Blue Check: Advancing Early Caries Detection and Minimally Invasive Care

Dr. Klein, Blue Check changed 100% my life as a pediatric dentist. It really changed my approach of caries lesions. It really changed my approach of the treatment that I provide to my patients because now I have a tool that I can see that is not susceptible for interpretation, that is pretty objective, that is really helping me to decide the next step in the continuum of caries treatment. Welcome to the Phil Klein Dental Podcast. I think for most of us, especially general dentists, we spend a great deal of our time looking for decay in our patients. And most of us were trained on the basics. Your trusty explorer, a good visual exam, and of course, x-rays. And while these tools have served dentistry well for decades, we all know they're not perfect, especially when it comes to spotting early lesions before they get out of hand. Over the years, new technologies have come along to give us some extra help. like electronic carries detection devices. Some practices have adopted them, others haven't, and today we'll get into why that might be. But what's really exciting is that there's a brand new innovation on the scene called BlueCheck by incisive technology, and it could change the way we approach carries detection altogether. Joining us to talk about it is our guest, Dr. Juan Yepes. He's a professor and associate dean for graduate education, Indiana University School of Dentistry, and an attending at Riley Children Hospital in Indianapolis, Indiana. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases, and our entire production team will really appreciate it. Dr. Yepes, welcome to the show. Dr. Klein, it's a pleasure to see you, a pleasure to be with you again. I really enjoy talking to you and sharing some of the knowledge in dentistry, so happy to be here. Yeah, for sure. Yeah, the feeling is mutual. We had some great podcasts in the past. Before we get started, tell our audience what you're currently doing real quickly as far as teaching and practicing. Yes, thank you. Very quick, I'm a pediatric dentist and I have literally one foot in academia teaching at Indiana University. And my other foot is in private practice. I own three offices, private practices in pediatric dentistry in Indianapolis. So literally teaching and practicing. So this is an important topic because, you know, we've had through the years various tools that have helped us to detect caries. Dentistry has expanded in many areas over the last hundred years. But for sure, the bread and butter. stuff that we're doing on a day-to-day basis involves identifying dental decay. And we, you know, traditionally we use the Explorer. And then, of course, we add x-rays, which we continue to use. So walk us through the strengths and limitations of these long-standing methods. Yes, as you said, Dr. Klein, we, you know, dentistry, we... use through the years, and we are still using different ways to detect dental caries. I will probably say that 95% of our time as a dentist is around carie detection. So it's a critical, an absolutely critical duty that we have as a dentist in our offices. You know, the exploder, the visual inspection, they are obviously... related with your experience, how many years you have been in practice. And there is always this subjective approach. Even if you use the exploder and you have 10 different dentists and you ask to look at that changing color in the tooth, you know, the way that we put pressure in the exploder, the way that we approach the lesion with the exploder is different between us. And as you know, at the end of the day, you know, the perception, the feeling will be different from dentist one to dentist two to dentist three. So sometimes that means that, you know, the diagnosis of caries is challenged. Now, if you have a, and you know this better than me, you have a big cavity that you can put your finger, well, everybody will agree. But I think so in these days, 2025, 21 century dentistry, we really need to look for options that will help us to detect. dental caries as early as we can because you know that early detection means that we may can reverse decay and we now in these days we know that the decay can be reversed and early detection is really critical so the exploder the visual impact inspection they they are sometimes very limited in the ability to have an early detection of a caries lesion. I agree with you 100%, Dr. Yepes. Early detection, not only in caries, but in so many other areas in medicine is so important. And that's getting ahead of it. And instead of being reactive, to be proactive. And I think using an explorer, visual exams, x-rays, you're trying to find things that have already developed. Let's talk about radiographs. especially bite wings, what are some of the challenges dentists face in detecting early carious lesions before they progress too far? Yeah, you know, radiographs are a fundamental part of our practice, and they have been around us for, you know, a long time, and they will be around us for a long time. No question that, you know, radiographs, they... They help us a lot. Now, it is ionizing radiation. We always need to keep in mind, if you need it, you need it. But remember that when you take a radiograph, you are using ionizing radiation. And if you are working with children, as you know, children are more sensitive to radiation than adults. However, bite winds are a great tool for diagnosis of caries. Very technique sensitive, as you