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

Short-Wavelength Infrared Imaging of Infected and Affected Dentin

Stains produced by bacteria or those found in blood and food byproducts accumulate in highly porous caries lesions. They can interfere with accurate diagnosis and the selective removal of carious tissue during cavity preparations. Short-wavelength infrared (SWIR) imaging studies have shown that stain molecules do not absorb light beyond 1200 nm. The objective of this study was to image affected and infected dentin atSWIR wavelengths. Sections of 3 mm thickness were cut from the extracted teeth with deep dentinal lesions. The sound (normal), affected (stained), and infected (demineralized) dentin on each section were examined with reflected light at wavelengths from 400 to 1700 nm, red and green fluorescence, and with optical coherence tomography (OCT). Microcomputed tomography (microCT) was used to measure the mineral density at each location investigated. Significant (p < 0.05) differences were observed in the reflected light intensity at 400-850 nm and for fluorescence between the sound, affected, and infected dentin. SWIR imaging did not show significant reductions in reflectivity for the affected and infected dentin. SWIR images may be valuable for monitoring the lateral spread of dentinal lesions on the occlusal surfaces of teeth.

Caries Lesion Assessment Using 3D Virtual Models by Examiners with Different Degrees of Clinical Experience

Background and Objectives: Dental caries is a preventable, reversible disease in its early stages. This study evaluated the intra-rater agreement of International Caries Assessment and Detection System (ICDAS) scores with Medit i500® and Omnicam® scanners versus traditional clinical examinations and the inter-rater agreement using the Omnicam® among senior dentists and dental students and between these two groups. Materials and Methods: A total of 24 patients aged between 21 and 34 years, randomly selected from dental students and interns, underwent four examinations (three intraoral scans and one clinical examination), and the corresponding ICDAS scores were recorded by a randomly selected rater out of the 31 available examiners. The examination team consisted of dental students, dentists with less than 3 years, and dentists with more than 5 years of clinical experience. The following inter- and intra-rater agreement tests for the ordinal data were chosen: Fleiss' kappa coefficient, Cohen's weighted kappa, and inter-class correlations. Results: For all examination techniques, there was statistically significant agreement for the experienced raters (p < 0.05). The highest positive interclass correlation was obtained for inter-rater agreement tests of 288 observations recorded by senior dentists: ICC = 0.969 (95% CI 0.949-0.981). Conclusions: Intra-rater reliability was excellent for Omnicam compared to clinical exams conducted by senior dentists but moderate for Medit i500. Although inter-rater agreement using Omnicam was poor between students and between senior dentists and students, it was excellent among senior dentists.

Performance of the caries diagnosis feature of intraoral scanners and near-infrared imaging technology-A narrative review

PURPOSE

To describe and discuss the benefits and drawbacks of various dental caries diagnostic techniques, including the use of intraoral scanners for caries diagnosis based on near-infrared imaging (NIR) technology.

MATERIAL AND METHODS

A MEDLINE search from 1980-2023 focused on dental caries diagnostic techniques, emphasizing intraoral scanners using NIR technology. Alternative caries detection methods were also evaluated for their advantages and limitations, enabling a comparison with NIR. The review included traditional caries tools, the latest detection methods, and NIR's role in intraoral scanners, drawing from case reports and both in vivo and in vitro studies. Keywords like "caries detection," "intraoral scanners," and "Near Infrared Imaging (NIRI)" guided the search. After screening titles and abstracts for relevance, full texts with valuable insights were thoroughly analyzed. The data was grouped into three: traditional diagnostics, advanced digital methods, and intraoral scanner-based detection.

RESULTS

This comprehensive narrative review described and discussed the current state of dental caries diagnostic methods, given the insufficient number of clinical investigations suitable for a systematic review. Traditional caries diagnosis techniques have shown variable accuracy dependent on a dentist's experience and the potential over-removal of healthy tooth structures. Intraoral scanners have emerged as a novel caries detection method, because of their integration of NIR technology. Various studies have confirmed the efficacy of NIR in detecting interproximal caries and in the early diagnosis of non-cavitated caries. Specifically, intraoral scanners have demonstrated promising results, proving comparable to established diagnostic methods like bitewing radiography. Nevertheless, while the integration of NIR into intraoral scanners seems promising, the technology still faces challenges, notably its accuracy in detecting secondary and subgingival cavities. However, with anticipated integrations of AI, NIR in intraoral scanners could revolutionize early caries detection.

CONCLUSIONS

Intraoral scanners with NIR technology offer non-destructive imaging, real-time lesion visuals, and enhanced patient communication. Although comparable to bitewing radiography in some studies, a universally accepted diagnostic tool is lacking. Future research should compare them with existing methods, focusing on clinical outcomes, cost-effectiveness, and patient acceptance.

Masking-efficacy and caries arrestment after resin infiltration or fluoridation of initial caries lesions in adolescents during orthodontic treatment-A randomised controlled trial

OBJECTIVES

The aim of this randomised, controlled, split-mouth trial was to assess the masking results in initial caries lesions (ICL) that were either resin infiltrated or fluoridated during treatment with fixed orthodontic appliances.

METHODS

Adolescent patients (age range:12-18years) with fixed orthodontic appliances who had developed ICL [ICDAS 1 or 2 (International Caries Detection and Assessment System)] during orthodontic treatment were consecutively recruited and randomly assigned to either resin infiltration with up to 3 etching procedures (Group:Inf) or to 3-monthly application of a fluoride varnish (Group:FV). Both interventions were performed according to the manufacturer's recommendations. Primary and secondary outcomes (ΔE, ICDAS, DIAGNOdent) included the evaluation of the appearance of the ICL before (T0), 1 week after (T1) treatment and at the last appointment before debonding (T2).

RESULTS

Fifteen patients (8females, 7males) with 57ICL were included. Mean (SD) observation time at the last appointment before debonding was 0.5 (0.3) years. At T0 FV and Inf did not differ significantly in ΔE (median ΔE0,FV(25th/75th percentiles):11.6 (8.7/20.3): ΔE0,Inf:15.1 (11.4/19.5); pT0 = 0.135), ICDAS (pT0 = 0.920) and DD (pT0 = 0.367). At T1 and T2 ΔE values (pT1<0.001, pT2<0.001), ICDAS scores (pT1<0.001, pT2<0.001) and DIAGNOdent values (pT1 = <0.001, pT2 = <0.001) for Inf were significantly reduced whereas ΔE values (pT1 = 0.382, pT2 = 0.072) and ICDAS scores (pT1 = 0.268, pT2<0.001) for FV remained unchanged.

CONCLUSIONS

Resin infiltration effectively masked ICL during treatment with fixed orthodontic appliances both immediately after application and at the last appointment before debonding. Furthermore, the visual appearance of fluoridated lesions was not as satisfactory as that of the infiltrated ones at both T1 and T2.

CLINICAL SIGNIFICANCE

Resin infiltration effectively masked ICL during treatment with fixed orthodontic appliances both immediately after application and at the last appointment before debonding. Furthermore, the visual appearance of fluoridated lesions was not as satisfactory as that of the infiltrated ones immediately after first application as well as half a year after application.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00011797).

In Vivo Performance of Visual Criteria, Laser-Induced Fluorescence, and Light-Induced Fluorescence for Early Caries Detection

This study aims to compare the diagnostic reliability of ICDAS-II visual criteria, light-induced fluorescence (using the VistaCam iX, Dürr Dental, Bietigheim-Bissingen, Germany), and laser-induced fluorescence (using the DIAGNOdent Pen, KaVo, Biberach, Germany) on occlusal caries. Permanent and temporary molars were selected according to the inclusion criteria. Out of 160 teeth that met the inclusion criteria, 139 were chosen and examined by two previously trained and calibrated examiners. The kappa value was 0.95 for both VistaCam iX and DIAGNOdent Pen. Results from visual examination and the readings of the two fluorescence devices were computed, lesions being divided into non-cavitated, enamel lesions, and lesions extended to dentin. All statistical analyses were performed using R (version 4.2.2). Spearman's rank correlation was computed to assess the relationship between the scores of diagnostics reliabilities of the three methods mentioned above. There was a positive, statistically significant Spearman's rank correlation coefficient, ρ = 0.25, between VistaCam iX and ICDAS II, and a positive, not statistically significant Spearman's rank correlation coefficient, ρ = 0.11, between DiagnoDent Pen and ICDAS II. Considering the temporary teeth, there was a positive, statistically significant Spearman's rank correlation coefficient, ρ = 0.52, between VistaCam iX and DiagnoDent Pen; a positive, statistically significant Spearman's rank correlation coefficient, ρ = 0.35, between VistaCam iX and ICDAS II; and the lowest, not statistically significant Spearman's rank correlation coefficient, ρ = 0.16, between DiagnoDent Pen and ICDAS II. Conclusions: In conclusion, ICDAS II and light-induced fluorescence are better diagnostic methods than the laser-induced fluorescence devices for detecting occlusal caries. Clinical Significance: This study may support clinicians in selecting the most efficient tool for diagnosing carious lesion in the earliest stages possible. Furthermore, such technologies raise the availability for more preventive approaches, as opposed to invasive procedures.

