Developments in caries diagnosis and their relationship to treatment decisions and quality of care. ORCA Saturday Afternoon Symposium 1997

Perception of Pain With Bitewing, DIAGNOcam, and Teeth Separation Amongst Children

BACKGROUND

This study evaluated the pain and discomfort associated with 3 diagnostic techniques for proximal carious lesions in children aged 5 to 8 years: bitewing (BW) radiographs, DIAGNOcam, and temporary teeth separation.

METHODS

The study included 60 healthy children between the ages of 5 and 8 years who had no prior history of dry mouth or mouth breathing, were definitely positive or positive based on Frankl Behavioral Rating Scale, had at least one pair of matched bilateral primary molars and/or permanent first molars in close contact with the adjacent tooth, and were free of restorations and frank cavitation. Each patient evaluated all 3 techniques. The pain and discomfort ratings were obtained by the Wong-Baker FACES Pain Rating Scale immediately after taking 2 standardised BW radiographs or undergoing use of DIAGNOcam and 2 days after temporary teeth separation with elastic separators by a single trained and experienced paediatric dentist.

RESULTS

The DIAGNOcam procedure resulted in much higher pain and discomfort (3.69 ± 3.10) than the other 2 diagnostic techniques. Within-participant pain and discomfort scored significantly higher with DIAGNOcam compared to BW radiographs (P < .001) and temporary teeth separation (P = .002).

CONCLUSIONS

The DIAGNOcam diagnostic technique caused much more pain and discomfort than BW radiographs and temporary teeth separation using orthodontic elastic separators. The report is part of a randomised clinical trial that was registered at www.

CLINICALTRIALS

gov under the identifier NCT03685058.

Ear, nose and throat specialists’ awareness on oral and dental health and orthodontic problems in children with mouth breathing due to adenotonsillar hypertrophy

Introduction: Considering the nature of oral healthcare needs for children with adenotonsillar hypertrophy (ATH) and mouth breathing and the increased risk of oral disease faced by the children, we aimed ascertain the perception and experience of ear, nose and throat (ENT) specialists to dental referral for such children. Material and Method: A descriptive, cross-sectional survey was sent to a sample of ENT specialists in Turkey. The questionnaire, consisted of 27 questions in five domains. A total of 123 ENT specialists participated in the survey. Results: In the evaluation of the examination of the oral cavity of children with ATH, a low frequency of examination for the malocclusion (57.7%) and oral functional habits (68.3%) was found. Reasons ENT specialists referred patients to orthodontists varied from missing teeth 15.4% to sounds from tmj 66.7%. In the chi-square test for the effect of gender and the location of practice in the orthodontic referral of ENT specialists we could identify significant predictors (p

Detection and Characterization of Human Teeth Caries Using 2D Correlation Raman Spectroscopy

BACKGROUND

Carious lesions are formed by a complex process of chemical interaction between dental enamel and its environment. They can cause cavities and pain, and are expensive to fix. It is hard to characterize in vivo as a result of environment factors and remineralization by ions in the oral cavity.

OBJECTIVES

The development of a technique that gives early diagnosis which is non-invasive, is of crucial importance for publichealth. Raman spectroscopy is a technique that can fulfil these requirements. The main goal of this work was to use Raman spectroscopy to differentiate between normal and carious human teethinvivo. The samples used in this study were collected by traditional human teeth.

MATERIAL AND METHOD

An in vivo Raman spectroscopy system andspecialized fiber optic probe has been designed to obtain spectra from tissue. Theseprobes are filtered to reduce the background signal from the fiber optics and the collection fiberutilizes beam steering to optimize the collection effectiv.

RESULTS

In order to detect any demineralization and carious versus sound pit and fissure enamel, the spectral data sets are analyzed by the proposed scheme to demonstrate the utility of generalized 2D correlation spectra. Potential applications of this 2D correlation approach are then explored. The Raman spectra in the normal tissue showed thepresence of vibrational bands in 437.87 cm^-1, 581.89 cm^-1, 953.89 cm^-1 and 1054.73 cm^-1 with smaller intensity than in the carious spectra. Image construction from the peak intensity produced chemical maps of apatite concentration.

CONCLUSION

Such two-dimensional correlation spectra emphasize spectral features not readily observable in conventional one-dimensional spectra.No correlation is observed in mode-to-mode intensity fluctuations indicating that the changes inmode intensities are completely independent. Theoretical calculations provide convincing evidence that the fluctuationsare not the result of diffusion, orientation or local electromagnetic field gradients but rather are the result of subtle variations ofthe excited-state lifetime, energy and geometry of the molecule and producing a signature response for carious detection.

[Nearinfrared light transillumination for detection of incipient proximal caries in primary molars]

OBJECTIVE

To evaluate the practical value of nearinfrared light transillumination (NILT, DIAGNOcam) on detection of incipient proximal caries in primary molars.

METHODS

In this study, 4-9-year-old children with suspicious proximal lesions in primary molars were recruited. The target teeth were examined with clinical examination, bitewing radiograph and DIAGNOcam. And the caries indexes were rated as 0 (no caries), 1 (caries reaching outer 1/2 enamel), 2 (caries reaching inner 1/2 enamel), and 3 (dentine caries). Those primary molars with at least one of the adjacent molars according with the criteria of invasive treatment, i.e. the teeth were diagnosed as caries reaching inner 1/2 enamel or dentine with at least two detection methods, were included. The target teeth with caries index ≥2 accepted the invasive treatment. And the caries status of the adjacent teeth was observed under direct vision and those teeth of caries index ≥2 would also accept the invasive treatment. The relationship of lesions to enamel-dentine junction (EDJ) were recorded and used as reference standard to compare the sensitivity, specificity and accuracy of those three methods in detecting the incipient proximal caries in primary molars.

