Performance of a new fluorescence camera for detection of occlusal caries in vitro

Sensitivity and specificity of the ICDAS II system and bitewing radiographs for detecting occlusal caries using the Spectra™ caries detection system as the reference test in children

BACKGROUND

Most studies assessing the sensitivity and specificity of caries detection methods have been performed in vitro using the histological method as the gold standard showing inconsistent values. The aim of this study was to compare the sensitivity and specificity in detecting occlusal caries using the International Caries Detection and Assessment System (ICDAS II) with the radiographic method (RM), while using the Spectra™ Caries Detection System (SCDS) as the reference test.

METHODS

One hundred sixty children, ages 7-12 years, participated in the study. Five zones in the occlusal surfaces of 859 primary and 632 first permanent molars were examined visually using ICDAS-II, the RM using bitewing radiographs and SCDS. The descriptive statistics of sensitivity and specificity were calculated and compared.

RESULTS

For all molars combined and for primary molars only, the sensitivity of ICDAS II was higher for detecting total caries (p < 0.001), caries in enamel (p < 0.001), and caries in dentin (p = 0.016), but it was not different for detecting caries in the dentin of permanent first molars (p = 0.214), and primary second molars (p = 0.761). The specificity of RM was higher for detecting total caries, caries in enamel for all molars combined and for permanent first molars (p < 0.001). For caries in dentin, the specificity of ICDAS II was higher for all molars combined and for primary molars only (p < 0.001). For total caries in primary molars only, and caries in dentin of permanent first molars only, the specificity was not different (p = 0.156 and p = 0.181 respectively).

CONCLUSIONS

The sensitivity and specificity of ICDAS II and RM changes depending on whether the carious lesion compromises the enamel or dentin, and if the caries detection is performed in the primary molars or permanent first molars.

Emerging Technologies for Dentin Caries Detection-A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed at assessing the diagnostic accuracy of emerging technologies, such as laser fluorescence (LF), transillumination, light-emitting diode devices, optical coherence tomography (OCT), alternating current impedance spectroscopy, fluorescence cameras (FC), photo-thermal radiometry, and modulated luminescence technology. In vivo and in vitro results of such non-ionizing, non-invasive, and non-destructive methods' effectiveness in non-cavitated dentin caries detection are sometimes ambiguous. Following the PRISMA guidelines, 34 relevant research articles published between 2011-2021 were selected. The risk of bias was assessed with a tool tailored for caries diagnostic studies, and subsequent quantitative uni- and bi-variate meta-analysis was carried out in separate sub-groups according to the investigated surface (occlusal/proximal) and study setting (in vivo/in vitro). In spite of the high heterogeneity across the review groups, in vitro studies on LF and FC proved a good diagnostic ability for the occlusal surface, with area under the curve (AUC) of 0.803 (11 studies) and 0.845 (five studies), respectively. OCT studies reported an outstanding performance with an overall AUC = 0.945 (four studies). Promising technologies, such as OCT or FC VistaProof, still need well-designed and well-powered studies to accrue experimental and clinical data for conclusive medical evidence, especially for the proximal surface. Registration: INPLASY202210097.

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.

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.

Development of a Fluorescence-Based Caries Scoring System for an Intraoral Scanner: An in vitro Study

OBJECTIVES

To develop an automated fluorescence-based caries scoring system for an intraoral scanner and totest the performance of the system compared to state-of-the-art methods.

METHODS

Seventy-three permanent posterior teeth were scanned with a three-dimensional (3D) intraoral scanner prototype which emitted light at 415 nm. An overlay representing the fluorescence signal from the tissue was mapped onto 3D models of the teeth. Multiple examination sites (n = 139) on the occlusal surfaces were chosen, and their red and green fluorescence signal components were extracted. These components were used to calculate 4 mathematical functions upon which a caries scoring system for the scanner prototype could be based. Visual-tactile (International Caries Detection and Assessment System, ICDAS), radiographic (ICDAS), and histological assessments were conducted on the same examination sites.