Effect of resin composite shade on digital fiber-optic transillumination imaging in vitro

Digital imaging fiber-optic transillumination (DIFOTI) devices have been used to detect caries, a technique without using X-rays. However, the effects of resin composites (RCs) shades on the images acquired with DIFOTI devices have not been investigated. Thus, this study aimed to elucidate the influence of RC shade on the images obtained with DIFOTI technique. Three shades (A1, A3, and Opaque) for each of four flowable RCs were filled on a cavity prepared in a left mandibular first premolar obtained from a donated body. Then, transmission images with a DIFOTI device (DIAGNOcam; KaVo, Biberach, Germany) were acquired, and the average lightness values of the images in the RC and enamel were used to calculate differences between those areas. To clarify the influence of the optical translucency and color on DIFOTI images, the color parameters (L*, a* and b*) of each RC were obtained with black and white backgrounds. The color differences between the backgrounds were calculated as transparency parameter (TP) values. The number of repetitions was set to 10. Differences in the lightness value of the shades varied in each RC. The difference in lightness was significantly associated with the TP value and color parameters of L* (p < 0.01), with negative (R = - 0.81) and positive (R = 0.84) correlations, respectively. In conclusion, DIFOTI images of RCs with high optical translucency resembled those of the natural tooth structure.

The Assessability of Approximal Secondary Caries of Non-Invasive 3D-Printed Veneers Depending on the Restoration Thickness-An In Vitro Study

To date, no scientific data is available regarding the development and radiographic assessment of approximal caries development after the insertion of 3D-printed, non-invasive veneers of different restoration thicknesses. For the present study, non-invasive veneers were fabricated from two different materials for printing and milling (Vita Enamic and VarseoSmile Crown plus). Three different restoration thicknesses (0.5, 0.7, and 0.9 mm) were selected. After digital design, leaving the approximal space free, and manufacturing of the restorations, adhesive insertion followed. All specimens were placed in a demineralizing solution for 28 days. Subsequently, a radiological and fluorescent examination was performed. The present study showed statistically significant interactions for the day (p < 0.0001) and manufacturing method (p < 0.0001) but not for restoration thickness. Additive manufactured restorations showed less radiological caries progression compared to subtractive manufactured restorations after 21 and 28 days (0.7 and 0.9 mm restoration thickness) (p < 0.0001). DIAGNOdent proved that the restoration thickness affected the caries progression within the subtractive group (p < 0.0001). Radiographic and fluorescence examination showed equivalent results regarding approximal caries assessment. For additive manufacturing, less caries progression was shown without consideration of the restoration thickness.

Clinical evaluation of resin infiltration treatment masking effect on hypomineralised enamel surfaces

BACKGROUND

Resin infiltration is a micro-invasive treatment for molar incisor hypomineralisation (MIH). In this study it was aimed to evaluate the masking effect of resin infiltration treatment (ICON) on hypomineralised enamel surface of permanent anterior teeth by using laser fluorescence, spectrophotometer, and cross-polarisation photography.

METHODS

A total of 116 permanent central incisors in 37 patients were included in the study. The resin infiltration treatment (Icon®) was applied to the teeth with MIH; the healthy teeth received no treatment (control). Hypomineralised enamel lesions were evaluated by ICDAS II criteria. DIAGNOdent Pen was used to assess the lesions and healthy enamel surface quantitatively. Colour changes in enamel lesions were evaluated by using a spectrophotometer (VITA EasyShare). Each enamel lesion was imaged using a cross-polarization technique before and after treatment. All photos were assessed using Image J to evaluate the changes in lesion size. Enamel lesions were evaluated before; immediately after; 1; 3; and 6 months after treatment. Statistical significance was set as p < 0.05.

RESULTS

After the resin infiltration, significant decreases were found in the mean DIAGNOdent values for the treatment group (p < 0.05). The colour differences before and after treatment significantly differed in all follow-ups (p < 0.05). In the treatment group, lesion areas decreased significantly after treatment (p < 0.05).

CONCLUSIONS

The resin infiltration treatment has a masking effect on MIH lesions without cavities, with stable outcomes after six months. The cross-polarization photography technique may be use to evaluate the lesion size instead of photography with flash.

TRIAL REGISTRATION

NCT04685889 (registered 28 December 2020).

Bibliometric Analysis of Dental Caries Detection

The main purpose of this bibliometric analysis is to conduct a quantitative and qualitative analysis of the publications on dental caries. Research productivity can be measured with the use of bibliometric analysis. In this study, we conducted a bibliometric analysis using the Scopus database to identify dental caries research trends and patterns over the years. The search yielded 1630 scientific articles. The data was analysed using bibliometric indicators such as the h-index, the total number of citations and the number of publications. An analysis of the data highlighted that the United States of America (USA) and Brazil have the highest number of single-country publications. Top authors were listed based on the h-index and the total number of citations. Top cited countries, institutions etc. were also analysed using this bibliometric study. This bibliometric evaluation provides a wide area of literature carried out to date. The existing knowledge can be used to direct future research.

DIAGNOdent versus International Caries Detection and Assessment System in detection of incipient carious lesions: A diagnostic accuracy study

Aim

The present investigation aimed at assessing the diagnostic accuracy of DIAGNOdent compared to the International Caries Detection and Assessment System-II (ICDAS-II) in the detection of facial, smooth surface noncavitated carious lesions.

Settings and Design

Sixty patients were enrolled in the current study according to the eligibility criteria. There were 161 teeth with noncavitated, white spot carious lesions and 32 sound teeth.

Materials and Methods

Before examination, teeth were cleaned and polished and all patients were assessed under standardized operating conditions: preset dental unit position, operating light, and prolonged air drying (approximately 5 s). All teeth were assessed by two calibrated examiners individually without any contact using ICDAS-II and DIAGNOdent.

Statistical Analysis

The diagnostic accuracy of DIAGNOdent device was determined, including sensitivity, specificity, overall accuracy, positive and negative predictive values, and receiver operating characteristic curve analysis. Chi-square test was conducted to compare the distribution of ICDAS-II and DIAGNOdent scores. Inter-observer agreement between assessors was evaluated using Cohen's kappa test.

Results

In the current study, DIAGNOdent had an overall accuracy of 84.45% with sensitivity and specificity of 87.58% and 96.87%, respectively, and +PV and -PV of 97.7% and 83.9%, respectively, when score 0 represented sound tooth surface, while scores 1 and 2 were considered clinically noncavitated carious lesions. Moreover, when only ICDAS score 1 was considered representing first visual change in enamel, DIAGNOdent had an accuracy of 74.15% with sensitivity and specificity of 83.53% and 90.62%, respectively, and +PV and -PV of 93% and 78.6%, respectively. In the present study, when only ICDAS score 2 was considered representing distinct visual change in enamel, DIAGNOdent had an accuracy of 100% with sensitivity and specificity of 100% and 100%, respectively, and +PV and -PV of 100% and 100%, respectively.

Conclusions

The overall performance of DIAGNOdent was equivalent to the visual inspection using ICDAS-II. DIAGNOdent might be considered a useful adjunctive device for detection and monitoring development of noncavitated carious lesions on facial smooth surfaces.

Short-term efficacy of caries resin infiltration during treatment with orthodontic fixed appliances. A randomized controlled trial

OBJECTIVES

Objective of this trial was to assess the masking results in initial caries lesions (ICL) that were resin infiltrated during fixed orthodontic treatment in comparison to contralateral teeth that were fluoridated only.

TRIAL DESIGN

A randomized, controlled, split-mouth trial.

METHODS

Adolescent patients (age range: 12-18 years) with fixed orthodontic appliances who had developed ICL [ICDAS 1 or 2 (International Caries Detection and Assessment System)] during orthodontic treatment were consecutively recruited and randomly assigned to either resin infiltration (Icon) with up to 3 etching procedures (Inf) or to a fluoride varnish (Tiefenfluorid) (FV). Both interventions were performed according to the manufacturer's recommendations. Outcome assessors were blinded to the applied intervention. Primary and secondary outcomes included the evaluation of the appearance of the ICL before (T0) and 1 week after (T1) treatment by digital photographs (ΔE), laser fluorescence readings (DD), and ICDAS scores.

BLINDING

Due to the treatment nature neither the operators nor the patients could be blinded. However, outcome assessors and the statistician were blinded.