RESULTS

In this study, 36 children with 104 suspicious proximal lesions in primary molars were recruited, of which 5 were diagnosed as no caries, 20 were diagnosed as superficial enamel caries, and 79 accepted invasive treatment, of which 22 were diagnosed as EDJ caries, and 57 as dentine caries. The sensitivity of clinical examination, bitewing radiograph, and DIAGNOcam were 68.69%, 81.82%, 78.79%, respectively. The specificity were 100.00%, 100.00%, 80.00%, and the accuracy were 75.96%, 85.65%, 78.85%, respectively. As for superficial enamel caries, the sensitivity of clinical examination was lowest, only 10%, while DIAGNOcam was 60%, higher than 40% of bitewing radiograph. As for EDJ caries, the sensitivity of bitewing radiograph was highest as 86.36%, followed by DIAGNOcam 72.73% and clinical examination 68.18%. As for dentine caries, the sensitivity of the three detection methods were higher than 85%, of which bitewing radiograph was the highest as 94.74%.

CONCLUSION

The accuracy of DIAGNOcam in detecting incipient proximal caries in primary molars was comparable to that of bitewing radiograph. It was safe, and convenient with no exposure to radiation, which was applicable to be used in pediatric dentistry.

Validity and reliability of remote dental screening by different oral health professionals using a store-and-forward telehealth model

Objective This study was conducted to evaluate the validity and reliability of intraoral photographic assessments by different members of a dental team as a means for dental screening in children.Methods The intraoral photographic records of 126 children (2 to 18 years old) were obtained from routine clinical records taken before dental treatment. Intraoral photographs were obtained using a DSLR camera and then uploaded to a cloud-based server using store-and-forward telehealth technology. Images were reviewed by an expert panel to formulate a benchmark screening baseline, to which the screeners' data were compared. The photographic assessments conducted by a mid-level dental practitioner (MLDP) and dentist, were compared to the benchmark expert panel assessment.Results The screeners' assessments by means of intraoral photography, when compared to the expert panel assessment had a sensitivity value of 82-89% and specificity value of 97%. The inter-examiner agreement between the expert panel assessment and photographic method (assessed by a dentist and MLDP), was almost perfect, with a kappa score ranging from 0.82 to 0.88. The mean DFT/dft score for the children as determined by the expert panel's review and photographic assessment ranging from 5.41 to 5.79, with mean scores between the two assessment methods not significantly different (P = 0.746).Conclusion Our results suggested that oral health professionals (other than dentists) have the potential to screen for caries from intraoral photographs with the same diagnostic accuracy and reliability as dentists. This strategy has implications for supporting the use of MLDPs such as dental therapists or hygienists to screen for oral disease using telehealth.

Three-year survival of ART high-viscosity glass-ionomer and resin composite restorations in people with disability

OBJECTIVES

To assess the 3-year cumulative survival rate of atraumatic restorative treatment (ART) and conventional resin composite restorations (CRT) placed in persons with disability.

MATERIALS AND METHODS

Patients referred for restorative care to the Haemophilia Foundation special care service were treated by one of two specialists. Patients and/or caregivers were provided with written and verbal information regarding treatment options and selected the alternative they preferred. Treatment was provided as selected unless this option proved clinically unfeasible when an alternative technique was proposed. The treatment protocols were ART (hand instruments/high-viscosity glass-ionomer) in the clinic or CRT (rotary instrumentation/resin composite) in the clinic or under general anaesthesia (GA). After 6, 12, 24 and 36 months, two independent, trained and calibrated examiners evaluated restoration survival using established ART codes. The proportional hazard model with frailty corrections gave survival estimates over 3 years.

RESULTS

Sixty-six patients (13.6 ± 7.8 years) with 16 different disability profiles participated. CRT in the clinic proved feasible for five patients (13%), and 14 patients received CRT under GA (21%). ART was used for 47 patients (71.2%). Altogether, 298 dentine carious lesions were restored in primary and permanent teeth (182 ART; 116 CRT). The 3-year cumulative survival rates and jackknife standard errors for the 182 ART and 116 CRT restorations were 94.8 ± 2.1 and 82.8 ± 5.3%, respectively (p = 0.01).

CONCLUSIONS

The 3-year follow-up results confirm that ART is an effective treatment protocol.

CLINICAL RELEVANCE

Patients with disability, many of whom have difficulty coping with CRT, may benefit from the ART approach.

Modern Concepts of Caries Measurement

Following the consideration of several recent systematic and other reviews, there is a growing professional and scientific consensus that caries measurement methodology in caries clinical trials (CCT) should be updated to reflect progress made elsewhere in cariology. In this paper, therefore, “modern” means accepted in contemporary dental research and dental practice on the basis of sound research evidence—not necessarily new or requiring the use of new technology. Caries measurement should be seen in the context of the objectives of modern clinical caries management and the continuum of disease states, ranging from sub-surface carious changes through to more advanced lesions. Measurement concepts can be applied to at least three levels: the tooth surface, the individual, or the group/population. All are relevant to CCTs. Modern clinical caries management can be seen as comprised of seven discrete but linked steps (Steps 2, 3, and 4 are directly concerned with measurement.): (1) ‘Caries detection’ represents a yes/no decision as to whether caries is present; (2) lesion measurement assesses defined stages of the caries process, taking into account the histopatholgical morphology and appearance of different sizes and types of lesion and the diagnostic threshold(s) being used; (3) lesion monitoring by repeated measures at a series of examinations is used when lesions are less advanced than the stage judged to require operative intervention (A comparison of serial measurements permits the efficacy of preventive care aiming either to arrest or to reverse the lesion to be assessed.); (4) caries activity measures would be very valuable, but are relatively poorly developed and tested at present; (5) diagnosis, prognosis, and clinical decision-making are the important human processes in which all the information obtained from steps 1 to 4 is synthesised; (6) interventions/treatments, both preventive and operative, are now routinely used for caries management; and (7) outcome of caries control/management assesses caries management by examining evidence on the long-term outcomes. A challenge for the future is to define a range of optimal caries measurement methods—in use or in development in recent trials, in clinical practice, and/or in caries epidemiology—that will best contribute to more efficient, modern caries clinical trials.