RESULTS

Most index tests showed significant correlation with histology. The strongest correlation was observed for the visual-tactile examination (rs = 0.80) followed by the scanner supported by the caries classification function that quantifies the overall fluorescence compared to sound surfaces (rs = 0.78). Additionally, this function resulted in the highest intra-examiner reliability (κ = 0.964), and the highest sum of sensitivity (SE) and specificity (SP) (sum SE-SP: 1.60-1.84) at the 2 histological levels where the comparison with visual-tactile assessment was possible (κ = 0.886, sum SE-SP = 1.57-1.81) and at the 3 out of 4 histological levels where the comparison with radiographic assessment was possible (κ = 0.911, sum SE-SP = 1.37-1.78); the only exception was for the lesions in the outer third of dentin, where the radiographic assessment showed the highest sum SE-SP (1.78).

CONCLUSION

A fluorescence-based caries scoring system was developed for the intraoral scanner showing promising performance compared to state-of-the-art caries detection methods. The intraoral scanner accompanied by an automated caries scoring system may improve objective caries detection and increase the efficiency and effectiveness of oral examinations. Furthermore, this device has the potential to support reliable monitoring of early caries lesions.

Use of DIAGNOdent and VistaProof in diagnostic of Pre-Cavitated Caries Lesions-A Systematic Review and Meta-Analysis

Objective: To analyse the published evidence of the validity of DIAGNDOdent and VistaProof in diagnosing carious depths in pre-cavitated lesions. Material and methods: A systematic review was carried out after identifying a total of 184 articles, including 27 concerning the qualitative review and a subsequent meta-analysis. The quality of the studies was evaluated by using the QUADAS-2 tool. Results: For DIAGNOdent, the sensitivity value was 0.77, the specificity value was 0.75 and AUC was 0.81 for the global meta-analyses. In relation to subgroups, the values estimated 0.85, 0.76 and 0.86, respectively, for the in vivo group and 0.71, 0.75 and 0.83 for the in vitro group. For VistaProof, sensitivity was 0.81, specificity 0.75 and AUC had a value of 0.80 in the global meta-analysis. For the subgroups, these were considered at 0.75, 0.81 and 0.89, respectively, for the in vivo group and 0.91, 0.74 and 0.76 for the in vitro group. Neither case presented publication bias when analysing the funnel plot, the classic fail-safe number and Egger’s intercept. Conclusion: Both VistaProof and DIAGNOdent are valid as they offer a moderate to high diagnostic effectiveness for dentine depth in pre-cavitated lesions.

In-vitro validation of near-infrared reflection for proximal caries detection

The aim of this study was the in-vitro validation of VistaCam iX HD, which uses near-infrared reflection (NIRR), for proximal caries detection. It was compared with digital bitewing radiography (BWR), and micro-computed tomography (µCT) was used as the reference standard. One-hundred teeth with either sound (n = 54) or carious (n = 46) proximal surfaces were selected using visual-tactile criteria. Images of these surfaces were generated using BWR and NIRR. Evaluation was performed by two examiners, twice, at an interval of 2 weeks. All samples were scanned with a micro-computed tomograph. Thresholds were defined for sound surfaces, and for enamel and dentin lesions, for all methods. Both BWR and NIRR showed moderate sensitivity for the detection of any caries (0.50 for NIRR and 0.53 for BWR). For enamel lesions, sensitivity was lower (0.13 for NIRR and 0.31 for BWR). Specificity was high (≥0.94) in all categories for both methods. Inter-rater reliability ranged from 0.89 to 0.93 and intra-rater reliability from 0.80 to 0.89. Surface evaluation of images generated using NIRR was complicated by overexposed areas; approximately 25% of the images were not clearly interpretable. In conclusion, NIRR and BWR were found to be reproducible methods with comparable diagnostic accuracy. However, NIRR cannot be recommended as a complementary diagnostic method for assessing proximal caries in permanent molars because of problems with image quality and artefacts.