RESULTS

Fifteen patients (9 female) with 60 ICL were included (mean age: 14.6 years). At baseline FV and Inf did not differ significantly in ΔE (median ΔE0,T (25th/75th percentiles):10.7(9.1/20.9): ΔE0,I:13.4(10.3/18.5); P = 0.469), DD (P = 0.867) and ICDAS (P = 0.521). One-week after treatment (T1) ΔE values (P < 0.001), DD values (P < 0.001), and ICDAS scores (P = 0.014) for Inf were significantly reduced, whereas ΔE values (P = 0.125) and ICDAS scores (P = 0.073) for FV remained unchanged.

LIMITATION

Natural remineralizing in the standard interventional control group cannot be observed yet, since up to 6 months are needed to naturally remineralize ICL.

CONCLUSIONS

Based on our short-term data, resin infiltration effectively masked ICL during treatment with fixed orthodontic appliances. Fluoridation was not able to immediately improve the visual appearance of ICL. Further longer-term assessment should focus not only on the aesthetic outcome, but also on the caries inhibitory effect of resin infiltration during treatment with fixed orthodontic appliances.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00011797).

Diagnostic Validity in Occlusal Caries Detection of ICDAS II, DIAGNOdent, Radiography and a Combination of the Three Methods: An In Vitro Study

In this study, we compare the efficacy and diagnostic concordance of the ICDAS, the radiographic criterion and the instrument known as the DIAGNOdent fluorescence laser pen on occlusal caries lesions using a histological section as the gold standard. Of 100 teeth that did not present cavitated occlusal lesions or occlusal fillings, 80 were chosen through a randomization program and examined by two previously trained and calibrated researchers. Subsequently, the teeth were sectioned with a diamond disk and observed under an optical microscope. The results were studied for caries with a limit established in enamel and caries with extension to dentin. The intra-examiner (0.821–0.933) and inter-examiner (0.817–0.924) reproducibility obtained for both ICDAS and DIAGNOdent for the diagnosis of borderline enamel caries was high. Similarly, intra-examiner (0.686–1.000) and inter-examiner (0.809–0.944) reproducibility for diagnosis of caries with dentin extension was also high for both methods. The sensitivity obtained was 0.76 (ICDAS), 0.87 (DIAGNOdent) and 0.58 (Rx), whereas the specificity obtained was 0.66 (ICDAS), 0.4 (DIAGNOdent) and 0.77 (Rx) for lesions limited to enamel. For lesions with extension to dentin, the sensitivity obtained was 0.73 (ICDAS), 0.82 (DIAGNOdent) and 0.09 (Rx), and the specificity obtained was 0.79 (ICDAS), 0.52 (DIAGNOdent) and 0.97 (Rx). Sensitivity increases in both cases by combining diagnostic methods. In conclusion, ICDAS and DIAGNOdent are better diagnostic methods than Rx for the detection of occlusal caries, and the combination of these methods helps to obtain a better diagnosis.

Effectiveness of Visual-Tactile Examination and DIAGNOdent Pen in Detecting Early Enamel Caries and Its Remineralisation: An In Vitro Study

Background

The caries preventive effect of Colgate Duraphat® and GC Tooth Mousse Plus® has been widely studied, but the remineralisation potential of initial occlusal caries using these two remineralisation materials remains unclear.

Aim

This study is aimed at evaluating and comparing the remineralisation of early enamel caries on the occlusal surface of permanent posterior teeth using ICDAS II caries scoring system and DIAGNOdent Pen (DDPen) after remineralisation with Colgate Duraphat® and GC Tooth Mousse Plus®.

Materials and Methods

Extracted posterior teeth (N = 120) with incipient occlusal caries were included in this study. The occlusal surface of each tooth was scored using DDPen and ICDAS II scoring before remineralisation. Then, remineralisation of the teeth of the experimental group was carried out using either CPP-ACP-F or fluoride varnish. After the remineralisation procedures, the occlusal surface of each tooth was again scored using DDPen and ICDAS II scoring. The teeth were then fixed in dental stone blocks and sectioned longitudinally for histological examination using a stereomicroscope. Statistical analysis was performed to calculate the sensitivity and specificity of DDPen and ICDAS II to detect remineralisation and compare with the gold standard histological examination.

Results

According to ICDAS-II scores, a significant difference was noted in GC Tooth Mousse Plus® and Duraphat® study samples, whereas the difference between the pre-and post-remineralisation of the control group was not significant. According to the DDPen score criteria, a statistically significant difference was noted among all study groups; however, a greater significance level was noted in the GC Tooth Mousse Plus® and Duraphat® study samples compared with the control group. The Spearman's rank correlation of ICDAS-II and DDPen with Downer's histological score (gold standard) revealed a higher association of DDPen score (.738) as compared to ICDAS-II scores (.430).

Conclusion

The study concluded that both ICDAS II and DDPen could detect remineralisation of early enamel occlusal caries. DDPen was more sensitive than ICDAS-II to detect remineralisation compared with the Downers histological scores.

Effects of different remineralization agents on MIH defects: a randomized clinical study

OBJECTIVES

The aim of this study was to present a comparative evaluation of the long-term efficacy of fluoride varnish and pastes containing CPP-ACP and CPP-ACP with fluoride (CPP-ACFP) in the remineralization of creamy-white and yellow-brown defects in permanent first molars with MIH.

MATERIALS AND METHODS

The study included 120 teeth with yellow-brown or creamy-white defects in 67 children (37 girls, 30 boys) aged 6-9 years (mean, 7.2) who were newly diagnosed with MIH with no substance loss or caries or prior restorative treatment. The patients were randomly divided into the experiment groups; control (oral hygiene motivation only), fluoride varnish, and pastes containing CPP-ACP and CPP-ACPF, and followed up for 24 months. The evaluations were made based on the ICDAS criteria and the measurements which were performed using the laser fluorescence method (DIAGNOdent, KaVo, Biberach, Germany) in the follow-ups.

RESULTS

The research was completed with 49 patients (23 females, 26 males; mean age, 7.7) and 90 teeth. All remineralization agents increased remineralization rates in both creamy-white and yellow-brown colored defects without presenting any statistically significant difference at the end of the follow-up period (p > 0.05). However, the effects of fluoride varnishes were late to observe when compared to pastes containing CPP-ACP and CPP-ACPF.

CONCLUSIONS

Pastes containing calcium and phosphate may be recommended for the longer-term preservation of teeth with yellow-brown defects which showed a post-eruptive breakdown in a shorter time.

CLINICAL RELEVANCE

There is a lack of studies investigating MIH treatments in which lesion appearance was recorded. This study evaluated creamy-white and yellow-brown MIH defects separately and reported long-term results of different remineralization agents.

In vivo effectiveness of visual inspection and laser fluorescence in the diagnosis of early pit-and-fissure carious lesions: A cross-sectional study in a group of Romanian children

General practitioners are still facing great challenges in the management of occlusal caries. Therefore, the development of better diagnostic protocols and assessment of caries activity might improve the results of nonoperative treatment. This study aimed to evaluate the effectiveness of visual inspection based on ICDAS-II (International Caries Detection and Assessment System) and DiagnoDent pen in the detection of pit-and-fissure early lesions in young permanent molars. The evaluation of 237 occlusal surfaces and caries risk assessment were performed in 96 children aged 7 to 15 years. The presence of pit-and-fissure noncavitated lesions was recorded using ICDAS-II scoring system and laser fluorescence. Statistical analysis was performed using McNemar test, with a level of significance of P < .05. The caries risk was measured for all participants. In 109 occlusal surfaces both methods identified enamel changes (46%) and in 62 cases both methods excluded the carious lesion (26.2%). The statistical analysis showed a significant moderate agreement between ICDAS-II code and DiagnoDent pen measurements (McNemar chi-squared statistic 9.5, P = .002 and Cohen kappa coefficient = 0.427). The majority of children (69.8%) had moderate caries risk and the most frequent risk factors recorded were sugar intake between meals, lack of regular dental control and poor oral hygiene. We concluded that ICDAS-II is a valuable and reliable diagnostic tool for early pit-and-fissure lesions and could be used alone during dental examination in children. The evaluation of caries risk should become clinical routine, as parameters belonging to high risk were frequently recorded in our study group.

The efficacy of dental sealant used with bonding agent on occlusal caries (ICDAS 2-4): A 24-month randomized clinical trial

BACKGROUND

Bonding before sealant application enhances retention on saliva-contaminated sound teeth; however, there are few studies of bonding's efficacy on sealant retention on occlusal caries.

AIM

To evaluate a bonding agent's efficacy on sealant retention on occlusal caries and caries transition.