know, depending how you put the film, depending on the angulation of the X-ray beam. But the main issue with radiographs is by the time that you are able to see a carious lesion in a radiograph, that carious lesion has been there for a while. So if we go back to the frame of this amazing conversation with you, early detection, definitely radiographs are not going to be the best tool for an early detection of a carious lesion. You know, early detection in medicine, they have been working around early detection about everything. So we in dentistry, we also... are just starting to, well, not last year, for the last 10 years, we just jump into the early detection. How critical is that? Radiographs, by the time that you see the radiographic lesion, assuming that you have a perfect paralleling technique and you put the film in the way that's supposed to be, the processing of the film, the viewing conditions, by the time that we see and we agree this is a curious lesion, that caries lesion is now a brand new caries lesion. It has been there for a while, and radiographs underestimate the extension of the decay. So by the time that you see a small lesion, in real life, it's not really a small lesion. So it's really short in terms of early diagnosis of dental caries. Yeah, I mean, I remember in dental school, we weren't allowed to even treat the tooth surgically. you know, instrument the tooth with a burr unless it was clearly into the dentin. Am I right? And they always told us that it's further than it shows up on the film. We would look at the bite wing and say, well, it's at the... cemento enamel or the dentin enamel junction, but it's probably further in than that. And it was just so unscientific in so many ways. As a dental student, I was like, man, this is a weird profession I'm getting into. Every instructor I talked to in the dental clinic here, and I went to a decent dental school at Penn, had a different opinion whether that particular tooth was ready for, you know, getting drilled. And even the fact that we had to drill it is another controversial topic that we could talk about on another podcast episode. which is, you know, we shouldn't be doing surgical intervention before medical intervention. And the people that are proponent, the doctors that... proponent of medical intervention are looking at silver diamine fluoride and glass ionomer, that's a whole other discussion, right? Dr. Klein, by the way, I went to Penn as well. Let me tell you something. If we, as a dentist, as the dental community, if we can find the holy grail of dentistry, a tool who is going to help us in an objective way in the early detection of... caries lesions. That would be the holy grail. I mean, if we are able to have something in our toolbox that we can use for early detection of caries lesions, we are really moving forward because the key is early detection of caries lesions means that you may are able to remineralize that lesion and not provide any surgical treatment. Right. No removal of tooth structure. That's the key. Minimal intervention is really the best way to treat this. No question about it. In the last 10 years, there is a lot of information, sometimes overwhelming, about minimally invasive dentistry or minimally invasive restorative dentistry. And we can stay here for hours because, obviously, depending on how many years ago you graduated from dental school, you may well, oh my God, no way. I'm not going to be on the side of minimally intervention restorative dentistry. But if we can... use something who is going to help us objective without a lot of issues with interpretation? Because you didn't ask me, but I'm going to ask myself, how about, Dr. Yepes, about the fluorescence in the detection of dental caries? All these kind of methods that we watch in the last 10 years that they also claim that they help in the early detection of dental caries. Yeah, you're talking about the electronic caries detection devices. They hit the market big over 10, 12 years ago, 15 years ago. They were huge. marketing blitz showing the benefits of these electronic detection devices. I'm sure dentists are still using it, but you don't seem to be a huge fan of it. Yes, but you know, and you are right. When we start to go to the dental shows and we start to see the near infrared transillumination, the fluorescence, all these electronic methods, we all open our eyes and said, here we go. Finally, this is the holy grail. We are now able to detect early caries lesions. But in these days, I'm sure many dentists are still using, but definitely one of the main issues with all these electronic systems is the interpretation. It's challenge. is subjective very often. And also you are in the gray zone of maybe false positives. And that false positives, I think so, is one of the reasons why many then decide to move away from that. Because the false positive means that the device is telling you that there is maybe decay when it's not decay. So you may end up doing an intervention when you don't need to do the intervention. And, you know, the variability of the results between providers, the learning curve, because, you know, these devices were very sensitive in the way that you use it. I was, you know, believe me, when these devices started to pop in the market, I really started to say, okay, here we go. We are now able to do something for early detection of caries lesions. Now, 12, 15 years later, I don't think so that excitement about the electronic tools. It's still as high as it