Comparison of diagnostic effects of infrared imaging and bitewing radiography in proximal caries of permanent teeth

This study aimed to compare the diagnostic efficacy of VistaCam iX intraoral camera system using infrared light and bitewing radiography for detection of proximal caries in permanent teeth. This in vitro study was performed on 108 teeth. The proximal surfaces of the teeth were examined for caries using ICDAS II criteria, bitewing radiography, and the Proxi head of VistaCam iX. The teeth were then sectioned and histologically analyzed (gold standard). Data were analyzed using SPSS version 25 via the correlation test at P < 0.05 level of significance. The overall and segmental sensitivity and specificity values were calculated for (1) the contact area and higher regions, (2) below the contact area to the cementoenamel junction (CEJ), and (3) below the CEJ. Radiography had the highest specificity. VistaCam had the highest overall and segmental sensitivity for enamel caries. Radiography had the highest segmental sensitivity for dentin. In region 1, VistaCam had the highest sensitivity and lowest specificity, and radiography and ICDAS II had the highest specificity and lowest sensitivity. In region 2, radiography showed the highest sensitivity and specificity. VistaCam had the lowest sensitivity and ICDAS II had the lowest specificity in this region. In region 3, VistaCam did not detect any caries and radiography had a better performance than ICDAS II. The specificity value was equal for both methods. VistaCam had the highest diagnostic efficacy among the three methods for caries in region 1; however, bitewing radiography had a superior efficacy in regions 2 and 3.

Clinical performance of the near-infrared imaging system VistaCam iX Proxi for detection of approximal enamel lesions

OBJECTIVES/AIMS

Apart from the visual detection of caries, X-rays can be taken for detection of approximal lesions. The Proxi head of VistaCam iX intraoral camera system uses near-infrared light (NIR) to enable caries detection in approximal surfaces. The aim of this study was to evaluate the performance of the NIR for the detection of approximal enamel lesions by comparison with radiographic findings.

MATERIALS AND METHODS

One hundred ninety-three approximal surfaces from 18 patients were examined visually and using digital radiographs for presence or absence of enamel lesions. Then digital images of each surface were produced using the near-infrared light. Correlation between methods was assessed using Spearman's rank correlation coefficient (rs). Agreement between radiographic and NIR findings was calculated using the kappa coefficient. McNemar's test was used to analyse differences between the radiographic and NIR findings (α=0.05).

RESULTS

Moderate correlation was found between all detection methods (rs=0.33-0.50, P<0.0001). Agreement between the radiographic and NIR findings was moderate (κ=0.50, 95% CI=0.37-0.62) for the distinction between sound surfaces and enamel caries. No significant differences were found between the findings (P=0.07).

CONCLUSION

Radiographs and NIR were found to be comparable for the detection of enamel lesions in permanent teeth.

The effects of three remineralizing agents on regression of white spot lesions in children: A two-week, single-blind, randomized clinical trial

BACKGROUND

This study investigated the effect of three remineralizing agents on improving white spot lesions (WSLs).

MATERIAL AND METHODS

This clinical trial included children who had at least one WSL on anterior teeth of upper or lower jaws. The participants were randomly assigned to 4 groups by treatment: 1) a cream containing casein phosphopeptide-amorphous calcium phosphate and fluoride (MI Paste Plus); 2) a cream containing hydroxyapatite and fluoride (Remin Pro); 3) a 2% sodium fluoride gel; and 4) usual home care (control). The treatment was performed for 3 times over 10 days using special trays for retaining remineralizing agents. The area and mineral content of WSLs were measured at baseline (T1) and 1 day after finishing treatment (T2). Blinding was applied for outcome assessment.