DESIGN

One hundred twenty pairs of first permanent molars with occlusal caries (ICDAS 2-4) from 98 children aged 7.3-9.9 years were included. One molar was randomly selected to use bonding (Adper™ Single Bond 2, 3M ESPE) applied before sealant application (Helioseal^® clear, Ivoclar Vivadent). Bonding was not used on the contralateral tooth. Retention was determined using Simonsen's criteria; caries transition was evaluated using ICDAS scores, DIAGNOdent values, and bitewings at baseline, 6, 12, and 24 months. Data were analyzed with McNemar's and Fisher's exact tests.

RESULTS

Bonding agent use significantly increased sealant retention rates (P < .001). Bonded (B) sealants had a higher retention rate (83.3%) than non-bonded (NB) sealants (53.7%). The difference in the caries-transition rate was not significant between the groups (P > .05). Three teeth (1.4%; NB:B = 2:1) were restored due to radiographic dentin-caries progression.

CONCLUSIONS

Using a bonding agent before applying sealant on permanent molar occlusal caries (ICDAS 2-4) significantly enhanced sealant retention. Caries progression was rarely detected at the 24-month follow-up.

Efficacy of resin infiltration to mask post-orthodontic or non-post-orthodontic white spot lesions or fluorosis - a systematic review and meta-analysis

OBJECTIVE

The present review systematically analyzed clinical studies investigating the efficacy of resin infiltration on post-orthodontic or non-post-orthodontic, white spot lesions (WSL), or fluorosis.

MATERIALS

Five electronic databases (Central, PubMed, Ovid MEDLINE, Ovid EMBASE, LILACS) were screened. Article selection and data abstraction were done in duplicate. No language or time restrictions were applied. Outcomes were visual-tactile or DIAGNOdent measurements.

RESULTS

Eleven studies with 1834 teeth being affected in 413 patients were included. Nine studies were randomized control trials, one a prospective cohort study, and one had an unclear study design. Meta-analysis could be performed for "resin infiltration vs. untreated control," "resin infiltration vs. fluoride varnish," and "resin infiltration without bleaching vs. resin infiltration with bleaching." WSL being treated with resin infiltration showed a significantly higher optical improvement than WSL without any treatment (standard mean difference (SMD) [95% CI] = 1.24 [0.59, 1.88], moderate level of evidence [visual-tactile assessment]) and with fluoride varnish application (mean difference (MD) [95% CI] = 4.76 [0.74, 8.78], moderate level of evidence [DIAGNOdent reading]). In patients with fluorosis, bleaching prior to resin infiltration showed no difference in the masking effect compared to infiltration alone (MD [95% CI] = - 0.30 [- 0.98, 0.39], moderate level of evidence).

CONCLUSION

Resin infiltration has a significantly higher masking effect than natural remineralization or regular application of fluoride varnishes. However, although the evidence was graded as moderate, this conclusion is based on only very few well-conducted RCTs.

CLINICAL RELEVANCE

Resin infiltration seems to be a viable option to esthetically mask enamel white spot lesions and fluorosis.

Visual or visual-tactile examination to detect and inform the diagnosis of enamel caries

BACKGROUND

The detection and diagnosis of caries at the initial (non-cavitated) and moderate (enamel) levels of severity is fundamental to achieving and maintaining good oral health and prevention of oral diseases. An increasing array of methods of early caries detection have been proposed that could potentially support traditional methods of detection and diagnosis. Earlier identification of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol-generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.

OBJECTIVES

To determine the diagnostic accuracy of different visual classification systems for the detection and diagnosis of non-cavitated coronal dental caries for different purposes (detection and diagnosis) and in different populations (children or adults).

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 April 2020); Embase Ovid (1980 to 30 April 2020); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 April 2020); and the World Health Organization International Clinical Trials Registry Platform (to 30 April 2020). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared a visual classification system (index test) with a reference standard (histology, excavation, radiographs). This included cross-sectional studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were considered. Studies that explicitly recruited participants with caries into dentine or frank cavitation were excluded. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.

DATA COLLECTION AND ANALYSIS

We extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on QUADAS-2 specific to the review context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence intervals (CIs) and regions, and 95% prediction regions. The comparative accuracy of different classification systems was conducted based on indirect comparisons. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

MAIN RESULTS

We included 71 datasets from 67 studies (48 completed in vitro) reporting a total of 19,590 tooth sites/surfaces. The most frequently reported classification systems were the International Caries Detection and Assessment System (ICDAS) (36 studies) and Ekstrand-Ricketts-Kidd (ERK) (15 studies). In reporting the results, no distinction was made between detection and diagnosis. Only two studies were at low risk of bias across all four domains, and 15 studies were at low concern for applicability across all three domains. The patient selection domain had the highest proportion of high risk of bias studies (49 studies). Four studies were assessed at high risk of bias for the index test domain, nine for the reference standard domain, and seven for the flow and timing domain. Due to the high number of studies on extracted teeth concerns regarding applicability were high for the patient selection and index test domains (49 and 46 studies respectively). Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies: sensitivities ranged from 0.16 to 1.00 and specificities from 0 to 1.00. For all visual classification systems the estimated summary sensitivity and specificity point was 0.86 (95% CI 0.80 to 0.90) and 0.77 (95% CI 0.72 to 0.82) respectively, diagnostic odds ratio (DOR) 20.38 (95% CI 14.33 to 28.98). In a cohort of 1000 tooth surfaces with 28% prevalence of enamel caries, this would result in 40 being classified as disease free when enamel caries was truly present (false negatives), and 163 being classified as diseased in the absence of enamel caries (false positives). The addition of test type to the model did not result in any meaningful difference to the sensitivity or specificity estimates (Chi²(4) = 3.78, P = 0.44), nor did the addition of primary or permanent dentition (Chi²(2) = 0.90, P = 0.64). The variability of results could not be explained by tooth surface (occlusal or approximal), prevalence of dentinal caries in the sample, nor reference standard. Only one study intentionally included restored teeth in its sample and no studies reported the inclusion of sealants. We rated the certainty of the evidence as low, and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and inconsistency of results.

AUTHORS' CONCLUSIONS

Whilst the confidence intervals for the summary points of the different visual classification systems indicated reasonable performance, they do not reflect the confidence that one can have in the accuracy of assessment using these systems due to the considerable unexplained heterogeneity evident across the studies. The prediction regions in which the sensitivity and specificity of a future study should lie are very broad, an important consideration when interpreting the results of this review. Should treatment be provided as a consequence of a false-positive result then this would be non-invasive, typically the application of fluoride varnish where it was not required, with low potential for an adverse event but healthcare resource and finance costs. Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Wherever possible future studies should be carried out in a clinical setting, to provide a realistic assessment of performance within the oral cavity with the challenges of plaque, tooth staining, and restorations, and consider methods to minimise bias arising from the use of imperfect reference standards in clinical studies.

Effect of Chlorhexidine Varnish and Fluoride Varnish on White Spot Lesions in Orthodontic Patients- a Systematic Review

Aim:

The aim of this study is to critically review the studies that studied the effect of Chlorhexidine varnish and fluoride varnish on White Spot Lesion (WSL) in patients undergoing orthodontic treatment.

Materials and Methods:

The electronic database PubMed, The Cochrane Library, Medline, Embase, Google Scholar, Web of Knowledge along with a complimentary manual search of all orthodontic journals till the first week of December 2019 was searched. English language study performed on humans, randomized or nonrandomized clinical trials, comparing the effect of fluoride and chlorhexidine varnish on WSL was included in the review. Quality assessment of included studies was performed.

Clinical Significance:

The need for an adjunct oral hygiene aid to reduce the incidence and prevalence of white spot lesions in orthodontic patients is necessary. The use of these varnishes will aid in the same and thus make the adverse effects of fixed orthodontic treatment negligible.

Review of Literature:

Enamel demineralization is a significant risk associated with orthodontic treatment when oral hygiene is poor. Prevention of demineralization during orthodontic treatment is one of the greatest challenges faced by clinicians despite modern advances in caries prevention. The development of White Spot Lesions (WSLs) is attributed to prolonged plaque accumulation around the brackets.

Results:

The search identified a total of 3 studies that were included in this review. One study had Low risk of bias and the remaining 2 studies had moderate overall risk. Results showed that there was a reduction in the incidence of white spot lesions in orthodontic patients after application of chlorhexidine and Fluoride varnish.

Conclusion:

Low level evidence is available to conclude that the use of chlorhexidine varnishes and fluoride varnishes reduces the prevalence of white spot lesions in patients undergoing fixed orthodontic treatment. Due to its limitations, the results of this systematic review should be handled with caution and further well-planned Randomized Clinical Trial (RCT) are needed to provide a discrete conclusion.