used to be. Yeah, and the false positives, that's a big problem. Now, the companies could blame it on the technique of the dentist and the dentist could blame it on the mechanics of the actual device, but it doesn't really matter because a device has to be easy to use, reliably consistent, and not have false positives because the last thing you want is something to influence your diagnostic determination based on some... bad data you're getting, right, from an electronic device. So we addressed the traditional ways that we typically detect caries, but there's something new out there now, and I want to talk to you about it. It's called BlueCheck. Some really brilliant research and development is part of this product, which is really based on its chemistry. Tell us about how it works and the potential that this brings to early detection of dental decay. This technology of the blue check is a technology that had been around for a while. I still remember an article in the Journal of Dental Research. And by the way, the Journal of Dental Research is the highest impact research journal in the dental field. I am the associate editor of the Journal of the American Dental Association. Quite honestly, in terms of research, the Journal of Dental Research is really the beacon that we follow. So in 2010 was an article published in the Journal of Dental Research about potential molecule that will bind to the hydroxyapatite. And this molecule and the binding with the hydroxyapatite will help us to map. early porosities. And these early porosities will help us to detect early demineralized areas. And that means that we maybe are able to detect even before it's a white spot lesion. Remember, this article is in 2010, thinking that this new technology will give us some tools for early detection of dental care. So essentially, you're talking about the earliest possible stage of decay. This is the most incipient stage. in the progression to dental caries which you could not see with the naked eye you couldn't feel with an explorer no electronic device will probably pick it up and x-rays will certainly not pick it up you're saying that this molecule in itself will identify this low level demineralization yes this molecule is a natural protein and this protein they basically add a blue dye and they place that in a saline solution so the fundamental without getting too deep because we really want the audience of our podcast to have a good sense of how it works and they may well actually look for more information if they want to go deeper but basically what this natural protein together with the blue dye in a saline solution will do is it will go through the porosities created by demineralization and will go through that into the enamel and dentin and bind to the hydroxyapatite. And that binding is reversible, so you can wash it out. And that will give us a dye blue. that will give us a visual helper that is telling us that it's demineralization. And that demineralization, look, Dr. Klein, how critical is that? Because this is framed by minimally invasive restorative dentistry. Because now we know that demineralization means that you are still within the reversible frame of caries lesions. So if we can identify a demineralized area, then we can... Patient education, we can show to the patient, we can target the remineralized techniques that we have with the toothpaste or with all the different options that we have for remineralization. So basically, blue check, using this natural protein, who is linked with a blue dye, will go through the porosities created by the demineralization. And remember, the demineralization is created by the production of acid by the bacteria that is... Yeah. Let me ask you this question. The color of the blue, if we have a deep blue visually, is that different than a lighter blue? Is there any difference in the way it visually looks? And will that determine, in our mind, how to go about to treat that demineralized lesion? Yes. More blue means that... that is more demineralized areas. And Dr. Klein, I just want to repeat something that I think is important for the audience, the dentists, and the dental team members who are listening to this podcast. This is even before we have the white spot lesion. Because the white spot lesion, we know and we learned this in dental school, that's a demineralized area. But we know that to get into the white spot lesion is already some time. So blue check will help us to go even before we can detect white spot lesion. Will help us to detect that areas who are starting to be demineralized. And that is helping us as a dentist to put together a plan, an action plan, which depending what you want to do, you can use silver diamine, you can use different options that we have, not even using the high speed yet. Plus... And I want to, because I use blue check daily in my office. It's also a good tool for patient education. You know, when you have a radiograph, when you have using the exploder, yeah, you can use the camera, you can take a picture, you can show to the patient. But now with the blue check, you can really, and we are going to probably talk in a few minutes about how we use blue check, because it's pretty easy, straightforward. But once we see these blue areas, then you can show to the patient. You can take a picture or you can use the mirror or whatever you want to use, but now the patient will help you to visualize areas that you need to pay more attention when you are brushing or areas that definitely