RESULTS

Eighty patients were assigned to MI Paste Plus, Remin Pro, NaF or control groups. The application of all remineralizing agents caused a significant decrease in area and a significant increase in mineral content of WSLs (p<0.05), whereas the control patients did not experience any significant alteration (p>0.05). At T2, the area of WSLs was significantly lower in three experimental groups compared to the control group (p=0.023), but between-group difference in mineral content of WSLs failed to achieve statistical significance (p=0.08).

CONCLUSIONS

The in-office application of either MI Paste Plus or Remin Pro was as effective as 2% NaF for reducing area and increasing mineral content of WSLs. MI Paste Plus and Remin Pro could be recommended as suitable alternatives to NaF for managing WSLs. Key words:White spot lesion, caries, casein phosphopeptide-amorphous calcium phosphate, hydroxyapatite, sodium fluoride, CPP-ACP, MPlus, Remin Pro, NaF.

Clinical effectiveness of fluorescence, digital images and ICDAS for detecting occlusal caries

Abstract Introduction The detection of small caries lesions is still a challenge for dental professionals who in their clinical practice have a wide variety of methods to detect caries on occlusal surfaces. Objective To clinically assess the effectiveness of the Vista Proof fluorescence camera, the Vista Cam digital intraoral micro camera and the International Caries Detection and Assessment System (ICDAS) visual criterion for detecting caries lesions on occlusal surfaces of permanent teeth. Material and method One hundred and seven posterior teeth from adult patients were examined visually and by means of digital radiographs by an examiner who rated them according to the presence or absence of occlusal caries. The teeth were then assessed by the other examiner using ICDAS, fluorescence and magnified digital images. The effectiveness of the methods was measured based on sensitivity, specificity, positive and negative likelihood ratio. For each method, the Receiver Operating Characteristic (ROC) curve and the Area Under the ROC curve (AUROC) were estimated. Result There was exceptional discrimination capacity for the intraoral images (AUROC=.93) and the ICDAS (AUROC=.91), with no significant statistical difference between them (z=.35, p=.73). The fluorescence exhibited an acceptable discrimination capacity (AUROC=0.78), although it was lower than the others. The positive likelihood ratio for the fluorescence was only 2.32, compared to 20.58 for the intraoral image and 58.11 for the ICDAS. Conclusion Both methods and the ICDAS exhibited an adequate clinical performance, although the ICDAS and intraoral image were more effective than the fluorescence.

Dental calculus detection using the VistaCam

The VistaCam® intra-oral camera system (Dürr Dental, Bietigheim-Bissingen, Germany) is a fluorescence system using light emitting diodes that produce a 405-nm violet light. This wavelength has potential application for detection of dental calculus based on red emissions from porphyrin molecules. This study assessed the digital scores obtained for both supragingival and subgingival calculus on 60 extracted teeth and compared these with lesions of dental caries. It has also examined the effect of saliva and blood on the fluorescence readings for dental calculus. VistaCam fluorescence scores for both supragingival (1.7-3.3) and subgingival calculus (1.3-2.4) were higher than those for sound root surfaces (0.9-1.1) and dental caries (0.9-2.2) (p < .05). The readings for calculus samples were not affected by the presence of saliva or blood. These results suggest that the use of violet light fluorescence could be a possible adjunct to clinical examination for deposits of dental calculus.