Efficacy of a self-assembling peptide to remineralize initial caries lesions - A systematic review and meta-analysis

INTRODUCTION/OBJECTIVES

The present review systematically analyzed clinical studies investigating the efficacy of self-assembling peptides (SAP) to reduce initiation of or to remineralize initial caries lesions.

DATA

Prospective controlled (non-)randomized clinical trials investigating the efficacy of a self-assembling peptide compared to any other (placebo) treatment or untreated/standard control. Outcomes were visual analog scale (VAS), laser fluorescence, ICDAS score or morphometric measurements.

SOURCES

Three electronic databases (Central, PubMed, Ovid EMBASE) were screened. No language or time restrictions were applied.. Risk of Bias and level of evidence was graded using Risk of Bias 2.0 tool and Grade Profiler 3.6.

STUDY SELECTION/RESULTS

Seven studies with 508 teeth being affected in 294 patients were included. All studies were randomized controlled trials (RCT), five with a split-mouth and two with a parallel-arm design. Meta-analysis could be performed for SAP (plus fluoride varnish (FV)) vs. no treatment (plus FV) (control treatment). Depending on the outcome after up to 12 months SAP showed a significantly higher optical improvement than the control treatment (laser fluorescence: Standardized Mean Difference (SMD)[95 %CI] = -0.87[-1.39,-0.34; VAS: Mean Difference (MD)[95 %CI] = -35.38[-43.13,-27.64]) or no significant difference could be observed (ICDAS/activity score; Relative Risk (RR)[95 %CI] = 0.6[0.21,1.74]; morphometric measurements: SMD[95 %CI] = -1.95[-4.54,0.65]). Level of evidence was very low for all 4 outcomes. Furthermore, six studies showed a high risk of bias and six studies were (partially) funded by the manufactures of the tested products.

CONCLUSION

Based on a low number of clinical trials with relatively short follow up-periods and high risks of bias, self-assembling peptides may be a viable option to remineralize enamel caries.

CLINICAL SIGNIFICANCE

Self-assembling peptides may be a viable option to remineralize enamel caries. However, results should be interpretated with caution due the low number of clinical trials, the short follow-up periods and the limiting grade of evidence.

Light-based diagnostic methods for the in vivo assessment of initial caries lesions: Laser fluorescence, QLF and OCT

OBJECTIVES

To evaluate different light-based caries diagnostic methods for assessment of non-cavitated initial carious lesions on smooth surfaces.

METHODS

39 participants were included. For each participant, three regions of interest (ROI) with ICDAS codes 0, 1 or 2 were defined. All ROIs (n = 117) were investigated/imaged with laser fluorescence (LF, DIAGNOdent 2095; KaVo dental GmbH), quantitative light-induced fluorescence (QLF; Biluminator 2+, Inspektor Research Systems B.V.) and spectral-domain optical coherence tomography (SD-OCT; Telesto II, Thorlabs GmbH). The values of LF, ΔF of QLF, and the lesion extent assessed by OCT were categorized. Frequency distribution of LF-/QLF- and OCT-scores was determined for each ICDAS code included. Inter- and intra-examiner reproducibility of QLF and OCT measurements were assessed by unweighted kappa coefficient (ĸ) and Wilcoxon test (α = 0.05).

RESULTS

Compared with LF and QLF, OCT showed various manifestations of carious lesions for visually sound ROIs and a larger variation of caries extent in depth within the same ICDAS code groups. Intra-examiner reproducibility ranged between 0.49 and 1.00 for the QLF analysis and between 0.95 and 0.99 for the OCT analysis. Inter-examiner reproducibility ranged between 0.17 and 0.32 for the QLF analysis and between 0.65 and 0.79 for the OCT analysis.

CONCLUSION

LF and QLF were insensitive to less pronounced smooth-surface lesions while OCT allowed differentiation based on the penetration depth of the carious lesions. This makes OCT a suitable method to complement conventional visual inspection in order to detect and assess (very) early lesions.

The accuracy of laser fluorescence (DIAGNOdent) in assessing caries lesion activity on root surfaces, around crown margins, and in furcations in older adults

The authors conducted a case series to assess accuracy of DIAGNOdent (DD) in assessment of activity of dental caries lesions in root surfaces and in furcations and at crown margins. The study was a prospective, single center case series. The patients were 123 adults (age ≥ 55 years). To be included, a patient needed to have at least one active root caries lesion. The study was conducted at the Roseman College of Dental Medicine in South Jordan, Utah, USA and at area nursing homes. Lesions were rinsed and dried with air, and DD readings were obtained. Lesions were then isolated and 38% silver diamine fluoride was applied repeatedly for two minutes with a microbrush. DD readings and treatments were repeated every six months. Mean DD values were significantly different between active (unarrested) and inactive (arrested) caries for all comparisons, p-value < 0.0001. The optimal cut-off values for DD were between 20 and 35 except optimal cut-offs were higher for furcation and crown margin surfaces, particularly in the posterior (optimal cut-offs 40-45). This study demonstrates DD is a potentially valuable tool for assessing lesion activity in root surfaces, at restoration margins, and in furcations.

Effects of healthcare policy and education on reading accuracy of bitewing radiographs for interproximal caries

Objectives

The aim of this study is to assess the accuracy of bitewing radiograph interpretation of predoctoral students, residents and general dentists who work under different core curriculum of dental education and healthcare policy.

Methods

A total of 118 examiners including predoctoral dental students, residents and general dentists from USA and Japan were tasked with evaluating a series of bitewing radiographs and diagnosing interproximal carious lesions. This study was approved by the Harvard Medical School Institutional Review Board (IRB). Participants graded interproximal aspects of those images and categorized the following criteria; “intact”, “enamel caries <1/2 width”, “enamel caries >1/2 width” or “caries into dentin”. The gold-standard was determined by the consensus of two HSDM full-time faculty.

Results

There was significant difference in the sensitivity for all three caries levels between the two groups but there was no significant difference on specificity. The positive-predictive and negative-predictive values of the USA group for the enamel caries (<1/2 of enamel) were significantly higher than the Japanese group. The average of AUC (ROC) was significantly higher in the USA group (0.885 ± 0.04) than the Japanese group (0.785 ± 0.08, p<0.01).

Conclusion

Teaching and adopting BW radiographs for diagnosis of interproximal caries is integral for dental providers to accurately and efficiently use them in their practices. It is critical that all dental educators approach policymakers to explain the importance of BW radiographs and promote their efficacy for prevention and early diagnosis of interproximal caries.

Fluorescence devices for the detection of dental caries

BACKGROUND

Caries is one of the most prevalent and preventable conditions worldwide. If identified early enough then non-invasive techniques can be applied, and therefore this review focusses on early caries involving the enamel surface of the tooth. The cornerstone of caries detection is a visual and tactile dental examination, however alternative methods of detection are available, and these include fluorescence-based devices. There are three categories of fluorescence-based device each primarily defined by the different wavelengths they exploit; we have labelled these groups as red, blue, and green fluorescence. These devices could support the visual examination for the detection and diagnosis of caries at an early stage of decay.

OBJECTIVES

Our primary objectives were to estimate the diagnostic test accuracy of fluorescence-based devices for the detection and diagnosis of enamel caries in children or adults. We planned to investigate the following potential sources of heterogeneity: tooth surface (occlusal, proximal, smooth surface or adjacent to a restoration); single point measurement devices versus imaging or surface assessment devices; and the prevalence of more severe disease in each study sample, at the level of caries into dentine.

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 May 2019); Embase Ovid (1980 to 30 May 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 May 2019); and the World Health Organization International Clinical Trials Registry Platform (to 30 May 2019). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared a fluorescence-based device with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. Studies that explicitly recruited participants with caries into dentine or frank cavitation were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently using a piloted study data extraction form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Sensitivity and specificity with 95% confidence intervals (CIs) were reported for each study. This information has been displayed as coupled forest plots and summary receiver operating characteristic (SROC) plots, displaying the sensitivity-specificity points for each study. We estimated diagnostic accuracy using hierarchical summary receiver operating characteristic (HSROC) methods. We reported sensitivities at fixed values of specificity (median 0.78, upper quartile 0.90).