The Role of Risk Factors in the Identification of Appropriate Subjects for Caries Clinical Trials: Design Considerations

In seeking new and more effective therapies to delay or prevent caries development, investigators must design clinical trials focused on high-risk populations with a predictable incidence of caries over a limited period of time. In children and adolescents, the strongest predictors of caries incidence appear to be baseline levels of caries activity (present caries, e.g., dmfs, DMFT, caries lesions in first molars). Other predictors of caries risk typically include oral hygiene level, counts of cariogenic micro-organisms in plaque and saliva, fluoride history, sucrose intake, and parent's socio-economic level. This paper will briefly review existing literature to address the most useful and relevant prognostic factors for predicting future caries onset. The relative merits of identifying high-risk subjects based on these factors, either singly or in combination, will be explored in terms of statistical efficiency. Particular attention will focus on the advantages of covariate adjustment in the context of survival-based methods for the analysis of caries data. Further, with the advent of more sophisticated diagnostic procedures ( e.g., quantitative light fluorescence) to screen and monitor study subjects for caries activity, there is the potential for earlier states of lesion initiation and progression (or regression) to be detected, with, therefore, improved experimental sensitivity to treatment effects. The validity of risk assessment and outcome measurement on the basis of these new diagnostic tools vs. more conventional methods will be examined.

Detection and treatment of proximal caries lesions: Milieu-specific cost-effectiveness analysis

OBJECTIVES

Dental caries lesions are highly prevalent, concentrated in high-risk groups, and often affect proximal tooth surfaces. Choosing a caries detection method determines the available treatment options: radiographically detected early lesion stages might receive non-, micro-, or invasive treatments, whilst visually tactile detected lesions are often advanced and mostly require invasive treatment. Thus, the choice of detection method impacts on patients via the applied treatment. We compared the cost-effectiveness of combinations of detections and treatments of proximal lesions in different populations which did or did not receive prevention during adolescence. These cost-effectiveness comparisons of different detection-treatment combinations should aid clinical decision making and improve resource allocation.

METHODS

A Markov-model was constructed to follow a proximal posterior surface in a 12-year-old German over his lifetime. Prevalence, validity and transition probabilities were extracted from the literature. Microsimulations were performed to evaluate costs (Euro) per tooth-retention-time (years).

RESULTS

For populations with low risk, radiographic detection plus non-invasive treatment without (270 Euro, 61.5 years) and with prevention (312 Euro, 63.0 years), as well as radiographic detection plus micro-invasive treatment and prevention (373 Euro, 64.0 years) were cost-effective. For populations with high risk, radiographic detection plus micro-invasive treatment without (427 Euro, 58.5 years) and with prevention (436 Euro, 61.0 years) were cost-effective. Combinations involving invasive treatments had limited cost-effectiveness.

CONCLUSIONS

Caries detection methods should be evaluated regarding the cost-effectiveness resulting from their use in different populations.

CLINICAL SIGNIFICANCE

Caries detection methods are usually evaluated regarding their validity compared to a gold standard. We demonstrate that the cost-effectiveness stemming from using different detection methods additionally depends on the treatment options determined by different methods, and the examined population. Dentists' choice of a detection method should not only be guided by its validity, but also by its specific benefits in different populations.

The Effect of Combining Radiographs and DIAGNOdent With Visual Examination on Detection and Treatment Decisions of Noncavitated Occluso-dentinal Caries

The aim of this laboratory study was to evaluate the effectiveness of incorporating radiographic examination and DIAGNOdent with visual examination for the detection and treatment of noncavitated occluso-dentinal caries. Four examiners examined the occlusal surfaces of 160 extracted posterior teeth. Teeth were examined three times with a one-month interval in between. The first examination was visual (V), the second examination was visual with radiograph (VR), and the third examination was visual with radiograph and DIAGNOdent (VRD). Examiners were asked to detect the presence of caries (if any) and identify the extent of caries (if present; ie, enamel or dentin). The examiners were also asked to choose a treatment for each tooth. The examined teeth were later sectioned, and the presence of caries was charted as 0 = no caries, 1 = caries confined to enamel, 2 = caries in the outer dentin, and 3 = caries in the inner dentin. Sensitivity, specificity, area under the curve (Az values), rank correlation coefficient, interexaminer reproducibility, and McNemar χ(2) tests were calculated. VR had statistically higher specificity and lower sensitivity than V and VRD. The means of Az values ranged from 0.58 to 0.63, with no statistical difference between the three examinations (p>0.05). The means of the rank correlation coefficients with histology for detection of dentinal caries were 0.48, 0.23, and 0.44 using V, VR, and VRD, respectively. Interexaminer reproducibility was best for V alone. The percentages of teeth indicated for restorative treatment were 31%, 33%, and 41% using V, VR, and VRD, respectively. The percentages of teeth correctly treated according to histology were 69.4%, 70.0%, and 67.5% using V, VR, and VRD, respectively. There was no difference in the accuracy of treatment decisions between the three examination points (p>0.05). The addition of radiographs and DIAGNOdent to visual examination did not have a significant effect on the improvement of the detection or treatment decisions of examiners of noncavitated occluso-dentinal carious lesions.

Characteristics, detection methods and treatment of questionable occlusal carious lesions: findings from the national dental practice-based research network

Questionable occlusal carious lesions (QOC) can be defined as an occlusal tooth surface with no cavitation and no radiographic radiolucencies, but caries is suspected due to roughness, surface opacities or staining. An earlier analysis of data from this study indicates 1/3 of patients have a QOC. The objective of this report has been to quantify the characteristics of these common lesions, the diagnostic aids used and the treatment of QOC. A total of 82 dentist and hygienist practitioner-investigators from the USA and Denmark in the National Dental Practice-Based Research Network participated. When consenting patients presented with a QOC, information was recorded about the patient, tooth, lesion and treatments. A total of 2,603 QOC from 1,732 patients were analyzed. The lesions were usually associated with a fissure, on molars, and varied from yellow to black in color. Half presented with a chalky luster and had a rough surface when examined with an explorer. There was an association between color and luster: 10% were chalky-light, 47% were shiny-dark and 42% were mixtures. A higher proportion of chalky than of shiny lesions were light (22 vs. 9%; p < 0.001). Lesions light in color were less common in adults than in pediatric patients (9 vs. 32%; p < 0.001). Lesions that were chalky and light were more common among pediatric than among adult patients (22 vs. 6%; p < 0.001). This is the first study to investigate characteristics of QOC in routine clinical practice. Clinicians commonly face this diagnostic uncertainty. Determining the characteristics of these lesions is relevant when making diagnostic and treatment decisions.