Effect of oral fluids on dental caries detection by the VistaCam

The VistaCam® system (Durr Dental, Bietigheim‐Bissingen, Germany) has been suggested as an adjunct to clinical examination for dental caries. This study assessed whether the digital scores obtained for tooth surfaces were affected by the colour of the carious lesions present and by the presence of saliva or blood on the tooth surface. The VistaCam intra‐oral ries, or with sound enamel and root surfaces, with or without overlying dental plaque biofilm. Teeth that had undergone root treatment or were stained by tetracycline were also assessed. Readings were taken in the dry state and after application of human stimulated saliva or venous blood onto the surface of the samples. VistaCam fluorescence scores for all samples were similar in the dry state, and when covered with saliva (P > 0.05), however a coating of dilute blood elevated the readings for most samples to a high level (P < 0.01), other than tetracycline stained teeth and dental caries (P > 0.05). Readings for healthy enamel were 0.9–1.1, and these increased up to 2.8 in the presence of blood. VistaCam fluorescence scores are not affected by dryness or moisture from the presence of saliva but increase when traces of blood are present. This problem needs to be taken into account when the device is used clinically, because blood from the gingival crevice is a common contaminant of tooth surfaces when patients have widespread gingival inflammation. There are also issues with elevated scores from background fluorescence from tetracyclines, which need to be considered when the system is in clinical use.

Use of a fluorescence-based camera for monitoring occlusal surfaces of primary and permanent teeth

BACKGROUND

Sound teeth and incipient lesions require regular monitoring to detect possible progression of caries early on.

AIM

To evaluate the ability of the VistaProof (VP) fluorescence-based camera for monitoring occlusal surfaces.

DESIGN

A total of 419 posterior teeth (205 primary molars, 145 permanent molars, and 69 premolars) of 35 patients were examined (average age: 9.1 years). The occlusal surfaces were classified visually according to the criteria of the International Caries Detection and Assessment System (ICDAS). VP measurements were performed at baseline (t1), and the examinations were repeated after six (t2) and twelve month (t3). Correlation between methods was calculated using Spearman's rank correlation coefficient (r_s ). Wilcoxon test was used to monitor whether VP identified changes as well as ICDAS (α = 0.05).

RESULTS

Correlations between ICDAS and VP were significantly positive (r_s : 0.66-0.73, P < 0.001). No significant differences were found between all times for the ICDAS findings. Significant differences for the VP were ascertained for t1/t2 (P = 0.03). Results based on cluster randomization showed significant differences between ICDAS and VistaProof concerning the absence/presence of changes in the finding (P < 0.0005).

CONCLUSION

Correlation between ICDAS and VP was strong. The VP supported the findings of visual examination for monitoring occlusal surfaces, although not all changes could be detected with respect to the visual findings.

Performance of fluorescence-based methods for detecting and quantifying smooth-surface caries lesions in primary teeth: an in vitro study

BACKGROUND

Although smooth-surface caries can be subjectively assessed by visual inspection, quantitative methods would improve the monitoring of these lesions.

AIM

To evaluate the in vitro performance of laser fluorescence devices, namely DIAGNOdent (LF) and DIAGNOdent pen (LFpen), and a fluorescence camera (VistaProof; FC) in the detection and quantification of smooth-surface caries in primary teeth.

DESIGN

Two examiners evaluated 99 smooth surfaces of 65 extracted primary molars using FC, LF, and LFpen. As a reference standard, the actual and relative lesion depths were determined using stereomicroscopy and polarized light microscopy. Reproducibilities were assessed, and correlation analyses were performed. The sensitivities, specificities, and accuracies of the methods were calculated and compared.

RESULTS

There was a significant correlation between the values obtained using the fluorescence-based devices and the actual and relative lesion depths, although the correlation coefficient values were not higher than 0.7 (LF, 0.673; LFpen, 0.646; FC, 0.663). The sensitivities of the devices were similar for the detection of enamel caries, although LFpen was superior in detecting dentin lesions. The reliabilities of all methods were moderate to low, with similar accuracies at all depths.

CONCLUSION

Although the fluorescence-based devices showed similar performance in the detection of enamel and dentin lesions, the reliability of these devices and the correlation of their findings with the actual and relative lesion depths were moderate with regard to smooth-surface caries in primary molars.

