Clinical performance of a new laser fluorescence device for detection of occlusal caries lesions in permanent molars

Diffuse Reflectance Spectroscopy as a Novel Method of Caries Detection-An In Vitro Comparative Study in Permanent Teeth

This in vitro study aimed to compare outcomes of dental caries detection using visual inspection classified according to the International Caries Detection and Assessment System (ICDAS) with objective assessments using a well-established laser fluorescence system (Diagnodent pen) and a novel diffuse reflectance spectroscopy (DRS) device. One hundred extracted permanent premolars and molars were utilized, including sound teeth, teeth with non-cavitated caries, or teeth with small cavitated lesions. A total of 300 regions of interest (ROIs) were assessed using each detection method. Visual inspection, being a subjective method, was performed by two independent examiners. The presence and extent of caries were histologically verified according to Downer's criteria, serving as a reference for other detection methods. Histological results revealed 180 sound ROIs and 120 carious ROIs, categorized into three different extents of caries. Overall, there was no significant difference between the detection methods in sensitivity (0.90-0.93) and false negative rate (0.05-0.07). However, DRS exhibited superior performance in specificity (0.98), accuracy (0.95), and false positive rate (0.04) compared to other detection methods. Although the tested DRS prototype device exhibited limited penetration depth, it shows promise as a method, particularly for the detection of incipient caries.

Validation of clinical photography and a laser fluorescence device for assessment of enamel demineralization during multi-bracketed fixed orthodontic treatment

AIM

To compare the validity of DIAGNOdent pen™ 2190 and clinical photographs in the diagnosis (presence or absence) and assessment of white spot lesions (WSLs) during multi-bracketed fixed orthodontic treatment.

METHODS

A total of 1607 readings from 99 patients were obtained using DIAGNOdent pen™ 2190, clinical photographs, and visual assessment criteria to assess WSLs at 6 -, 12- and 18 months after bonding of brackets. Receiver operating characteristic curves were constructed, and areas under the curve (AUC) were calculated to assess the presence or absence of WSLs and distinguish the severity of WSLs as slight or severe. Sensitivities, specificities, and AUC were calculated for outcomes at an alpha of 0.05 and 95% confidence intervals (CIs).

RESULTS

The values of sensitivity and specificity of DIAGNOdent pen™ 2190 were found to be 0.78 and 0.83, respectively, to distinguish presence/absence of WSLs with good accuracy (AUC= 0.855; 95% CI: 0.820-0.889) and for digital photographs, accuracy was excellent (AUC= 0.973, 95% CI: 0.956-0.991) with sensitivity and specificity of 0.96 and 0.99, respectively. However, the accuracy of DIAGNOdent pen™ 2190 was poor (AUC= 0.543, 95% CI: 0.418-0.668) in delineating slight and severe WSLs with a sensitivity of 0.31 and specificity of 0.83; while the values of sensitivity and specificity for distinguishing slight or severe lesions for clinical photographs were 0.96 and 0.99, respectively with excellent accuracy (AUC=0.978, 95% CI: 0.936-1.000).

CONCLUSIONS

Clinical photographs had better validity than DIAGNOdent pen™ 2190 in diagnosis and assessment of severity of demineralized lesions during multi-bracketed fixed orthodontic treatment.

Systematic review and meta-analysis of diagnostic methods for occlusal surface caries

AIM

This systematic review and meta-analysis aimed to assess the diagnostic performance of commonly used methods for occlusal caries diagnostics, such as visual examination (VE), bitewing radiography (BW) and laser fluorescence (LF), in relation to their ability to detect (dentin) caries under clinical and laboratory conditions.

MATERIALS AND METHODS

A systematic search of the literature was performed to identify studies meeting the inclusion criteria using the PIRDS concept (N = 1090). A risk of bias (RoB) assessment tool was used for quality evaluation. Reports with low/moderate RoB, well-matching thresholds for index and reference tests and appropriate reporting were included in the meta-analysis (N = 37; 29 in vivo/8 in vitro). The pooled sensitivity (SE), specificity (SP), diagnostic odds ratio (DOR) and areas under ROC curves (AUCs) were computed.

RESULTS

SP ranged from 0.50 (fibre-optic transillumination/caries detection level) to 0.97 (conventional BW/dentine detection level) in vitro. AUCs were typically higher for BW or LF than for VE. The highest AUC of 0.89 was observed for VE at the 1/3 dentin caries detection level; SE (0.70) was registered to be higher than SP (0.47) for VE at the caries detection level in vivo.

CONCLUSION

The number of included studies was found to be low. This underlines the need for high-quality caries diagnostic studies that further provide data in relation to multiple caries thresholds.

CLINICAL RELEVANCE

VE, BW and LF provide acceptable measures for their diagnostic performance on occlusal surfaces, but the results should be interpreted with caution due to the limited data in many categories.

