IntroductionRadiographic methods have poor sensitivity for occlusal lesions and by the time the lesions are radiolucent they have typically progressed deep into the dentin. New more sensitive imaging methods are needed to detect occlusal lesions. In this study, cross‐polarization optical coherence tomography (CP‐OCT) and near‐IR imaging were used to image questionable occlusal lesions (QOC's) that were not visible on radiographs but had been scheduled for restoration on 30 test subjects.MethodsNear‐IR reflectance and transillumination probes incorporating a high definition InGaAs camera and near‐IR broadband light sources were used to acquire images of the lesions before restoration. The reflectance probe utilized cross‐polarization and operated at wavelengths from 1,500 to 1,700 nm where there is an increase in water absorption for higher contrast. The transillumination probe was operated at 1,300 nm where the transparency of enamel is highest. Tomographic images (6 × 6 × 7 mm3) of the lesions were acquired using a high‐speed swept‐source CP‐OCT system operating at 1,300 nm before and after removal of the suspected lesion.ResultsNear‐IR reflectance imaging at 1,500–1,700 nm yielded significantly higher contrast (P < 0.05) of the demineralization in the occlusal grooves compared with visible reflectance imaging. Stains in the occlusal grooves greatly reduced the lesion contrast in the visible range yielding negative values. Only half of the 26 lesions analyzed showed the characteristic surface demineralization and increased reflectivity below the dentinal‐enamel junction (DEJ) in 3D OCT images indicative of penetration of the lesion into the dentin.ConclusionThis study demonstrates that near‐IR imaging methods have great potential for improving the early diagnosis of occlusal lesions. Lasers Surg. Med. 49:215–224, 2017. © 2017 Wiley Periodicals, Inc.