searching for carious defects associated with restorative work. 4. The extent of caries penetration into the tooth substance influenced the relative efficiency o f the examination technics (Fig. 5 ). In interpreting the in formation in this illustration, it must be noted that for some cases in this group, numerous proximal lesions had been dis
covered by physical examination and treated within six months prior to the survey here reported. This fact does not affect a conclusion that the physical ex amination is conspicuously inefficient in disclosing beginning proximal lesions, and that it cannot by itself be relied on to discover all the deeper lesions. Indeed, a disturbingly large number of deep le sions remained to be disclosed by roent genographic study, after physical exami nations both prior to (in some cases) and during this survey. The deep proximal lesions revealed only by roentgeno graphic examination numbered no less than 1.98 per patient in this young adult group. An extreme example of this type of case is illustrated in Figure 6, in which two deep carious lesions are shown, both of which eluded detection throughout three physical examinations. The ex planation probably lies in the factor of the very narrow openings through the enamel making successful exploration unlikely between molar teeth with broad contact areas; in addition, the existing restorations contributed to obscure the reduced enamel translucency overlying a proximal lesion. 5. While on analysis of the data no re gion of the mouth emerged as offering possibility for effective study o f proximal surfaces by a single examination technic, no data were obtained for mandibular anterior teeth. It is pertinent to empha size the value of roentgenographic exami nation o f maxillary anterior teeth (T a bles 1 and 2) since physical exploration of the teeth supplemented by posterior interproximal films are too often re garded as fully meeting diagnostic re quirements. There was no indication of any situa tion in which either examination could routinely be considered adequate by it self. There are, doubtless, individual cases constituting exceptions, in which an ex aminer may be justified in assuming responsibility for dispensing with roent-
BARR—GRESHAM . . . VOLUME 41, AUGUST 1950 • 203
O M
uj
CO
“ o
o ° *“
CO
U. Uj
Ot
Z U < £ U Of ui
a.
P=physical examination
R=roentgenographic examination
Fig. 4 • Influence o f tw o factors on the relative efficiency of physical and roentgeno graphic examination for proxim al caries in posterior teeth. Examination findings are shown as percentages of total cavities disclosed, fo r three groups o f cases
genographic examination. But this ap proach would seem to be limited to the almost hypothetical case in which every tooth in the dentition would present an interdental space both mesially and distally, adequate to ensure certainty in visual inspection or exploration. It is safe to assert that the only diagnosis of proximal carious lesions adequately har monizing with the philosophy of con servation of natural vital teeth will re quire to be based on both physical and roentgenographic technics of examina tion. SU M M ARY
by different examiners. There was also wide variation in the efficiency of a given examiner on encountering characteristi cally different types of cases. It was evi dent that at the comparatively higher levels of apparent individual efficiency in physical examination, findings tended to include numerous sound surfaces er roneously reported as carious.
Table 2 • Results of physical and roentgenographic examinations in the case of (a) untreated proximal car ies and (b) carious defects about restorations
Group III, 162 cases
1. Findings by physical examination were Anterior teeth Virgin cavities consistently less than those disclosed by Defective restora tions roentgenographic examination. Teeth 2. There was surprising variation in Posterior Virgin cavities physical findings for identical cases or Defective restora tions strictly comparable groups as reported
By physical exam. (% of total disclosed)
By roentgeno graphic exam. (% o f total disclosed)
54.4
77.2
84.6
33.7
25.9
96.8
38.8
84.2
204 • THE JOURNAL OF THE AM ERICAN DENTAL ASSOCIATION
3. The efficiency of examination tech nics was studied in relation to specific conditions present in the dentition; for example, spaced teeth, the presence of restorations, the region being examined, the depth of caries penetration, the age o f the patient, and caries recurrence as compared with untreated lesions. The
1 0
PO STERIO R
R---------------------------------R— Fig. 6 • T w o d eep carious lesions which eluded detection through th ree successive physical examinations
P = physical examination. R = roentgenographic examination. Light gray area = percentages reported in common by both examination technics.
