Dr. Giuseppe Marano
DDS
• Dr. Marano graduated from the ‘La Sapienza’ University of Rome and is specialized in oral and maxillofacial surgery.
• With over 20 years of experience in the field, he has developed specialized skills in oral surgery and implantology and continues to be interested in conservative dentistry, periodontics and oral pathology.
• As a father of two children, he has learnt to treat pediatric patients by making them feel at ease in the course of the treatment and teaching them the value of oral hygiene at an early age.
*Dr. Giuseppe Marano is an independent consultant paid by Align Technology for this article. Any statements, views and/or opinions expressed in this material are those of the author only.
introduction
introduction
I stepped into digital dentistry at the end of 2018*, changing my workdays almost overnight. Impressions stopped requiring entire appointments, restorations were seated with fewer adjustments, and, most importantly, I finally had a way to show patients what I was seeing from the first consultation. The intraoral scanner moved from being a “nice gadget” to being vital.
This article does not showcase elaborate reconstructions. It aims to document how easy and fast the early diagnosis of interproximal caries becomes when near-infrared imaging (NIRI) is integrated into the first visit and to outline a workflow that other general practices could adopt. Clinical studies on an earlier iTero platform reported accuracies of ~88% for early enamel lesions and ~97% for dentin-enamel junction (DEJ)–level lesions when assessed by clinicians. These accuracies were even higher with expert readers, and early enamel changes were sometimes apparent on NIRI and not on bitewings [1].
How the iTero Lumina Pro imaging system works – and what’s new
How the iTero Lumina Pro imaging system works – and what’s new
Optics and Capture
The iTero Lumina Pro scanner couples 3D color scanning with NIRI frames captured during the scan pass. Compared with prior iTero scanners, this latest model offers approximately a 3× larger field of view (at ~12 mm scanning distance), simultaneous multi-angle capture (Multi Direct Capture™ technology) that reduces handpiece gymnastics, and a 25mm working capture distance (manufacturer’s specifications [8]).
In my experience, this means more data from more angles in fewer movements, with steadier hands and calmer patients.
Why This Matters
The newly introduced ergonomics and capture technology developments enabled me to sweep contact points in a single smooth pass, producing a review set that supports immediate decision-making with the patient present. NIRIs appear bright where enamel is demineralized (due to increased scatter) and dark where enamel is sound (relatively transmissive at near-infrared wavelengths) [3].
“With the intraoral scanner, I finally had a way to show patients what I was seeing from the first consultation.”
Background: why to use NIRI at the first consultation
How the iTero Lumina Pro imaging system works Background: why to use NIRI at the first consultation
Bitewings remain the standard, but their in vivo sensitivity for early proximal lesions is modest at about 0.24 with high specificity, meaning that a substantial fraction of early disease is radiographically invisible at a single time point [2]. In contrast, NIRI leverages differences in light scatter and has shown non-inferiority overall and higher sensitivity for early enamel lesions in clinical settings, corroborated by partial excavations [1]. Other studies using NIRI transillumination similarly support early lesion detection without the use of ionizing radiation [4-7].
Objectives
Objectives
- Describe how NIRI enables rapid, credible chairside identification of potential interproximal lesions during patient intake, prioritizing feasibility, speed, and patient communication.
- Provide a reproducible first visit workflow supported by Align Oral Health Suite and explain where AI-based detections on radiographs add value.
- Generate preliminary observations for a larger, controlled study.
Materials and Methods
Materials and Methods
Setting & Patients
Ten patients at their first general-practice visit. Radiographs were obtained as clinically indicated, and no imaging exceeded routine care.
Devices & Software
iTero Lumina Pro imaging system. Align Oral Health Suite for chairside visualization, markup, and documentation. Align X-ray Insights to assist with the AI-based review of bitewing or periapical X-rays. This software aggregates 3D color, intraoral photos, NIRI, and radiographs into a single view to support patient communication (manufacturer’s information [8]).
First Visit Workflow
- History and risk assessment.
- Full arch scan, made with smooth passes over contact points with NIRI captured concurrently (large field of view and multi-angle capture reduce rescans).
- Review in the Align Oral Health Suite with the patient. Toggle color ↔ NIRI on the contact of interest; loupe, annotate, and snapshot.
- Targeted intraoral X-rays as indicated, review AI detections, and reconcile with NIRI and clinical judgment.
- Shared decision-making on treatment possibilities. Discuss monitoring compared to minimally invasive care and preventive measures. Save annotated views to the patient’s record.
Interpretation Cues
Triangular brightening confined to enamel suggests an early enamel lesion. Trapezoid patterns crossing the DEJ indicate likely dentin involvement; visual language borrowed from the multicenter study and helpful in training readers [1].
Outcomes of Interest
Because this is a descriptive series embedded in routine care, the outcomes focus on:
- Time/feasibility of detection at the first visit.
- Concordance patterns across NIRI, bitewings, and AI detection.
- Patient communication value.
Results
Results
In each case, NIRI provided the first indication, typically within minutes of seating, by highlighting a bright contact against dark enamel. Where bitewings radiographs were taken, some signals matched NIRI well while others were equivocal or negative on bitewings but suggestive on NIRI, mirroring published sensitivity patterns [1, 2]. Importantly for this series and the accompanying figures, there were instances where panel (b) shows no AI overlay even though panels (c and d, NIRI) and subsequent clinical access confirm a lesion, illustrating that the software can occasionally miss early enamel changes, while the potential lesions are visible on NIRI during the same visit. Operationally, the larger field and multi-angle capture shortened scan times and reduced the need for rescans, so the review on the Align Oral Health Suite felt truly live. The patients responded to the toggling between color and near-infrared with immediate understanding—it was often the decisive moment for understanding their clinical condition and accepting preventative or minimally invasive care.