Reproducibility and diagnostic outcomes of two visual-tactile criteria used by dentists to assess caries lesion activity: a cross-over study

The aim of this study was to evaluate the reproducibility and differences in diagnostic outcomes by practicing dental clinicians previously inexperienced in using the Nyvad criteria and the ICDAS II criteria with the Lesion Activity Assessment system (ICDAS II + LAA). Four volunteer dentists were randomly allocated to one of two groups. Both groups of dentists examined the same voluntary sample (n = 140) of caries active young adults using Nyvad and ICDAS II + LAA criteria in different sequences. The first group used the Nyvad criteria during period 1, followed by ICDAS II + LAA during period 2; the second group did the examinations in the opposite sequence. Before the period 1 and 2 examinations, dentists from both groups were trained with the Nyvad or ICDAS II + LAA criteria, depending on the group to which they were assigned. Intra-examiner agreement for lesion severity was high for both diagnostic instruments (weighted kappa 0.62-0.80). For lesion activity the intra-examiner unweighted kappa values ranged from 0.31 to 0.61 for ICDAS II + LAA and from 0.36 to 0.51 for Nyvad. The mean number of active non-cavitated caries lesions was significantly higher for ICDAS II + LAA (6.14 ± 5.4) than for Nyvad (3.90 ± 3.9) (p < 0.001). Active cavitated/dentinal caries lesions were significantly higher for ICDAS II + LAA (4.14 ± 4.1) than for Nyvad (2.13 ± 3.1) (p < 0.001). Both the Nyvad and ICDAS II + LAA diagnostic criteria showed high reproducibility for lesion severity assessment. The mean number of active caries lesions among high caries risk subjects was significantly higher using the ICDAS II + LAA criteria, which may subsequently lead to more caries treatment.

TRIAL REGISTRATION

ISRCTN65592532.

Treatment planning in dentistry using an electronic health record: implications for undergraduate education

OBJECTIVE

Treatment planning, an essential component of clinical practice, has received little attention in the dental literature and there appears to be no consistent format being followed in the teaching and development of treatment plans within dental school curricula. No investigation, to our knowledge, has been carried out to explore the subject of treatment planning since the advent of electronic health record (EHR) use in dentistry. It is therefore important to examine the topic of treatment planning in the context of EHRs.

METHODS

This paper reports on how 25 predoctoral dental students from two U.S. schools performed when asked to complete diagnosis and treatment planning exercises for two clinical scenarios in an EHR. Three calibrated clinical teaching faculty scored diagnosis entry, diagnosis-treatment (procedure) pairing, and sequencing of treatment according to criteria taught in their curriculum. Scores were then converted to percent correct and reported as means (with standard deviations).

RESULTS

Overall, the participants earned 48.2% of the possible points. Participants at School 2 earned a mean of 54.3% compared with participants at School 1, who earned 41.9%. Students fared better selecting the appropriate treatment (59.8%) compared with choosing the correct diagnoses (41.9%) but performed least favorably when organizing the sequence of their treatment plans (41.7%).

CONCLUSION

Our results highlight the need to improve the current process by which treatment planning is taught and also to consider the impact of technology on the fundamental skills of diagnosis and treatment planning within the modern educational setting.

A clinical study of a laser fluorescence device for the detection of approximal caries in primary molars

OBJECTIVE

To evaluate the efficacy of laser fluorescence (LF) device in detecting approximal caries in primary molars.

METHODS

Two hundred and sixteen primary molars from 96 children were inspected visually to identify possible caries with contact approximal surfaces. Target molars and their contralateral molars were examined using bitewing radiographs (BR) and LF. Depending on the examination findings, invasive treatments were performed on molars to identify the presence of cavitation.

RESULTS

Of 256 surfaces evaluated from 216 primary molars, 128 were intact, 39 had white spots, and 89 had cavities. At the white-spot threshold, sensitivity and specificity, respectively, were 2.56% and 94.87% for visual inspection (VI); 64.10% and 97.43% for BR; and 56.41% and 94.87% for LF. At the cavity threshold, sensitivity and specificity, respectively, were 70.79% and 95.51% for VI; 97.75% and 93.26% for BR; and 92.14% and 97.75% for LF. Significant differences between intact surfaces and white spots, and white spots and cavities were shown through LF readings.

CONCLUSIONS

Both LF and BR can detect cavitations on approximal surfaces of primary molars. LF could be an alternative to radiographs in detecting approximal caries in primary molars.

In Vitro Evaluation of ICDAS and Radiographic Examination of Occlusal Surfaces and Their Association With Treatment Decisions

It has been suggested that occlusal caries detection has become more difficult due to the widespread use of fluoride, which slows down lesion progression and delays cavitation. The ability to detect caries lesions at an early stage has a significant impact on treatment decisions, improving the possibility for a successful preventive intervention. In this investigation, the authors found that the International Caries Detection and Assessment System associated with radiographic examination has the potential to support treatment decisions for occlusal surfaces.

Elastomeric impression as a diagnostic method of cavitation in proximal dentin caries in primary molars

The purpose of this study was to validate the elastomeric impression after temporary tooth separation as a method of cavitation detection in proximal caries lesions in primary molars with outer half dentin radiolucency. Fifty-one children (4-10 years old), presenting radiolucency in the outer half of the dentin at the proximal surfaces of primary molars and proximal anatomic contact with the adjacent tooth (without restoration/cavitated caries lesion) were enrolled in the study. Temporary tooth separation was performed with an orthodontic rubber ring placed around the contact point during 2-3 days. Thereafter, impression of the proximal surfaces was made. The elastomeric impressions were classified as "non-cavitated" or "cavitated" surfaces. Visual inspection after tooth separation was considered as the gold standard. Examiner reliability of visual inspection after tooth separation was determined (kappa 0.92). Impression examination was repeated every 5 participants to evaluate the reproducibility of the method. The frequency of cavitated lesions was 65%, and 67% of those were inactive. Sensitivity, specificity, positive and negative predictive values were 0.88% (95%CI 0.73-0.95), 0.89% (95%CI 0.67-0.97), 0.94% (95%CI 0.79-0.98) and 0.80% (95%CI 0.58-0.92), respectively. Impression examination showed total agreement regarding cavitation. The evaluation of elastomeric impression after tooth separation is a useful clinical resource in cavitation detection for clinicians and researchers when visual inspection is doubtful.