MAIN RESULTS

We included a total of 133 studies, 55 did not report data in the 2 x 2 format and could not be included in the meta-analysis. 79 studies which provided 114 datasets and evaluated 21,283 tooth surfaces were included in the meta-analysis. There was a high risk of bias for the participant selection domain. The index test, reference standard, and flow and timing domains all showed a high proportion of studies to be at low risk of bias. Concerns regarding the applicability of the evidence were high or unclear for all domains, the highest proportion being seen in participant selection. Selective participant recruitment, poorly defined diagnostic thresholds, and in vitro studies being non-generalisable to the clinical scenario of a routine dental examination were the main reasons for these findings. The dominance of in vitro studies also means that the information on how the results of these devices are used to support diagnosis, as opposed to pure detection, was extremely limited. There was substantial variability in the results which could not be explained by the different devices or dentition or other sources of heterogeneity that we investigated. The diagnostic odds ratio (DOR) was 14.12 (95% CI 11.17 to 17.84). The estimated sensitivity, at a fixed median specificity of 0.78, was 0.70 (95% CI 0.64 to 0.75). In a hypothetical cohort of 1000 tooth sites or surfaces, with a prevalence of enamel caries of 57%, obtained from the included studies, the estimated sensitivity of 0.70 and specificity of 0.78 would result in 171 missed tooth sites or surfaces with enamel caries (false negatives) and 95 incorrectly classed as having early caries (false positives). We used meta-regression to compare the accuracy of the different devices for red fluorescence (84 datasets, 14,514 tooth sites), blue fluorescence (21 datasets, 3429 tooth sites), and green fluorescence (9 datasets, 3340 tooth sites) devices. Initially, we allowed threshold, shape, and accuracy to vary according to device type by including covariates in the model. Allowing consistency of shape, removal of the covariates for accuracy had only a negligible effect (Chi2 = 3.91, degrees of freedom (df) = 2, P = 0.14). Despite the relatively large volume of evidence we rated the certainty of the evidence as low, downgraded two levels in total, for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the high number of in vitro studies, and inconsistency due to the substantial variability of results.

AUTHORS' CONCLUSIONS

There is considerable variation in the performance of these fluorescence-based devices that could not be explained by the different wavelengths of the devices assessed, participant, or study characteristics. Blue and green fluorescence-based devices appeared to outperform red fluorescence-based devices but this difference was not supported by the results of a formal statistical comparison. The evidence base was considerable, but we were only able to include 79 studies out of 133 in the meta-analysis as estimates of sensitivity or specificity values or both could not be extracted or derived. In terms of applicability, any future studies should be carried out in a clinical setting, where difficulties of caries assessment within the oral cavity include plaque, staining, and restorations. Other considerations include the potential of fluorescence devices to be used in combination with other technologies and comparative diagnostic accuracy studies.

Molecular Fingerprint Imaging to Identify Dental Caries Using Raman Spectroscopy

Tooth loss impairs mastication, deglutition and esthetics and affects systemic health through nutritional deficiency, weight loss, muscle weakness, delayed wound healing, and bone fragility. Approximately 90% of tooth loss is due to dental caries and periodontal disease. Accordingly, early treatment of dental caries is essential to maintaining quality of life. To date, the clinical diagnosis of dental caries has been based on each dentist’s subjective assessment, but this visual method lacks objectivity. To improve diagnostic ability, highly sensitive quantitative methods have been developed for the diagnosis and prevention of dental caries and are gradually becoming a mandatory item in modern dentistry. High-resolution Raman spectroscopy is a suitable tool for recognizing the subtle structural changes that occur in dental enamel in already developed or, more importantly, incipient dental caries. Raman analysis could soon emerge as a breakthrough in dentistry because of its high diagnostic sensitivity. In this study, we build upon our previous findings in a new analysis of dental caries using Raman spectroscopy imaging and discuss the possibility of using Raman photonic imaging in support of objective diagnostics in dentistry. Our findings support the Raman method of caries detection in comparison with other conventional or new approaches.

Spectral characteristics of caries autofluorescence obtained from different locations and caries severities

Dental caries usually occurs at interproximal and occlusal surfaces. The purpose of the present study was to determine if characteristic spectral factors extracted from autofluorescence (AF) spectra are informative regarding caries detection and the determination of caries stage as compared with DIAGNOdent results. AF spectra were obtained from caries lesions of different severities at two locations using a 405 nm laser. Three spectral factors, that is, spectral slope at 550 to 600 nm, spectral area under the curve at 500 to 590 nm and two-peak ratio between 625 and 667 nm, were extracted. The values of three spectral factors linearly decreased as caries progressed. According to micro-CT images, conventional visual and tactile inspections of lesions under or overestimated (25%-65%) caries states, and brown or thickly stained layer on interproximal or occlusal surfaces, respectively, caused misclassifications of caries stage. Of the spectral factors examined, spectral slope and area under curve for interproximal and occlusal surfaces, respectively, were found to be significantly related to caries stage and showed least data overlap. For interproximal and occlusal surfaces, DIAGNOdent readings of different stages overlapped considerably though their mean values were significantly different regardless of stage.

Occlusal Caries Detection and Diagnosis Using Visual ICDAS Criteria, Laser Fluorescence Measurements, and Near-Infrared Light Transillumination Images

OBJECTIVE

Current diagnostic tools for non-cavitated occlusal caries are not very reliable. For this reason, newer systems need to be developed. The aim of this study was to compare the performance of visual inspection (ICDAS-II), laser fluorescence (DIAGNOdent pen), and the near-infrared transillumination technique (DIAGNOcam) in the detection of non-cavitated occlusal caries lesions under clinical and laboratory conditions in 90 third molar teeth planned for extraction.

MATERIALS AND METHODS

Ninety third molar teeth were firstly examined in clinical conditions, scored according to ICDAS-II criteria, and examined with DIAGNOdent pen and DIAGNOcam devices. After finishing the clinical examination, the teeth were re-evaluated shortly after the extractions with the same methods. Then, the teeth were sectioned for histological validation according to Downer's criteria. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic (ROC) curves were calculated based on the histological results.

RESULTS

For the D0-D1-4 threshold, the area under the ROC curve values ranged between 0.754 and 0.881 for all systems. Sensitivity values ranged between 80.5 and 96.1%, and specificity values ranged between 61.5 and 84.6% for the three caries detection methods. DIAGNOcam had the best correlation value (0.616) according to histological observations and demonstrated a sensitivity rate of 96.1%, a specificity rate of 61.5%, and an accuracy rate of 91.1%.

CONCLUSIONS

DIAGNOcam was found to be the most effective method for the diagnosis of occlusal caries without cavitation in permanent molar teeth.

Remineralization Potential of Theobromine on Artificial Carious Lesions

Background and Aims:

This study aimed to investigate the remineralization potential of two concentrations of theobromine (100 mg/L and 200 mmg/L) with fluoridated dentifrice, NovaMin, and nanohydroxyapatite using DIAGNOdent, scanning electron microscopy (SEM), and energy dispersive X-ray (EDX) analysis.

Materials and Methods:

Two sections were taken from 50 teeth each. Artificial carious lesions were induced using demineralizing solution. Evaluation using DIAGNOdent, SEM, and EDX analysis for elemental evaluation of Ca/P ratio and fluoride ion was carried out. Teeth sections were then randomly assigned to five different groups: (1) fluoridated dentifrice (Colgate™, Colgate –Palmolive, India), Novamine- Shy NM™, Group pharamaceuticals, India), 3. Nano-hydroxyapatite- Remin Pro™, Voco, Germany) 4. 100mg and 5. 200mg of Theobromine toothpaste (Theodent classic™, Rennou, UK-853069003006). Remineralization was carried out for 14 days with two applications per day. Samples were reanalyzed using DIAGNOdent, SEM, and EDX.

Results:

A Tukey post-hoc test revealed statistically significant difference between NovaMin and all the other toothpastes (P < 0.001) for DIAGNOdent readings. On performing SEM-EDX analysis, it was seen that all agents had remineralization potential; however, no significant difference was found.

Conclusion:

Theobromine can be used as an effective novel remineralizing agent alternative to the already-available agents.

Effect of resin composite filler on digital imaging fiber-optic transillumination

Using a trans-illumination device that applies digital imaging fiber-optic transillumination (DIFOTI) technology, which involves the use of transmitted near-infrared laser light for inspection, the effect of composite resin (CR) restoration of a tooth on caries detection was evaluated. A cavity was formed in a tooth of the lower jaw cut from the specimen, experimental CRs with various filler rates were filled, and the influence of the filler on the obtained image was investigated. On the near-infrared images, the lightness differences between the CR-restored portion and the tooth portion were measured. The translucency parameter (TP) value and the correlation between the lightness differences and TP value of the CRs were investigated. The experimental results showed that the greater rate of macro-filler is, the lighter image and larger TP value. In other words, CR with hybrid filler to increase the TP value is less likely to affect caries detection by DIFOTI.

Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion-Dry and Wet Conditions

Objective

The aim of this study was to assess the effectiveness and reliability of magnification, DIAGNOdent in detection of smooth surface white spot lesions.

Study design

Three hundred children aged 5–10 years were examined by two examiners for presence of smooth surface white spot lesions using naked eye and magnifying loupes in wet and dry conditions followed by DIAGNOdent analysis. Data was analysed using Cohen's kappa coefficient, Friedman test and Paired t test. Accuracy was assessed by sensitivity and positive predicted values.