Fig. 5 • Percentages o f proxim al cavities dis closed by physical and roentgenographic exam inations, related to depth of penetration of caries. T he d epth of caries penetration is in dicated in the boxed diagrams at the bases of the columns
physical examination varied in efficiency under these differing circumstances; the roentgenographic examination was char acterized by remarkable stability in the level of its efficiency. 4. Neither technic by itself proved adequate for effective examination in any of the circumstances studied. The two examinations are to be regarded as mu tually complementary, the omission of either risking the probability that an im portant, if at times small, percentage of proximal lesions would fail to be dis closed. This applies to upper anterior teeth no less than to posterior sections of the dentition. 136 Harrison Avenue
Penetrating W ounds o f the Joints • Wounds can be treated safely by fixation and extension in cases
where chemotherapy can be administered. Similarly, extensive and even mildly infected wounds can be sutured per primam after adequate excision and surgical cleaning, provided that no tension exists on the suture line either in the deeper or superficial tissues, while delayed second suture in 48 hours can be carried out with impunity in the presence of adequate chemotherapy. Philip H . M itchiner, “ T he Surgery of Sepsis,” J. Internal. Coll. Surgeons, 1 2:407, July-August 1949.
The detection of carious lesions on the proximal surfaces of teeth John Haddin B arr* D.D.S., Boston, and A. Hallam Gresham, f B.D.S., Dunedin, N. Z.
Physical and roentgenographic examina tions o f the teeth of 416 patients were made concurrently in order to evaluate the two technics in the detection of cari ous lesions on proximal surfaces. The survey disclosed 3,389 cavities in patients ranging from 5 years of age to young adulthood (Table 1 ). The validity of the data obtained was checked by inde pendent duplication of the physical ex aminations in over 200 of the cases, with almost exact correspondence in total findings. The mouth examinations were performed by several experienced oper ators participating at different times dur ing the course o f the survey, individual variations in efficiency o f physical ex amination thereby being absorbed into grouped data. W e believe the physical and roentgenographic findings represent the same level of efficiency in mouth ex amination as would prevail under very favorable operating conditions in clinics or private dental offices. An evaluation o f examination technics is properly con cerned with data assembled on that basis if it is to find application in practice. Results are considered under three headings: (1) Comparative evaluation of physical and roentgenographic tech nics; (2) variability of the level o f ef ficiency of the physical examination; and (3) influence of some specific factors on
the efficiency of examinations for proxi mal caries. COMPARATIVE EVALU ATIO N OF P H Y S IC A L AN D R O EN TG EN O GRAPHIC T E C H N IC S
The total numbers o f cavities disclosed by physical and roentgenographic exami nations are shown in Table 1. W ith the exception o f maxillary anterior teeth in the group o f young adults, the efficiency of the roentgenographic examination was found to be substantially superior to the physical examination, and relatively more stable. When expressed in a form which reveals the additional number of proxi mal lesions disclosed per patient on com plementing physical examination with roentgenographic study, the results were as follows: Group I : 2.99 additional proximal lesions per patient in posterior teeth; Group I I : 1.08 additional cavi ties per patient in anterior teeth, 4.37 additional cavities per patient in poste rior teeth; and Group I I I : 0.77 addi tional lesions per patient in upper an terior teeth and 4.72 in posterior teeth.
*Tufts College Dental School, Boston. Formerly In the Department of Medicine, University of Texas School of Dentistry. fUniversity of Otago Dental School, New Zealand.