In situ and in vitro comparison of laser fluorescence with visual inspection in detecting occlusal caries lesions

The aim of this study was to compare the in situ and in vitro performances of a laser fluorescence (LF) device (DIAGNOdent 2095) with visual inspection for the detection of occlusal caries in permanent teeth. Sixty-four sites were selected, and visual inspection and LF assessments were carried out, in vitro, three times by two independent examiners, with a 1-week interval between evaluations. Afterwards, the occlusal surfaces were mounted on the palatal portion of removable acrylic orthodontic appliances and placed in six volunteers. Assessments were repeated and validated by histological analysis of the tooth sections under a stereomicroscope. For both examiners, the highest intra-examiner values were observed for the visual inspection when in vitro and in situ evaluations were compared. The inter-examiner reproducibility varied from 0.61 to 0.64, except for the in vitro assessment using LF, which presented a lower value (0.43). The methods showed high specificity at the D(1) threshold (considering enamel and dentin caries as disease). In vitro evaluations showed the highest values of sensitivity for both methods when compared to the in situ evaluations at D(1) and D(2) (considering only dentinal caries as the disease) thresholds. For both methods, the results of sensitivity (at D(1) and D(2)) and accuracy (at D(1)) showed significant differences between in vitro and in situ conditions. However, the sensitivity (at D(1) and D(2)), specificity and accuracy (both at D(1)) of the methods were not significantly different when the same condition was considered. It can be concluded that visual inspection and LF showed better performance in vitro than in situ.

Quantitative stain detection in vivo using fluorescent imaging

Quantitative Light-induced Fluorescence (QLF) has been used to measure tooth stain in vitro; however the current analysis method cannot be used in vivo, as it requires regions of interest to be surrounded by unstained tissue. In this study, an algorithm was developed to detect stain on QLF images of teeth captured in vivo. It uses convex hulls to reconstruct an image of the tooth, without stain, based on clean areas of the image, and subtracts the captured image from the reconstruction to find areas darkened by stain. A tooth outline (mask) must be provided to guide the reconstruction. Three versions of the algorithm are tested on images taken during a stain development study, using a range of values for the threshold parameter. The stain employed was produced using Chlorhexidine mouth rinse. The software output correlates well with manual scoring (Pearson's>0.7; p<0.001). The algorithm shows promise for examining groups of patients in an objective and reproducible way, conferring many benefits over clinical visual assessments.

The management of incipient or suspicious occlusal caries: a decision-tree analysis

OBJECTIVE

To perform a comprehensive decision-tree analysis for the management of the suspicious/incipient occlusal lesion on a molar tooth.

METHODS

A quantitative decision tree was constructed to assess the expected utility value of three global strategies to dentally manage the incipient or suspicious occlusal carious lesion.

RESULT

A preventive strategy offered an optimal expected utility value (0.98 utile) compared with the other two strategies of visual inspection (0.84 utile) or referring to one of four diagnostic tests (0.74-0.82 utile).

CONCLUSION

Although the general conclusion of this analysis agrees with current recommendations, this analysis offers a more complete mathematical model that provides a unified value for each strategy (i.e. expected utility value) thus allowing for complex quantitative comparison between strategies. This paper provides a specific example of how decision-tree analysis can be a powerful tool in guiding dental practice.

Caries detection and diagnosis: Novel technologies

Recent years have seen an increase in research activity surrounding diagnostic methods, particularly in the assessment of early caries lesions. The drive for this has come from two disparate directions. The first is from the dentifrice industry who are keen to develop techniques that would permit caries clinical trials (CCTs) to be reduced in duration and subject numbers to permit the investigation of novel new anti-caries actives. The second is from clinicians who, armed with the therapies to remineralise early lesions are now seeking methods to reliably detect such demineralised areas and implement true preventative dentistry. This review examines novel technologies and the research supporting their use. Techniques based on visual, optical, radiographic and some emerging technologies are discussed. Each have their benefits although systems based on the auto-fluorescence (such as QLF) of teeth and electrical resistance (such as ECM) seem to offer the most hope for achieving reliable, accurate detection of the earliest stages of enamel demineralisation.

Dental caries paradigms in diagnosis and diagnostic research

In this article, the fundamentals of caries diagnosis are reviewed from the three component perspectives, namely the strategy, the logics, and the tactics. Strategy concerns the objectives of the diagnostic process (i.e. why we diagnose caries). The logics describe how we assemble and evaluate the information collected and how this leads to an assessment of diagnostic value. Finally, tactics are about how we collect the information necessary to arrive at a correct diagnosis. We argue that the hitherto-dominant essentialistic caries paradigm should be replaced by a nominalistic caries concept. This allows us to circumvent the problem of a lack of a caries gold standard and to proceed in caries-diagnostic research to find the diagnostic methods that result in the best health outcomes for our patients. We also demonstrate the limitations of the medical model when attempting to understand caries diagnosis, and adhere to the Bader & Shugars caries script model. It is concluded that the current caries profile, characterized by lower prevalence and extent, and slower progression, has increased the need for an academic strengthening of the dental curriculum with respect to diagnostic reasoning and clinical decision-making processes.

Effect of different diagnostic thresholds on dental caries calibration - a 12 month evaluation

OBJECTIVE

To analyze the reproducibility of a calibration trial, at different diagnostic thresholds of dental caries, in a 12-month evaluation.

METHODS

A group of dental examiners (n = 11), who had previous experience in epidemiological surveys, participated in the study. An initial training phase (theoretical and clinical) and five calibration exercises (baseline, 3, 6, 9 and 12 months) were arranged. World Health Organization (WHO) criteria, including the active initial lesions (IL) were used. Six- to 7-year-old children took part in the study. They were selected according to past history and dental caries activity. The data were analyzed at WHO and WHO + IL diagnostic thresholds in accordance with tooth and dental surfaces.

RESULTS

Excellent mean intra- and inter-examiner Kappa values were obtained for both diagnostic thresholds, in accordance with tooth and surface, during the calibration phases. However, the most relevant errors were related to the decayed component and to IL diagnosis.