Results

Significant difference was found between naked eyes and magnifying loupes with and without air drying. While insignificant difference was found between DIAGNOdent and loupes.

Conclusion

Magnifying loupes with air drying is an effective method in detection of smooth surface white spot lesion.

Clinical significance

With the increased knowledge about the pathogenesis of dental caries and its ability to be remineralisable if detected early, makes it all the more important for the clinician to be vigilant in detection of early lesion to prevent the avoidable restorative approach for the same. Incorporation of magnification to routine dental examination by general dentist can help in early diagnosis and treatment of dental decay. This could prevent further progression of dental caries and reduces the incidence of tooth decay

How to cite this article

Gupta N, Sandhu M, et al. Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion—Dry and Wet Conditions. Int J Clin Pediatr Dent 2019;12(1):37–41.

Near-infrared imaging of demineralization on the occlusal surfaces of teeth without the interference of stains

Most new caries lesions are found in the pits and fissures of the occlusal surface. Radiographs have extremely low sensitivity for early occlusal decay, and by the time the lesion is severe enough to appear on a radiograph, it typically has penetrated well into the dentin and surgical intervention is required. The occlusal surfaces are often heavily stained, and visual and tactile detection have poor sensitivity and specificity. Previous near-infrared imaging studies at wavelengths beyond 1300 nm have demonstrated that stains are not visible and demineralization on the occlusal surfaces can be viewed without interference from stains. The objective of our study is to determine how the contrast between sound and lesion areas on occlusal surfaces varies with wavelength from the visible to 2350 nm and determine to what degree stains interfere with that contrast. The lesion contrast for reflectance is measured in 55 extracted teeth with suspected occlusal lesions from 400 to 2350 nm employing silicon and indium gallium arsenide imaging arrays. In addition, the lesion contrast is measured on 25 extracted teeth with suspected occlusal lesions from 400 to 1600 nm in reflectance and from 830 to 1400 nm in transillumination before and after stains are removed using a ultrasonic scaler. The highest lesion contrast in reflectance is measured at wavelengths >1700  nm. Stains interfere significantly at wavelengths <1150  nm (400 to 1150) for both reflectance and transillumination measurements. Our study suggests that the optimum wavelengths for imaging decay in the occlusal surfaces are >1700  nm for reflectance (1700 to 2350 nm) and near 1300 nm (1250 to 1350 nm) for transillumination.

A comparison of diagnosis of early stage interproximal caries with bitewing radiographs and periapical images using consensus reference

OBJECTIVES:

The purpose of this study was to assess the diagnostic property of intraoral bitewing radiographs (BTW) for early stage interproximal caries, and to compare them with periapical radiographs (PA) at different levels of caries progression.

METHODS:

A total of 241 interproximal surfaces of BTW and corresponding PAs were used. Seven teaching faculty consisting of three oral and maxillofacial radiologists, two operative faculty, and two prosthodontists evaluated the images. The observers graded images as either "intact", "enamel caries <1/2 width", "enamel caries >1/2 width", or "caries into dentin". The gold-standard was established by consensus of two experienced faculty with 35 years and 27 years of experience. Specificity, sensitivity, positive-predictive value, and negative-predictive value were calculated for the different level of caries progression. Furthermore, receiver operating curves) of BTW and PAs of each evaluator were made and the area under the curve of BTW and PAs were compared.

RESULTS:

There was no significant difference in the specificity of BTW and PAs. BTW showed significantly higher sensitivity than PAs in all levels of caries progression (p<0.01). Positive-predictive value and negative-predictive value of BTWs were also significantly higher than PAs. One-way ANOVA and Tukey HSD test showed a significant difference in sensitivity with different levels of caries progression. The average area under the curve was significantly higher for BTWs than PAs (p<0.01).

CONCLUSIONS:

BTWs offer a significant advantage over PAs in the diagnoses of early stages of interproximal carious lesions.

SWIR reflectance imaging of demineralization on the occlusal surfaces of teeth beyond 1700 nm

Most new lesions are found in the pits and fissures of the occlusal surface. Radiographs have extremely low sensitivity for early occlusal decay and by the time the lesion is severe enough on a radiograph it typically has penetrated well into the dentin and surgical intervention is required. The occlusal surfaces are heavily stained and visual and tactile methods for their detection also have poor sensitivity and specificity. Previous studies at wavelengths beyond 1300-nm have demonstrated that stains are not visible and demineralization on the occlusal surfaces can be viewed without interference from stains. New extended range InGaAs near-IR cameras allow access to wavelengths beyond 1700-nm. The objective of this study was to determine how the contrast of occlusal lesions varies with wavelength from the visible to 2350-nm. The lesion contrast was measured in 55 extracted teeth with suspected occlusal lesions using reflectance measurements from 400-2350-nm using Si and InGaAs imaging arrays. The highest lesion contrast in reflectance was measured at wavelengths greater than 1700-nm. Stains interfered significantly at wavelengths shorter than 1150-nm. This study indicates that the optimum wavelengths for reflectance imaging decay in the occlusal surfaces are greater than 1700-nm.

Diagnosis and staging of caries using spectral factors derived from the blue laser-induced autofluorescence spectrum

OBJECTIVE

The aim of this study was to identify the factors derived from the 405nm laser-induced autofluorescence (AF) spectra that could be used to diagnose and stage caries.

MATERIALS AND METHODS

Teeth (20 teeth per stage) were classified as sound, stage II, III, and IV based on a visual and tactile inspection. The specimens were re-examined and reclassified based on micro-CT analysis. From the teeth, the AF was obtained using a 405nm laser. Three spectral factors (spectral slope at 550-600nm, area under the curve at 500-590nm, and two-peak ratio between 625 and 667nm) were derived from the AF spectra. Using these factors, the diagnosis and staging of caries were tested, and the results were compared with those of DIAGNOdent.

RESULTS

After micro-CT analysis, only 13, 11, and 13 teeth were reclassified as stages II, III, and IV, respectively. The reclassified groups showed less data overlap between the stages, and the spectral slope was 40.1-74.6, 27.5-39.6, 11.1-27.4, and 1.0-9.7 for sound, stage II, III, and IV, respectively. The differentiation of stages III and IV using DIAGNOdent appeared to be difficult due to the considerable data overlap.

CONCLUSION

Among the factors tested, the spectral slope at 550-600nm showed the best match with the caries specimens, in which their stage had been identified precisely.

CLINICAL SIGNIFICANCE

The 405nm laser-induced AF spectra can be applied to the diagnosis and staging of caries alone or in conjunction with conventional methods, such as visual, tactile, and X-ray inspection.

Caries progression in non-cavitated fissures after infiltrant application: a 3-year follow-up of a randomized controlled clinical trial

Objectives

To evaluate the efficacy of a conservative treatment to prevent the progression of caries using an infiltrant on non-cavitated pit and fissures.

Material and Methods

This controlled clinical trial selected 23 volunteers with clinically and radiographically non-cavitated occlusal caries among patients presenting a “rather low” to “very high” caries risk. Eighty-six teeth were randomly divided into two experimental groups: teeth receiving a commercial pit-and-fissure sealant (Alpha Seal-DFL) and contralateral teeth receiving Icon infiltrant (DMG). Caries progression was monitored by clinical (laser fluorescence caries detection) and radiographic examination at 12-month intervals over a period of 3 years of monitored caries progression. Probing the sealing materials to detect areas of retention was also used to evaluate marginal integrity.

Results

Statistical analysis showed no difference in caries progression using laser fluorescence caries detection when both materials were compared, regardless of the evaluation times (p>0.05). No significance was observed when the marginal sealant integrity of both materials was compared, regardless of the evaluation time (p<0.05). Marginal integrity significantly reduced after 1 year for both materials (p<0.05), but remained stable after 2 and 3 years of evaluation, compared with 1-year results (p>0.05). SEM analysis exhibited a more homogeneous sealing for the infiltrant than obtained by the sealant.

Conclusions

The infiltrant was effective to prevent the caries progression in non-cavitated pit-and-fissures after 3 years of clinical evaluation, comparable with the conventional sealant. The infiltrant also presented better results in terms of caries progression at the 3-year evaluation time using the radiographic analysis.

Decalcification prevention around orthodontic brackets bonded to bleached enamel using different topical agents

BACKGROUND

The present study was conducted to evaluate the effect of different topical agents utilized for prevention of enamel decalcification around orthodontic brackets bonded to bleached and non-bleached enamel.