BARR-GRESHAM . . . VOLUME 41, AUGUST 1950 • 199
In the interpretation of results, the superiority of one or the other form of examination is not so important as the number or percentage of lesions which would have been overlooked if either method of examination had been omitted or not fully utilized. Even a single cavity, needlessly overlooked in its early stages, may prove sufficient to initiate disinte gration of an intact dentition. It seems clear that physical and roentgenographic technics together provide thé best and only adequate answer to the problem o f thorough examination for detection of proximal caries. W e have found that an adequate roentgenographic examination of proxi mal surfaces calls for a minimum o f ( 1 ) three small size no. 0 films to cover the upper anterior teeth and (2) four pos terior bi tewing films, two on each side of the mouth. The bitewing roentgenogram has not proved satisfactory for examina tion of anterior teeth because of the in evitable image distortion. This explains the recommendation for the use of small periapical films (Fig. 1 ). In the exami nation of posterior teeth, one film is used to cover the upper and lower bicuspid areas primarily, taking care to include
the distal surfaces of the cuspid teeth (Fig. 4 , below ). Another film is used primarily for the molar area (not illus trated), for it has been shown repeatedly that all proximal surfaces of the poste rior teeth cannot be shown satisfactorily on a single film on each side. This is partly due to limitations in the use of di vergent radiation between approximately parallel surfaces some distance apart, and partly because exposure requirements cannot be satisfied at the same time for teeth of such widely varying buccolingual dimensions as bicuspids and molars. VARIABILITY OF E F FICIEN C Y OF P H Y S IC A L E X A M IN A T IO N
A wide variation in the findings by physical examination from one operator to another prompted an illuminating ex periment which could be duplicated in many individual cases. Tw o experienced dentists independently made careful phys ical examinations for proximal lesions in an adult dentition; subsequently a final diagnosis o f proximal defects was arrived at by mutual consultation and agreement after roentgenograms had also been stud ied. The result depicted in Figure 2 illus-
Ta b le 1 • Findings by physical and roentgenographic examination of proximal surfaces for caries Number o f proximal cavities disclosed by each technic Case groups and region of mouth
Age range
Upper anterior teeth (Permanent dentition) II. Early adolescence 13-14 III. Young adults, median a g e 20.0 years 18-30 All posterior teeth M ixed dentition I Children, 194 cases, /5 -8 median age 7.5 years \9 -1 3 Permanent dentition II. Early adolescence 13-14 III. Young adults, med ian age 20.0 years 18-30
N o . of cases Roent genogram
Both exams
Per cent of total proximal cavities disclosed by each technic Findings Physical Roent common exam genogram to both exams
Total
Physical exam
60
182
127
174
119
69.8
95.6
65.4
162
352
221
229
98
62.8
65.0
27.8
T56 38
1073 206
587 104
991 190
oyo
54.7 50.5
92.4 92.3
I AA Ï /
60
453
191
441
179
42.4
97.3
39.5
162
1123
322
1057
256
28.6
94.2
22.8
Ì /
200 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
trates considerable variation between in dependent physical examinations, and also a possibility that sound proximal surfaces may be conscientiously but er roneously interpreted as carious. A single example cannot, of course, justify generalization; but it serves well to dramatize other findings based on ade quately large groups of cases. Through several unselected component sections of a homogeneous group of cases, the num bers of lesions discovered by physical ex amination, expressed as percentages of the total numbers disclosed by physical and rocntgenographic methods together, were reported in as follows: Examiner Examiner Examiner Examiner
C ........................... 46.8 D ........................... 56.2 A ............................56.4 E ............................62.7
per per per per
cent cent cent cent
In making a necessary correction for sound surfaces agreed to have been er roneously reported as carious, double the
error was deducted on the assumption that for each such instance, some other surface happened to be correctly re ported carious on no better evidence. This procedure placed the findings of the four examiners in a new perspective, confusing the order of their apparent efficiency as shown below: Examiner C ......................... 45.2 per (46.8 per cent less 1 .6 ) Examiner A ................. .41.9 per (56.4 per cent less 14.5) Examiner D ......................... 38.2 per (56.2 per cent less 18.0) Examiner E ......................... 37.8 per (62.7 per cent less 24.9)
cent cent cent cent
These figures suggest that there may be some optimum level of apparent effi ciency in physical examination, beyond which there tends to be a dispropor tionately large and undesirable error in cluded.
Fig. 1 • A b o v e : U pper anterior interproxim al exam ination, using three small-size ( # 0 ) films. Be low : Posterior interproximal ex amination should include the distal surfaces of the cuspid teeth. Four films ( tw o on each side) are re quired, of which only two are shown here
BARR-GRÈSHAM . . . VOLUME 41, AUGUST 1950 • 201
Surfaces Reported Carious
§] 6) 6] 5] 4j 4 j £ [4 M 0 M M 0 M 0 M 0
•
•
Examiner I
®
<§>
Examiner H
<§> X <§> <§>
Roen fenography
<§>
Final Diagnosis
%=
•
71 61 61 14 [5 [6
D 0 M 0 •
•
• X X X
®
Final diagnosis of caries.