Porphyrin and Pentosidine Involvement in the Red Fluorescence of Enamel and Dentin Caries

Proper treatment of dental caries demands detection of carious lesions at an early stage and a minimal invasive cavity preparation to preserve the maximum tooth structure. Various devices use fluorescence for caries detection via recording the red fluorescence generated by dentin caries under illumination.

The aim of this study was to evaluate the porphyrin and pentosidine involvement in the red fluorescence observed in enamel and dentin caries when illuminated with the Soprolife® camera (Sopro, Acteon Group, La Ciotat, France) and Vistacam® camera (Dürr Dental AG, Bietigheim-Bissingen, Germany). Three techniques were used: single photon fluorescence spectroscopy, micro-Raman spectroscopy, and color analysis with ImajeJ software. Cross-sections of human teeth, scored from 0–6 with the International Caries Detection and Assessment System (ICDAS), were examined by fluorescence microscopy. Teeth spectra of each ICDAS score were compared with those of protoporphyrin IX (PpIX), porphyrin I, and pentosidine solutions. A specific confocal Raman microscopy analysis was realized and a Red–Green–Blue model analysis of Soprolife® images was performed using ImageJ software to compare the color variations on ICDAS score 1 and 2. Fluorescence spectroscopy and micro-Raman spectroscopy revealed the presence of PpIX in carious enamel and dentin. The clinical relevance of this experimentation was that the increased knowledge of the fluorescence aids for caries detection could improve the preventive approach, thus reducing the operative one.

How to cite this article

Slimani A, Nouioua F, Panayotov I, Giraudeau N, Chiaki K, Shinji Y, Cloitre T, Levallois B, Gergely C, Cuisinier F, Tassery H. Porphyrin and Pentosidine Involvements in the Red Fluorescence of Enamel and Dentin Caries. Int J Experiment Dent Sci 2016;5(1):1-10.

Impact of different magnification levels on visual caries detection with ICDAS

OBJECTIVES

The aim of this in vitro study was to examine the effect of different levels of magnification on the accuracy and reliability of visual caries detection using ICDAS criteria.

METHODS

Occlusal surfaces of 100 extracted molars were assessed by 14 examiners (3rd and the 4th year dental students and dentists) using no magnification aids, a 2.5× Galilean loupe, a 4.5× Keplerian loupe, or a surgical microscope with 10× magnification. The assessments were repeated on a different day. Sensitivity, specificity, AUC and reliabilities were calculated according to the gold standard of histology.

RESULTS

We found that with increasing magnification, the number of surfaces rated as "sound" (ICDAS code 0) decreased, while the number of surfaces with a localized enamel breakdown (ICDAS code 3) increased. While the sensitivities increased, the values of the specificities decreased to an unacceptably low level irrespective of the clinical experience of the examiners.

CONCLUSIONS

ICDAS seems to be optimized for natural vision up to 2.0× magnification and not for high magnifications. The use of powerful magnification in visual caries detection involves the risk of unnecessary and premature invasive treatment.

CLINICAL SIGNIFICANCE

This paper discusses when it does and does not make sense to use magnification devices for visual caries detection using ICDAS criteria. Strong magnifications should be refrained from for this purpose.

Obtaining artificially caries-affected dentin for in vitro studies

AIM

This study evaluated and improved a protocol for obtaining standard caries-affected dentin (CAD) by Streptococcus mutans biofilm demineralization process.

MATERIALS AND METHODS

Forty-eight human molars were divided in six experimental groups, according to: period of cariogenic challenge (7, 14 or 21 days) and type of dentin (erupted or unerupted teeth). After complete cariogenic challenge sound and CAD dentin were evaluated by: visual inspection (VI), digital radiography (DR), optical coherence tomography (OCT) and laser fluorescence (LF).