“The larger field and multi‑angle capture shortened scan time and reduced rescans, so the review on the suite felt truly live.”
Representative images for the cases are compiled in Fig. 1–10.
“NIRI images appear bright where enamel is demineralized, due to increased scatter, and dark where enamel is sound, relatively transmissive at near infrared wavelengths.”
Align X‑ray Insights
WHAT IT IS
Align™ X‑ray Insights is a software‑only, computer‑assisted detection (CADe) tool that uses deep learning models to analyze dental radiographs and render color‑coded annotations directly on the image and on an interactive tooth chart. It is explicitly intended to support, not to replace, a clinician’s judgment, and it should not be relied upon as the sole basis for diagnosis.
HOW IT HELPS
In our workflow, Align X‑ray Insights structures the bitewing review and strengthens patient communication when overlays are present. In manufacturer surveys from a limited market release, clinicians reported higher patient trust and increased acceptance of restorative procedures when visuals were shown chairside [8].
Together, Align™ Oral Health Suite and Align™ X-ray Insights create a unified visual language for the consultation.
WHERE IT FALLS SHORT – AND WHY THAT’S EXPECTED
AI-based analysis of 2D radiographs inherits radiography’s limits for very early proximal disease. If the density change is not yet radiographically evident, an AI algorithm cannot report what the signal does not contain. In this series, several panels (b) show no red/colored regions even though NIRI (d) localizes the lesion and clinical access confirms it —precisely the complementarity we expect when leading with NIRI.
IMAGE QUALITY MATTERS
Like for traditional human-only visual radiograph assessment, it is recommended to use high-quality radiographs (with regard to exposure, contrast, noise, motion/positioning, and sensor resolution) for consistent AI-based diagnostic performance. To ensure the optimal radiographic exam, stable bitewing holders should be used, motion should be avoided, exposure/contrast should be optimized, collimation and cropping should be consistent, and blurred images should be reacquired.
FEATURE NOTES
The software standardizes the analysis across images. Higher-tier plans include automatic patient data retrieval and other workflow optimizations. As the training dataset grows and clinicians provide the system with clearer, cleaner images, its utility will likely continue to improve.
BOTTOM LINE FOR PRACTICE
We combine the use of NIRI and AI-supported radiographic analysis, first assessing with NIRI, and then corroborating with AI detection in bitewings. When suspicious areas are visible in NIRI but not on bitewings, discuss monitoring versus preventive and minimally invasive care with the patient and document the rationale.
Integrating Align Oral Health Suite into the first consultation
Integrating Align Oral Health Suite into the first consultation
- Single hub for evidence. The Align Oral Health Suite unifies the 3D model, intraoral images, NIRI frames, and bitewings, allowing patients to see their mouth rather than a stock diagram. In a limited market release survey, clinicians reported stronger consultation impact when using this scanner interface (manufacturer’s data on file [8]).
- Documentation at the speed of conversation. Markups and snapshots become a baseline for monitoring.
- Trust through transparency. Instant toggling between color and near-infrared over a specific contact helps patients understand why we recommend monitoring or treatment.
Discussion
Discussion
This approach has two notable benefits. Firstly, feasibility and speed: the iTero Lumina Pro imaging system’s optics package (field of view, multi-angle capture, and working distance) shortens the path from scan to diagnosis and patient conversion to treatment, which is crucial when we aim to screen at the first visit. Secondly, concordance: NIRI sometimes suggests early enamel changes that bitewings (and thus Align X-Ray Insights) and clinical examination do not, while remaining comparable for deeper lesions, consistent with the multicenter clinical data [1, 2].
There is also a communication dividend. When patients see a bright area on NIRI and then see the same site on the color model, the rationale for prevention or minimal intervention becomes self-evident. This clarity reduces chairside friction and improves adherence, which is arguably as important as any numerical accuracy metric for everyday practice.
Limitations
This series was small and involved a single operator. Additionally, the bitewings were acquired based on clinical judgment or after NIRI detection rather than a strict protocol, and AI detections were used qualitatively. Therefore, the observations should be treated as hypothesis-generating and not definitive
Implications
A scaled, prospective study comparing NIRI to bitewings, with blinded readers and per-surface outcomes (enamel versus dentin-enamel junction), could compute sensitivity/specificity and agreement (McNemar’s test for paired proportions, Cohen’s κ for agreement beyond chance) and include longitudinal monitoring to identify which NIRI-positive/bitewing-negative signals progress (i.e., precisely the domain where radiation-free repeat imaging adds value) [1, 2, 9-11].
“Align X-Ray Insights adds structure and communication value.”
Conclusion
Conclusion
Making NIRI the first step with the iTero Lumina Pro imaging system transformed early interproximal diagnosis into a quick and transparent conversation in our practice. Align X-Ray Insights adds structure and communication value, but, as shown in several cases, does not always identify potential early interproximal lesions visible with NIRI. Looking ahead, we expect AI support to strengthen as training datasets expand and the software matures. However, even then, its role will remain assistive. The dentist’s clinical examination and judgment remain at the forefront of treatment decisions. Finally, the quality and clarity of radiographs uploaded to the system are decisive—better images lead to better assessment. This series suggests that a larger, controlled evaluation of an NIRI first workflow complemented by bitewings is required.
SOURCES
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