CONCLUSION

It was possible to use the methodology proposed in this study in epidemiological surveys when examining the mixed dentition, although new strategies to improve training in IL diagnosis and calibration are necessary.

Restorative treatment decision making with unaided visual examination, intraoral camera and operating microscope

This study assessed the restorative treatment options of the occlusal surfaces of teeth examined with unaided visual assistance, an intraoral camera and an operating microscope. Sixty-eight extracted human molars were mounted to perform mouth models with a premolar in contact on both sides. Four observers examined the models in a phantom head, which simulated clinical conditions, using three techniques: unaided visual examination, intraoral camera and operating microscope. The observers were asked to assess the occlusal surface of each tooth and make a treatment decision based on the following scale: 1) the occlusal surface being sound and "not needing a restoration," 2) the occlusal surface having a subsurface or enamel lesion. No operative treatment was needed at this visit, but special attention was given to this surface at recall visits: "preventive care-defer treatment" and 3) the surface had a carious lesion and "needed a restoration." The teeth were then sectioned in the mesio-distal direction and examined under a stereomicroscope with 10x magnification to determine the true extent of caries. Statistical analysis was conducted by calculating percentages and kappa values of the restorative treatment scores based on examinations by four observers. According to all the observers' treatment decisions, the kappa values were found to be 0.341 (p<0.001), 0.471 (p<0.001) and 0.345 (p<0.001) for unaided visual examination, intra-oral camera and operating microscope, respectively. There was a statistically significant difference between the intraoral camera and the other two methods (p<0.05), while there was no significant difference between the unaided visual examination and operating microscope (p>0.05). As a result of a comparison between the unaided visual examination and operating microscope, the use of an intraoral camera improved the restorative treatment decisions of the occlusal surfaces on posterior teeth.

Ability of laser fluorescence device associated with fluorescent dyes in detecting and quantifying early smooth surface caries lesions

A laser fluorescence (LF) device is a portable tool, but it does not measure minor mineral changes. Our in vitro study aim is to propose the association of an LF with two fluorescent dyes and to evaluate the performance in detecting and quantifying early demineralization. Artificial caries lesions are created in 40 primary canine teeth using a demineralizing solution (pH=4.8) for 12, 24, 48, and 96 h. LF measurements are performed with DIAGNOdent after demineralization in these samples and in 20 sound primary teeth. Measurements with LF with 0.2-mM tetrakis(N-methylpyridyl)porphyrin (LF TMPyP) and with 4-mM protoporphyrin IX (LF PPIX) are made. The amount of calcium loss is determined by atomic emission spectrometry. A correlation between LF and LF with dyes and mineral loss and receiver operating characteristics analysis are performed, as well as comparisons of sensitivity, specificity, and accuracy values. Significant correlation is obtained with LF TMPyP and mineral loss of lesions demineralized for 24, 48, and 96 h. Better performance is achieved with LF TMPyP for all parameters than with LF alone. LF PPIX does not present good results. In conclusion, LF TMPyP provides good performance in detecting and quantifying very early enamel caries lesions.

Clinical effectiveness of laser fluorescence, visual inspection and radiography in the detection of occlusal caries

The aim of this in vivo study was to compare a laser fluorescence (LF) device with Ekstrand's visual scoring system and radiographic assessment for detection of occlusal caries. Thirty-eight adults aged 19-35 years participated in the study; a total of 57 third molars with macroscopically intact occlusal surfaces were selected. Two examiners assessed 110 sites by visual inspection (VI), bitewing radiography (BW) and LF. Teeth were then extracted and caries extent assessed by histology. The detection methods were compared by means of sensitivity, specificity, inter-examiner reproducibility (kappa statistics) and area under the ROC curve. VI and LF had similar (p > 0.05) and superior sensitivities than BW (p < 0.05). VI and BW showed similar specificities, which was superior to LF. The inter-examiner reproducibility was good for VI and BW and moderate for LF. The area under ROC curves showed that VI was better than LF. It was concluded that Ekstrand's visual scoring system is the most valid method for caries diagnosis. LF should be considered an adjunct to caries diagnosis.

Caries risk assessment: methods available to clinicians for caries detection

It is hypothesized that occlusal lesions are initiated on the fissure walls and can therefore be obscured by sound superficial tissue. Additionally, there is evidence that one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called 'hidden lesions'. Dental radiographs are inadequate for detecting decay in the occlusal surfaces until the lesion is well advanced through the enamel and into the dentin. The clinician relies on visual observation of texture and discoloration, clinical judgment based upon experience, and on tactile sense by probing with an explorer. An objective detection method to complement the traditional visual assessment is used by the clinician for arriving at clinical decisions on the management of the carious lesion: whether invasive therapy or a more conservative, noninvasive approach. Objective and reliable longitudinal monitoring of the lesion's response to preventive measures allow the selection of an appropriate therapy before the lesion progresses to the stage where invasive treatment is required. This paper discusses the problem of the lack of appropriate clinical methods for the detection and quantification of carious lesions. A few commercially available methods are described (the quantitative light-induced fluorescence method, the DIAGNOdent device, and electrical caries monitor) and some new techniques mentioned.

Assessing the accuracy of caries diagnosis via radiograph

BACKGROUND

The authors conducted this study to determine if proximal caries diagnoses made using bitewing radiographic images printed on photographic paper were comparable with diagnoses made using traditional radiographic film images.

METHODS

The authors digitized 15 posterior bitewing radiographs that contained 74 carious and 127 sound unrestored proximal surfaces and printed them on photographic paper. Fourteen dentists evaluated the radiographs and two printed image formats (4 x 3 centimeters and 8 x 6 cm) for evidence of caries. The diagnostic accuracy and interobserver agreement for caries diagnoses obtained in the two printed image formats were compared with those for radiographic film images.

RESULTS

Overall, the diagnostic accuracy of printed images did not differ significantly from radiographic film images for dentinal caries. However, for caries limited to the enamel surface, a decrease in sensitivity was noted in six of the 14 observers for the smaller print images, while no significant differences in the diagnoses of enamel caries were observed among any of the observers in the enlarged print format.

CONCLUSION

This study provides evidence that printed images can be used to diagnose dental caries reliably.