they are showing that we need to do something else besides just having a good brush. Right. So when you do that blue check exam and you paint this material on, which you'll talk about with us, how you use it clinically in a second, because I'd like our audience to know actual clinical steps in applying this material. When you record the information that you see in the mouth, in the chart, and let's say you see some light blue activity in the molar area, in the grooves and the fossa, where you typically would get decay in a child, and it's very mild. You don't even pick it up with an explorer. What do you put down in the chart when you record this early blue indication that there's some demineralization going on? That's a great question. Imagine two number K, you know, and you use blue check, and then we will go through the technique in a minute, which is really pretty simple. And you see this in the groups, this kind of blue, not too dark. And how we record that? Well, that is... what you mentioned before that will be the watch that we used to put in the old days can't get rid of that watch can't get rid of it and and but but the the nice about that is that now we are for sure using you know this chemical technique we know that there is a demineralized enamel and that is a fact That is an objective way to see that. And the demineralized enamel, if we don't pay attention and we don't work with the family, we don't work with the parents, we don't work with the patient, depending on the age, we know that that demineralized is just one step behind having a cavitation and having a carous lesion who is going to need a surgical approach. Let me ask you this. Do you change the frequency of the re-care visit based on this? using blue check if you consistently find that blue check is is visible in these areas where we're talking about in in pedo patients would they come in more often to evaluate those same areas since they're considered i would say high risk yes yes and and um i i do that in my private practice when we have you know the classification of the carry risk is something that i hope everybody and our dentists who are listening to this podcast. I hope that you do that because definitely there are patients at high risk that they need to come to the office more often. And as you said, if I'm using the blue check and I detect some areas of demineralize and I decide not to intervene, that's one of the goals because we are catching the lesion early on. And we know that, you know, at that point, you probably don't need to go into the surgical option. That patient probably, I will... let my assistant and my front desk know that I want to see the patient back in three months or that I want to see the patient more often than just twice a year because we want to follow that lesion. So tell us how you incorporate BlueCheck into your workflow because you mentioned you use it practically on every patient. The idea is using BlueCheck is to provide us with a visual help that is going to Again, the holy grail for the early detection of caries lesion that maybe don't need any surgical treatment. We just do education and do other techniques to remineralize the enamel. Super easy, Dr. Klein. You clean the tooth. You can do that with a profi cup or you can do that with a toothbrush. And then using a micro brush is coming in a little container, which is blue. It's like a little liquid blue, and you apply that over the area. And then you wait for at least a minute, a minute and a half, and then you wash and rinse that, and then you will see the blue areas. Remember, this is reversible. So then after that, you can just use the toothbrush again, and then you can remove the blue area. So the patient is not going home with all the teeth blue for the next 24 hours. Right. Now, do you look at this tool? As the best adjunct dentists have today, when you look at cost, when you look at convenience as far as workflow, when you look at compliance with doctors using it. Dr. Klein, blue check changed. 100% my life as a pediatric dentist. It really changed my approach of caries lesions. It really changed my approach of the treatment that I provide to my patients because now I have a tool that I can see that is not susceptible for interpretation, that is pretty objective, that is really helping me to decide the next step in the continuum of caries treatment. We talked about this offline, Dr. Yepes, molar hypomineralization syndrome. And you see that. more and more tell us how blue check helps you with that specifically with determining the extent of this condition In the molar hypomineralization syndrome, that is something that we are seeing these days more than never before, blue check is a wonderful tool because one of the issues when we see these molars with these huge hypomineralized areas is to determine the extension of the demineralization, how far I need to go. And as a clinician, that's a big challenge because you don't know. You see the tooth is muggy, soft, and you see that enamel that... and you don't know how far you need to go when you are providing a restoration. With blue check, it will tell you how far you need to go because blue check will mark the demineralized areas, will give you a limit that you know that you need to go up to that. And then if the enamel or the dentin is not blue, that means that it's not demineralized, so you can stop there. Finally, in dentistry, and again, the radiographs are still there, the exploder is still there, your eyes are