METHODS

Human maxillary premolars (n = 120) were divided into two equal groups. Teeth in group I were left without bleaching while those in group II were bleached with Vivastyle gel. Metal brackets were bonded to all the teeth using light-cured adhesive. Each group was divided into six equal subgroups (A, B, C, D, E, and F). In subgroup A, no material was applied (control). In subgroups B, C, D, E, and F, the following materials were applied respectively: Profluorid varnish, Enamel Pro Varnish, Ortho-Choice Ortho-Coat, GC Tooth Mousse, and GC MI Paste Plus. All teeth were cycled in a demineralization solution/artificial saliva for 15 days. Laser fluorescence was used to measure the level of enamel mineralization. The data were statistically analyzed.

RESULTS

Regarding the non-bleaching subgroups, all studied material revealed significant demineralization reduction in comparison to the control subgroup (P < 0.05). Ortho-Choice Ortho-Coat revealed the highest significant effect while GC Tooth Mousse showed the least effect. In bleached subgroups, Profluorid varnish, Enamel Pro Varnish, and Ortho-Choice Ortho-Coat significantly reduced demineralization (P < 0.05) while either GC MI Paste Plus or GC Tooth Mousse had no significant effects (P > 0.05).

CONCLUSIONS

Ortho-Choice Ortho-Coat, and Profluorid and Enamel Pro varnishes could be utilized successfully to reduce enamel demineralization around brackets bonded to either bleached or non-bleached enamel. GC MI Paste Plus and GC Tooth Mousse were effective only in non-bleached enamel.

Near-IR and CP-OCT imaging of suspected occlusal caries lesions

INTRODUCTION

Radiographic 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.

METHODS

Near-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.

RESULTS

Near-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.

CONCLUSION

This 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.

In Vitro Assessment of Enamel Permeability in Primary Teeth with and without Early Childhood Caries Using Laser Scanning Confocal Microscope

OBJECTIVE

To compare the permeability of the enamel of primary teeth from individuals free of Early Childhood Caries (ECC) with that from individuals affected with ECC by assessment of dye penetration using Laser Scanning Confocal Microscope (LSCM).

STUDY DESIGN

Experimental in vitro study. Exfoliated primary maxillary anterior teeth (n = 44) were collected and divided into two groups (n=22 per group): samples with ECC (Group 1) and without ECC (Group 2). The samples were immersed in Rhodamine B dye solution for 1 day, cut longitudinally into 3 sections, observed using LSCM. Dye penetration depths in the incisal, middle, cervical thirds and on labial, lingual surfaces were recorded. Data were analyzed by the Mann-Whitney test (α = 5%, p < .005).

RESULTS

The overall mean penetration depth for group 1 (100.6 μm ± 58.48 μm) was significantly higher than that of group 2 (31.55 μm ± 23.40 μm, p < .000). Mean penetration depth in the incisal, middle, and cervical thirds and on the labial and lingual surfaces of group 1 also presented significantly higher scores than in group 2 (p < .005).

CONCLUSION

There was significantly more dye penetration in the ECC group than in the non-ECC group. This could be related to a higher level of enamel permeability in teeth affected with ECC.

Effectiveness of Air Drying and Magnification Methods for Detecting Initial Caries on Occlusal Surfaces Using Three Different Diagnostic Aids

Objective-The aim of this study was to assess the effect of magnification and air-drying on detection of carious lesion. Study Design-44 human extracted premolars were selected with sound occlusal surfaces without frank cavitation. The Diagnostic techniques used were Unaided visual examination, Magnifying Loupes (4.2×) and Stereomicroscope (10×, before and after air-drying) and then the teeth were sectioned bucco-lingually and both the surfaces were examined under Stereomicroscope (50×) to assess the presence or absence of carious lesion in the pit and fissures. The scores were compared to obtain Cohen's kappa coefficient (Reproducibility) and subjected to the Friedman Test and Paired t test. Sensitivity, specificity and positive predictive value used to assess accuracy. Results-On Statistical analysis, visual examination before and after air drying had highest specificity but lowest sensitivity compared to different diagnostic techniques. Magnifying loupes after air-drying had highest sensitivity and lowest specificity compared to other diagnostic techniques. Conclusion-Air drying combined with magnifying aids are cost-effective, reliable method for detection of early carious lesion. If used in pediatric clinical practice, any undesirable pain and discomfort to the patient due to invasive procedures and helps in employing preventive measures.

Oral Health Screening Using a Caries Detection Device

Children from low-income families are more likely to have dental disease and less likely to have regular dental care. Children’s dental-related illnesses are responsible for more than 880,000 lost school days each year. The lack of reliable state-level data often makes monitoring the oral health of children a challenge. By conducting oral health screenings, school nurses could promote prevention and early identification of dental problems and could aid in the collection of data. This innovative project used a convenience sample of students to test a caries detection device. Children in Grades 3 and 6 ( n = 2,622) received oral health screening by the school nurse using a noninvasive laser fluorescent dental device. Findings revealed that 82% of students referred to the dentists received dental care. School nurses can contribute to improving the oral health status of the school-age population by early detection of dental caries and referrals for a dental evaluation.

Pen-type laser fluorescence device versus bitewing radiographs for caries detection on approximal surfaces

Background

The accurate detection of approximal caries is generally difficult. The aim of this study was to assess the ability of the pen-type laser fluorescence device (LF pen) to detect approximal carious lesions in comparison to bitewing radiographs (BW).

Methods

Three hundred forty-one tooth surfaces were diagnosed in 20 patients with an average age of 26.70 (±2.82) years. Each test tooth was sequentially assessed by a single calibrated examiner using visual inspection, BW, and the LF pen. Radiographs were used as the gold standard to calculate an appropriate cut-off.

Results

Sensitivity, specificity and accuracy values for cut-off limits of 15, measured by the LF pen were compared using the chi² test (McNemar test). For approximal caries at D3 level, the highest values of specificity and sensitivity were observed for the LF pen at a cut-off value of 15 (96.8 and 83.0 %) and for visual inspection (99.3 and 4.3 %).

Conclusion

Within the limitations of this study, dentin caries on approximal surfaces could be detected equally well by the LF pen as by the bitewing radiographs. Therefore, the LF pen can be recommended as an alternative to radiographs for the detection of approximal caries in a regular dental practice setting.

Trial registration

DRKS00004817 on DRKS on 12^th March 2013.

Laser fluorescence of caries detection in permanent teeth in vitro: a systematic review and meta-analysis

BACKGROUND/OBJECTIVES

The detection of dental caries in the early stages, particularly on the occlusal surfaces, has become a mainstay of contemporary clinical practice. The objective of the study was to verify the accuracy of laser fluorescence for caries detection.

METHODS

A comprehensive search of the MEDLINE (PubMed), EMBase, Cochrane Central Register of Controlled Trials, IBECS, BIOSIS, Web of Science, SCOPUS, Congress Abstracts, and Grey literature databases was undertaken from 1980 through January 2016. We included cross-sectional studies that evaluated laser fluorescence in caries diagnoses in vitro and compared them with histological analyses.

RESULTS

A total of 39 articles were included in the meta-analysis, which included 2082 caries sites. The pooled sensitivity was 0.71 (0.69, 0.73), and the specificity was 0.81 (0.73, 0.82). The diagnostic odds ratio was 14.93 (11.2, 19.9). A summary receiver operating characteristic curve was constructed. The area under the curve was 0.865.

CONCLUSION

This meta-analysis showed that laser fluorescence in vitro had the ability to diagnose occlusal caries lesions in permanent teeth and enamel and dentin caries.

Enhancement of OCT images with vinyl polysiloxane (VPS)

Several studies have shown that optical coherence tomography (OCT) can be used to measure the remaining enamel thickness and detect the location of subsurface lesions hidden under the sound enamel. Moreover studies have shown that high refractive index liquids can be used to improve the visibility of subsurface lesions in OCT images. In this study, we demonstrate that vinyl polysiloxane (VPS) impression materials which are routinely used in dentistry can be used to enhance the detection of dentinal lesions on tooth occlusal surfaces. Lesion presence was confirmed with polarized light microscopy and microradiography.

Applications of Light Amplification by Stimulated Emission of Radiation (Lasers) for Restorative Dentistry

Light amplification by stimulated emission of radiation (laser) has been used widely in a range of biomedical and dental applications in recent years. In the field of restorative dentistry, various kinds of lasers have been developed for diagnostic (e.g. caries detection) and operative applications (e.g. tooth ablation, cavity preparation, restorations, bleaching). The main benefits for laser applications are patient comfort, pain relief and better results for specific applications. Major concerns for using dental lasers frequently are high cost, need for specialized training and sensitivity of the technique, thereby compromising its usefulness particularly in developing countries. The main aim of this paper is to evaluate and summarize the applications of lasers in restorative dentistry, including a comparison of the applications of lasers for major restorative dental procedures and conventional clinical approaches. A remarkable increase in the use of lasers for dental application is expected in the near future.