CLINICAL IMPLICATIONS

The results of this study indicate that the diagnostic information obtained by viewing printed images is equivalent to that obtained by viewing standard radiographs. Size of the printed image also may be important in caries diagnosis and care must be taken to print bitewing radiographic images at a size that optimizes interpretation. Other factors that must be considered are the type of printer, printer resolution, paper quality and type of ink used. With careful consideration of printing parameters, clinicians can be assured of diagnostic quality in printed images.

Nonintrusive, noncontacting frequency-domain photothermal radiometry and luminescence depth profilometry of carious and artificial subsurface lesions in human teeth

Nonintrusive, noncontacting frequency-domain photothermal radiometry (FD-PTR or PTR) and frequency-domain luminescence (FD-LUM or LUM) have been used with 659-nm and 830-nm laser sources to detect artificial and natural subsurface defects in human teeth. The major findings of this study are (1) PTR is sensitive to very deep (>5 mm) defects at low modulation frequencies (5 Hz). Both PTR and LUM amplitudes exhibit a peak at tooth thicknesses of ca. 1.4 to 2.7 mm. Furthermore, the LUM amplitude exhibits a small trough at ca. 2.5 to 3.5 mm. (2) PTR is sensitive to various defects such as a deep carious lesion, a demineralized area, an edge, a crack, and a surface stain, while LUM exhibits low sensitivity and spatial resolution. (3) PTR frequency scans over the surface of a fissure into demineralized enamel and dentin show higher amplitude than those for healthy teeth, as well as a pronounced curvature in both the amplitude and phase signal channels. These can be excellent markers for the diagnosis of subsurface carious lesions. (4) PTR amplitude frequency scans over the surface of enamels of variable thickness exhibit strong thickness dependence, thus establishing depth profilometric sensitivity to subsurface interfaces such as the dentin/enamel junction.

Validity of a laser fluorescence system (DIAGNOdent) for detection of occlusal caries in third molars: an in vitro study

The aim of this study was to compare the validity of the measurements of the laser fluorescence device, KaVo DIAGNOdent, with the result of polarized light microscopy in the detection of occlusal fissure caries in extracted third molars. Ten impacted, surgically removed, and 25 extracted third molars with macroscopically intact occlusal surfaces were selected. The DIAGNOdent measurements of the occlusal test site were recorded by two observers at intervals of 2 days. The teeth were then sectioned at the specified test sites for histological examinations. Prepared specimens were evaluated under the polarized light microscopy and all images were scored with the caries classification of D1 (sound and fissure lesion in the half of the outer enamel), D2 (enamel decay) and D3 (dentin decay) level (gold standard). The kappa value for the inter-observer repeatability was calculated and the value 0.83 for the first measurements and 0.67 for the second measurement were obtained,respectively. Inter-observer correct classification percentages were 88.5 and 77.1 for the first and second measurements, respectively. The kappa value for intra-observer repeatability was 0.79 for the first observer and 0.75 for the second observer. Intra-observer correct classification percentage values were 85.7 and 82.8 for the first and second observer, respectively. Value of specificity for the detection of enamel caries at D1 level was 0.74 and sensitivity values at D2 and D3 levels were 0.66 and 1.00, respectively. The present study indicates that the DIAGNOdent provides not only almost perfect agreement but also sufficient repeatability at D1, D2, D3 levels and better specificity at D1 level as well as lower sensitivity at D2 level and excellent sensitivity at D3 level.

An in vitro comparison of a combined FOTI/visual examination of occlusal caries with other caries diagnostic methods and the effect of stain on their diagnostic performance

The aims of this in vitro study were to compare the combination of FOTI and visual inspection to other diagnostic methods for the detection and evaluation of the depth of occlusal caries and assess the effect of stain on diagnostic performance. Five diagnostic methods (combined FOTI/Visual (CFV), Visual, FOTI, DIAGNOdent and Electrical Caries Monitor) were considered. Histological validation was performed in the 152 occlusal molar sites (111 teeth) using 350-microm sections and a stereomicroscope. The rank correlation coefficients with histology ranged from 0.42 (DIAGNOdent) to 0.66 (CFV). The area under the ROC curves (AUC) for enamel lesions ranged from 0.82 (ECM) to 0.88 (CFV) and from 0.81 (DIAGNOdent) to 0.91 (CFV) for dentine lesions. The AUC at the dentine level for CFV and FOTI were similar (p > 0.05), but the AUC for CFV was significantly greater than for visual (p < 0.001), DIAGNOdent (p = 0.005) and the ECM (p = 0.04). FOTI was found to be particularly useful for the detection of dentine lesions. The exclusion of stain and brown spot lesions improved performance for all methods. It is concluded that CFV is useful for the determination of occlusal lesion depth and that in the presence of stain and brown spot lesions different cut-off points may be required for the ECM and DIAGNOdent to identify dentine lesions.

Occlusal caries detection and quantification by DIAGNOdent and Electronic Caries Monitor: in vitro comparison

The Electronic Caries Monitor (ECM) and the recently introduced laser-based KaVo DIAGNOdent have been developed as clinical diagnostic aids in the detection and quantification of occlusal carious lesions. The aim of this in vitro study was to compare their reproducibility and validity. The ability of DIAGNOdent to retrieve sites of occlusal carious lesions without reference to photographs or drawings from previous assessments was also tested. The material comprised 87 premolar teeth: the occlusal surfaces were sound or exhibited non-cavity carious lesions of varying severity. All were photographed and measured by DIAGNOdent and ECM on 2 occasions, 2 weeks apart. The teeth were then sectioned into 300 microm thick slices. Two observers independently classified the sections according to the histopathology, into 5 categories, ranging from sound to dentinal caries in the inner part of the dentin. Statistical analysis comprised intra-class correlation coefficients (ICC) to test reproducibility and regression analysis of validity. Sensitivity and specificity were also calculated for detection of D3 lesions for both devices. DIAGNOdent recorded maximum readings at identical sites on both occasions in 89% of the teeth. The ICC for readings on 2 separate occasions was 0.97 for DIAGNOdent and 0.71 for ECM. The correlations with histology were r = 0.93 and 0.83, for DIAGNOdent and ECM, respectively. For detection of D3 lesions, the sensitivity and specificity were 0.8 and 1 for DIAGNOdent and 0.75 and 0.88 for ECM. In this in vitro study, DIAGNOdent was superior to ECM for occlusal caries detection.

Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis

OBJECTIVES

Recently, a device for detecting occlusal caries lesions based on laser fluorescence measurements (DIAGNOdent) has been introduced. The reliability (reproducibility) and validity of this laser-fluorescence device were investigated.

METHODS

In the in vitro part of the study, 49 permanent molars were measured by two observers using two DIAGNOdent devices. In addition, visual inspection was performed. The teeth were sectioned to measure the actual depth and area of the caries lesions. In the in vivo part of the study, 45 sites at the occlusal surfaces of permanent molar teeth in 13 patients were measured by two observers using two DIAGNOdent devices, manufactured in two successive years.

RESULTS

The reliability of both DIAGNOdent devices expressed in the intraclass correlation coefficient (ICC=0.90 for observer 1, and 0.88 for observer 2) was high, and so was the interobserver reliability (ICC=0.85 for the 1998-device, ICC=0.90 for the 1999-device). The correlation between DIAGNOdent measurements and the actual depth of the caries lesions was lower than that of visual inspection by one observer, yet higher than that of a second observer. The specificities of visual inspection (0.94 and 0.88) were higher than those of the DIAGNOdent devices, whereas the sensitivities of the DIAGNOdent devices (0.93-1.00) exceeded those of visual inspection The validity of the DIAGNOdent, expressed as the area under the receiver operating characteristic curve, was not statistically significantly different from that of visual inspection (P>0.05). The DIAGNOdent measurements showed a higher association with the enamel part of the caries lesion than with the dentinal part.

CONCLUSIONS

The DIAGNOdent is suitable for monitoring small caries lesions. Because of the high reproducibility of DIAGNOdent devices produced in successive years, a DIAGNOdent device may be replaced by a new one. Due to the higher specificity, visual inspection should be preferred to diagnose occlusal caries lesions in populations with a low caries prevalence.

Comparison between visual examination and a laser fluorescence system for in vivo diagnosis of occlusal caries

This study compared a laser fluorescence (LF) system (DIAGNOdent) with a visual caries scoring system for in vivo detection and diagnosis of occlusal caries under the conditions of an epidemiological study, in 132 mandibular and 38 maxillary first permanent molars in 170 children (mean age: 6.85 +/- 0.58 years). The teeth were cleaned and occlusal caries status in a selected investigation site recorded using both visual and LF systems. The LF readings were interpreted both according to the cut-off points recommended by the manufacturers and those based on laboratory research with histological validation. The percentage agreement of the LF and visual scoring system was better using the cut-off limits recommended by the manufacturer. Histological validation was not possible in this clinical study, but it appeared that either the LF method was overscoring some lesions or the visual method was underscoring them. Since the LF instrument cannot be expected to differentiate caries from hypomineralisation, it should probably be used as an adjunct to a clinical examination.

How to measure the effects of fluoride treatments in clinical trials? Assessment: modern versus traditional methods

In recent years there has been a pronounced change in the epidemiology and disease pattern of dental caries. In the current context, traditional methods of caries assessment, discriminating lesions at cavitation, are clinically inappropriate, and obsolete for research requiring detection of a very early phase of mineral loss. Modern prospective caries studies require sensitive methods permitting the measurement of small changes in tooth mineral content, and objective, quantitative measurements of such changes are now possible in a single caries lesion. For longitudinal studies there are noninvasive methods for assessment of new lesions as well as quantitative changes (progression or regression) in existing lesions. Among as yet unresolved issues are improved methods to assess the current activity of a lesion, methods for detection and quantification of secondary caries and root caries, calibration of methodologies between different research institutes, and methods capable of assessment of the whole continuum in the development of a caries lesion, from initial loss of mineral to cavitation.

Detection of natural white spot caries lesions by an ultrasonic system

Ultrasound has been used in industrial business as one of the nondestructive measurement methods. It was hypothesized that nondestructiveness of the ultrasonics could be useful in determination of demineralization of noncavitated carious lesions on human enamel. This investigation was designed to determine the presence of natural carious lesions on proximal surfaces of human molar teeth using an ultrasonic system compared to radiography and histology as the gold standards. Measurements were made directly from proximal surfaces of 20 mandible molar teeth with white spot carious lesion by 2 examiners independently with the ultrasonic system. Ultrasonic evaluation of each natural white spot lesion had a sensitivity of 88%, specificity of 86%, positive predictive value of 88% and a negative predictive value of 86%, and the chance-corrected agreement was also satisfactory (kappa=0.74) compared to histology. The radiograph demonstrated chance-corrected agreement of 0.41:0.38 for the first and second examiners, respectively. Duncan test analysis of the numerical values was significantly different for the intact and the noncavitated carious surfaces (p<0.05). The results indicated that the ultrasonic evaluation is a sensitive method for the detection of the natural white spot carious lesions and can differentiate the changes in elastic properties of enamel numerically.

Occlusal caries detection with KaVo DIAGNOdent and radiography: an in vitro comparison

A new laser fluorescence method, KaVo DIAGNOdent, was tested with respect to reproducibility and validity and compared with radiography regarding accuracy in the detection of occlusal caries. Seventy-six extracted premolar and molar teeth were measured twice with DIAGNOdent under both wet and dry conditions, at an interval of 2 weeks. Conventional film radiographs were exposed. Microradiographic analysis of sections of the teeth served as the gold standard. Intra-class correlation coefficient and Pearson's correlation coefficient were used to assess the reproducibility and the validity of the method, respectively. The influence of time and varying humidities on DIAGNOdent readings were analysed by two-way repeated measure ANOVA. ROC curves were plotted for DIAGNOdent readings and radiographic registration of caries by 6 observers, and the areas under the curves were compared using Student's t test. Under both wet and dry conditions, the reproducibility of the DIAGNOdent method was excellent: R = 0.97 and 0.96, respectively. The diagnostic accuracy of DIAGNOdent was significantly better than that of radiography (p< or =0.001). In this in vitro study of detection of occlusal caries, the diagnostic performance of the DIAGNOdent method was superior to that of radiography.