•
0
M
•
•
®
<§>
<§> <§> X
X ®
<§> <§>
® ®
® = Correctly reported as carious.
X = Sound surfaces reported as carious. Fig. 2 • Findings from two independent physical examinations and from roentgenographic examination for proxim al caries in an adult perm anent dentition, related to a final diagnosis arrived at by consultation with the original examiners
be enhanced in cases characterized by some teeth being lost or missing from the dentition. Figure 4, left, shows the physical examination to have become more efficient as the number of lost or missing teeth increased; the efficiency of roentgenographic examination re mained stable at a constantly high level. At certain age levels, many interdental spaces normally exist in the dentition, notably during transition from the de ciduous to the permanent teeth, but study of the data by age groupings (T a ble 1) fails to indicate any age level at which either form of examination was completely adequate by itself. 2. The presence of restorative work in teeth could be expected to reduce the potential value of roentgenographic ex amination by obscuring proximal caries IN F L U E N C E OF SO M E SPECIFIC in some locations. This, view is supported FACTORS ON T H E EFFICIENCY by reference to Figure 4, right (posterior O F E X A M IN A T IO N S teeth ); and also by data for upper an Further analyses of the data were made terior teeth, in which for dentitions .to study specific circumstances in which grouped according to increased numbers either examination might present un of restorations present, the physical ex amination increased in efficiency from a usual advantage. 1. Possibilities for thorough physical minimum of 46.3 per cent to a maximum examination of proximal surfaces should of 65.9 per cent. Roentgenographic efThe constancy of the efficiency of given examiners, through two groups of cases whose dentitions were characteristically different, is shown in Figure 3. The re sults not only confirm variation in ef ficiency between operators as already discussed, but also reveal considerable (and in this instance opposite) variations in the level of efficiency of each operator on encountering a different type of case. Applied in terms of practice, roentgenographic and physical examinations — each technic of acknowledged value for its own primary role in the disclosure of carious lesions— are seen to acquire new values as mutual checks for the validity of diagnoses originated by the other technic.
202 • THE JOURNAL OF THE AM ER IC AN DENTAL ASSOCIATION
Fig. 3 • Comparison of findings by tw o e x aminers from physical exam inations fo r prox imal caries in anterior teeth o f unselected cases from G roup I I and from G roup I I I , shown as percentages o f total cavities dis closed by physical and roentgenographic tech nics used together. In the one instance more cavities w ere disclosed by exam iner B than by exam iner A ; in the other case the situation is reversed, illustrating the variability in effi ciency o f individual physical examinations. G roup 11: Exam iner A (3 0 ca ses), 6 3 .4 % ; exam iner B (3 0 ca ses), 7 6 .4 % . G rou p I I I ; Exam iner A (4 8 ca ses), 7 4 .3 % ; exam iner B (1 2 2 cases), 5 8 .6 %
ficiency decreased concurrently from 80.0 per cent to 56.3 per cent. 3. Untreated proximal caries as com pared with carious defects associated with proximal restorations were studied (see Table 2 ). The roentgenographic examination is seen to reach a higher level of efficiency in disclosing virgin lesions ; the physical examination is, how ever, far from adequate for sole reliance in searching for carious defects associated with restorative work. 4. The extent of caries penetration into the tooth substance influenced the relative efficiency o f the examination technics (Fig. 5 ). In interpreting the in formation in this illustration, it must be noted that for some cases in this group, numerous proximal lesions had been dis
covered by physical examination and treated within six months prior to the survey here reported. This fact does not affect a conclusion that the physical ex amination is conspicuously inefficient in disclosing beginning proximal lesions, and that it cannot by itself be relied on to discover all the deeper lesions. Indeed, a disturbingly large number of deep le sions remained to be disclosed by roent genographic study, after physical exami nations both prior to (in some cases) and during this survey. The deep proximal lesions revealed only by roentgeno graphic examination numbered no less than 1.98 per patient in this young adult group. An extreme example of this type of case is illustrated in Figure 6, in which two deep carious lesions are shown, both of which eluded detection throughout three physical examinations. The ex planation probably lies in the factor of the very narrow openings through the enamel making successful exploration unlikely between molar teeth with broad contact areas; in addition, the existing restorations contributed to obscure the reduced enamel translucency overlying a proximal lesion. 5. While on analysis of the data no re gion of the mouth emerged as offering possibility for effective study o f proximal surfaces by a single examination technic, no data were obtained for mandibular anterior teeth. It is pertinent to empha size the value of roentgenographic exami nation o f maxillary anterior teeth (T a bles 1 and 2) since physical exploration of the teeth supplemented by posterior interproximal films are too often re garded as fully meeting diagnostic re quirements. There was no indication of any situa tion in which either examination could routinely be considered adequate by it self. There are, doubtless, individual cases constituting exceptions, in which an ex aminer may be justified in assuming responsibility for dispensing with roent-
BARR—GRESHAM . . . VOLUME 41, AUGUST 1950 • 203
O M
uj
CO
“ o
o ° *“
CO
U. Uj
Ot
Z U < £ U Of ui
a.