RESULTS

Visual inspection confirmed the formation of CAD based on tissue yellowing and loss of surface gloss. Digital radiography detected the presence of radiolucent images, suggesting caries. Three calibrated examiners viewed all images obtained by VI and DR and were able to distinguish healthy from CAD. Fisher's exact statistical test (p < 0.05) confirmed no difference between groups by VI (G1/G4: p = 0.6; G2/G5: p = 1; G3/G6: p = 1) or DR (G1/G4: p = 1; G2/G5: p = 1; G3/G6: p = 1). Both LF values and demineralization depth, as determined by OCT, were subjected to ANOVA (p < 0.05). For LF, a statistically significant difference was observed for the type of substrate (p = 0.001). For OCT, no statistically significant differences in the type of substrate (p = 0.163), length of cariogenic challenge (p = 0.512) or interaction between factors (p = 0.148) were observed. Scanning electron micrographs confirmed the presence of CAD; a more uniform demineralization surface was observed in the dentin of unerupted teeth.

CONCLUSION

This protocol suggests that standard CAD can be obtained in 7 days of cariogenic challenge using unerupted teeth. Clinical significance: With the new perspective on the clinical treatment of caries lesions, bonding is increasingly performed to demineralize CAD, which is susceptible to remineralization. A useful protocol to standardize the production of CAD, by microbiological cariogenic challenge, would be an important contribution to laboratorial test in the field of operative dentistry.

In vivo assessment of caries excavation with a fluorescence camera compared to direct bacteriological sampling and quantitative analysis using flow cytometry

The aim of this study was to assess the performance of the fluorescence camera device VistaCam iX (VC) for the control of caries excavation compared to visual assessment and bacteriological evaluation. Twenty-three patients with 32 dentinal carious lesions were included in the study. The lesions were classified using the International Caries Detection and Assessment System. Fluorescence images were taken at the surface of each lesion using the VC before excavation (stage 1), during (stage 2) and after excavation (stage 3). At each stage, dentine samples were collected. All cavities were closed after excavation using permanent fillings. Bacteria were counted within each dentine sample using flow cytometry. Significant moderate correlation between the fluorescence readings and the bacteria count was found at stage 3 (Spearman correlation coefficient rs = 0.40, p = 0.027). Area under the ROC curve (AUC) was calculated for fluorescence readings and bacteria count using the clinical status at stage 3 as a reference. AUC was 0.954 for the VC readings and 0.797 for bacteria count. Using the median bacteria count at stage 3 as a reference, the AUC for the fluorescence readings was 0.753. The results indicate that the fluorescence camera appears to be a useful supplementary tool in assessing the endpoint of caries excavation with the advantage of enabling data to be digitally visualized and stored. When an experienced dental clinician determined the excavation endpoint, the performance with respect to remaining bacteria count was good.

Use of ICDAS-II, Fluorescence-Based Methods, and Radiography in Detection and Treatment Decision of Occlusal Caries Lesions: An In Vitro Study

Aim. To use visual inspection (ICDAS-II), laser fluorescence (LF), fluorescence based camera (FC) and radiographic examination (BW) for detection of caries and for treatment decision. Methods. The occlusal sites of 84 extracted permanent teeth were examined using all methods and treatment decisions (preventive or operative care) were recorded based on each method independently. For validation of the findings, fissures were opened with rotating instruments and clinical depth was determined as gold standard. Correlations (r(s)), sensitivity, specificity and AUC were calculated. McNemar test was used to show whether different methods led to significant changes in treatment decisions. Results. Highest correlation was found between ICDAS-II and FC (r(s) 0.84), ICDAS-II and gold standard (0.82) and FC and gold standard (0.81). ICDAS-II provided the highest performance (AUC 1.0), followed by FC (0.95) and LF (0.88). The greatest difference was found for treatment planning of dentine lesions, where the use of FC (cut-offs according to the literature) had the greatest agreement between operative treatment and dentine lesions, followed by use of ICDAS-II. Conclusion. ICDAS-II may have high potential for detection and treatment planning, and other devices, especially the fluorescence camera, can add substantial information to the visual examination, enabling examiners plan treatment more accurately.