still there, years of experience is still there. But now we are adding a new tool that is helping us for that early detection. So essentially the blue check follows the demineralization. How far can it go down into the tooth? Depending how far down is the demineralization. So it can go five millimeters? It can go five millimeters. And remember, when you are working in this model, with this massive demineralization. You really want to have kind of the borders who are healthy sound and blue check will help you to determine the borders and know how extensive is the lesion. Because the principle is this natural molecule together with the dye they will go through the porosities of the enamel and bind the hydroxyapatite. So if the enamel is fine, if the dentin doesn't let the dye to go through and bind the hydroxyapatite, that means that you don't have demineralization. But if you continue seeing the blue, that means that you have demineralization. Now, are you using hand instruments when you're doing this? Because if you used a high speed with water, it would be washing this dye out. Yes, I use low speed with a round burp. Okay, so the water is not flushing this blue out of the area, so it's still useful to you visually, because that's another practical thing I was thinking of. You know, I interview a lot of dentists, Dr. Yepes, but I do sense a kind of enthusiasm that's kind of extraordinary when it comes to how this diagnostic tool has changed the game for you. We all are. in that page of history of dental caries. You know, that's the 2025, 21 century understanding of caries. So you don't need to have an extra effort to understand that. And blue check fits perfectly within that concept of demineralized, remineralized, because now we have a tool, a visual tool, objective, who is going to help us to identify areas of demineralized enamel, which we now know does a... early care resolution. And in addition, Dr. Yepes, based on everything we talked about, the benefits of this chemistry on the clinical level of helping the dentist determine the extent of the demineralized zone and so forth, it's also a really good tool to use for patient education in a pediatric practice. With a pediatric patient, you are not just only working with the kid, you are working with the parents or the caregiver. Sometimes my residents, when they complain, oh, my God, pediatric dentistry is always a challenge because we need to deal with parents. I tell my resident, you are in the wrong place because pediatric dentistry means dealing with the parents. You know, a two-year-old, a three-year-old, you need to work with the parents. So what's a wonderful idea that now you have a visual helper that you can... Take a picture. You can show to the parents and say, you know, this area of this particular tooth is starting to show early demineralization, which mom and dad, that means if we don't pay attention, that will be a swimming pool. And swimming pool means that you can put your finger. And we don't want to do that. So what we are going to do in that blue spot, we are going to pay attention when you brush. We may actually place a ceiling. And so when you have the parents on board and they understand, I do that. All the time. All the time. Because moms and dads are as important as the patient that I have in the dental chair. Absolutely. Yeah. No, great hearing from you, Dr. Yepes. Everything you're saying makes sense. It seems like we've reached a time in the dental innovation timeline where we have now something that makes sense, that's very practical, that actually helps everybody in the entire exchange. when you're talking about helping people get better, which is including the parents, the kids, and the actual dentists themselves. And this blue check is something worth checking out. And that's through incisive technology, by the way, for our audience. Dr. Yepes, thank you very, very much. We really appreciate your input, and we look forward to having you on future programs. Oh, Dr. Klein, it's always a pleasure to talk to you. I really enjoy talking to you. And, you know, the work that you do helping us, the dental profession, to move forward and to disseminate the knowledge is super critical. We always need to be aware that we are moving forward as a profession. And the only way to don't be in the back is, you know, listen to podcasts and reading. Amen to that, man. As a podcaster, I'm all for that. Thank you very much. Sometimes my colleagues, they say, well, when I'm driving, I listen to your podcast. Well, you can listen to this podcast driving, eating, you know, whatever you, but at the end of the day, the benefit is for our patients. Yeah, absolutely. That's the ones who are getting the benefit of the time that you spend listening to my Kentucky accent or my We Are accent. The benefit is not for you. The benefit is for the human that you have in the dental chair. Yeah, amen to that. That's the justification of doing this. Yeah, and that's what makes my job worth it, and that's what gets me out of bed. And I can't agree with you more, Dr. Yepes. And it's interviewing people like you, talking to people like you that actually care about the health and the patient as a human being, not just a tooth. Yes. And not just as a dental business where you're looking to make money, which is important. You have to have a successful practice. But there's a human being behind all of this. And fantastic. Very well said. And let's do some more of these soon, okay? Okay. Thank you so much.