P=physical examination
R=roentgenographic examination
Fig. 4 • Influence o f tw o factors on the relative efficiency of physical and roentgeno graphic examination for proxim al caries in posterior teeth. Examination findings are shown as percentages of total cavities disclosed, fo r three groups o f cases
genographic examination. But this ap proach would seem to be limited to the almost hypothetical case in which every tooth in the dentition would present an interdental space both mesially and distally, adequate to ensure certainty in visual inspection or exploration. It is safe to assert that the only diagnosis of proximal carious lesions adequately har monizing with the philosophy of con servation of natural vital teeth will re quire to be based on both physical and roentgenographic technics of examina tion. SU M M ARY
by different examiners. There was also wide variation in the efficiency of a given examiner on encountering characteristi cally different types of cases. It was evi dent that at the comparatively higher levels of apparent individual efficiency in physical examination, findings tended to include numerous sound surfaces er roneously reported as carious.
Table 2 • Results of physical and roentgenographic examinations in the case of (a) untreated proximal car ies and (b) carious defects about restorations
Group III, 162 cases
1. Findings by physical examination were Anterior teeth Virgin cavities consistently less than those disclosed by Defective restora tions roentgenographic examination. Teeth 2. There was surprising variation in Posterior Virgin cavities physical findings for identical cases or Defective restora tions strictly comparable groups as reported
By physical exam. (% of total disclosed)
By roentgeno graphic exam. (% o f total disclosed)
54.4
77.2
84.6
33.7
25.9
96.8
38.8
84.2
204 • THE JOURNAL OF THE AM ERICAN DENTAL ASSOCIATION
3. The efficiency of examination tech nics was studied in relation to specific conditions present in the dentition; for example, spaced teeth, the presence of restorations, the region being examined, the depth of caries penetration, the age o f the patient, and caries recurrence as compared with untreated lesions. The
1 0
PO STERIO R
R---------------------------------R— Fig. 6 • T w o d eep carious lesions which eluded detection through th ree successive physical examinations
P = physical examination. R = roentgenographic examination. Light gray area = percentages reported in common by both examination technics.
Fig. 5 • Percentages o f proxim al cavities dis closed by physical and roentgenographic exam inations, related to depth of penetration of caries. T he d epth of caries penetration is in dicated in the boxed diagrams at the bases of the columns
physical examination varied in efficiency under these differing circumstances; the roentgenographic examination was char acterized by remarkable stability in the level of its efficiency. 4. Neither technic by itself proved adequate for effective examination in any of the circumstances studied. The two examinations are to be regarded as mu tually complementary, the omission of either risking the probability that an im portant, if at times small, percentage of proximal lesions would fail to be dis closed. This applies to upper anterior teeth no less than to posterior sections of the dentition. 136 Harrison Avenue
Penetrating W ounds o f the Joints • Wounds can be treated safely by fixation and extension in cases
where chemotherapy can be administered. Similarly, extensive and even mildly infected wounds can be sutured per primam after adequate excision and surgical cleaning, provided that no tension exists on the suture line either in the deeper or superficial tissues, while delayed second suture in 48 hours can be carried out with impunity in the presence of adequate chemotherapy. Philip H . M itchiner, “ T he Surgery of Sepsis,” J. Internal. Coll. Surgeons, 1 2:407, July-August 1949.