Identifying and Avoiding Risk of Bias in Caries Diagnostic Studies

Caries diagnostic studies differ with respect to their design, included patients/tooth samples, use of diagnostic and reference methods, calibration, blinding and data reporting. Such heterogeneity makes comparisons between studies difficult and could represent a substantial risk of bias (RoB) when it is not identified. Therefore, the present report aims to describe the development and background of a RoB assessment tool for caries diagnostic studies. The expert group developed and agreed to use a RoB assessment tool during three workshops. Here, existing instruments (e.g., QUADAS 2 and the Joanna Briggs Institute Reviewers' Manual) influenced the hierarchy and phrasing of the signalling questions that were adapted to the specific dental purpose. The tailored RoB assessment tool that was created consists of 16 signalling questions that are organized in four domains. This tool considers the selection/spectrum bias (1), the bias of the index (2) and reference tests (3), and the bias of the study flow and data analysis (4) and can be downloaded from the journal website. This paper explores possible sources of heterogeneity and bias in caries diagnostic studies and summarizes the relevant methodological aspects.

Detection Methods for Early Caries Diagnosis: A Systematic Review and Meta-Analysis

The aim was to appraise the evidence on the performance of various means for the detection of incipient caries in vivo. Five databases of published and unpublished research were searched for studies from January 2000 to October 2019. Search terms included "early caries" and "caries detection." Inclusion criteria involved diagnostic test accuracy studies for early caries detection in permanent and primary teeth. A risk-of-bias assessment was performed using the QUADAS-2 tool. We performed the study selection, data extraction, and risk-of-bias assessment in duplicate. The review protocol was a priori registered in the Open Science Framework. Of the initially 22,964 search results, 51 articles were included. For permanent teeth, when histologic examination was considered as the reference for occlusal surfaces, the sensitivity (Se) range appeared high for the DIAGNOdent Pen (DD Pen) at 0.81-0.89, followed by ICDAS-II at 0.62-1, DIAGNOdent (DD) at 0.48-1, and bitewing radiography (BW) at 0-0.29. The corresponding specificity (Sp) range was: DD Pen 0.71-0.8, ICDAS-II 0.5-0.84, DD 0.54-1, and BW 0.96-1. When operative intervention served as the reference for occlusal surfaces, again, the DD means valued the most promising results on Se: DD 0.7-0.96 and DD Pen 0.55-0.90, followed by ICDAS-II 0.25-0.93, and BW 0-0.83. The Sp range was: DD 0.54-1, DD Pen 0.71-1, ICDAS-II 0.44-1, and BW 0.6-1. For approximal surfaces, the Se was: BW 0.75-0.83, DD Pen 0.6, and ICDAS-II 0.54; the Sp was: BW 0.6-0.9, DD Pen 0.2, and ICDAS-II 1. For primary teeth, under the reference of histologic assessment, the Se range for occlusal surfaces was: DD 0.55-1, DD Pen 0.63-1, ICDAS-II 0.42-1, and BW 0.31-0.96; the respective Sp was: DD 0.5-1, DD Pen 0.44-1, ICDAS-II 0.61-1, and BW 0.79-0.98. For approximal surfaces, the Se range was: DD Pen 0.58-0.63, ICDAS-II 0.42-0.55, and BW 0.14-0.71. The corresponding Sp range was: DD Pen 0.85-0.87, ICDAS-II 0.73-0.93, and BW 0.79-0.98. Se and Sp values varied, due to the heterogeneity regarding the setting of individual studies. Evidently, robust conclusions cannot be drawn, and different diagnostic means should be used as adjuncts to clinical examination. In permanent teeth, visual examination may be enhanced by DD on occlusal surfaces and BW on approximal surfaces. In primary teeth, DD Pen may serve as a supplementary tool across all surfaces.

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.

Fissure caries inhibition with a CO2 9.3-μm short-pulsed laser-a randomized, single-blind, split-mouth controlled, 1-year clinical trial

OBJECTIVES

The objective of this randomized, single-blind, split-mouth controlled, clinical trial was to evaluate whether the use of a short-pulsed 9.3-μm CO₂ laser increases the caries resistance of occlusal pit and fissures in addition to fluoride therapy over 12 months.

MATERIALS AND METHODS

A total of 60 participants, average age 13.1 years, were enrolled. At baseline, second molars were randomized into test and control, and assessed by ICDAS, SOPROLIFE, and DIAGNOdent. An independent investigator irradiated test molars with a CO₂ laser (wavelength 9.3 μm, pulse duration 4 μs, pulse repetition rate 43 Hz, beam diameter 250 μm, average fluence 3.9 J/cm², 20 laser pulses per spot). Test molars received laser and fluoride treatment, control teeth fluoride alone. Fluoride varnish was applied at baseline and at 6 months. After 6 and 12 months, teeth were again assessed.

RESULTS

A total of 57 participants completed the 6-month and 51 the 12-month recall. Laser-treated surfaces showed very slight ICDAS improvements over time with ICDAS change - 1 in 11% and 8%, no changes (ICDAS change 0) in 68% and 67%, and slightly worsened (ICDAS change 1) in 19% and 24% at 6- and 12-month recalls, respectively, and worsened by two scores in 2% at both recall time points. Control teeth showed significantly higher ICDAS increases, with 47% and 25% showing ICDAS change 0, ICDAS change 1 in 49% and 55%, and ICDAS change 2 in 4% and 20% at 6- and 12-month recalls, respectively. Differences in ICDAS changes between the groups were statistically significant (P = 0.0002 and P < 0.0001; Wilcoxon's signed-rank test, exact). A total of 22% of the participants developed ICDAS 3 scores on the control teeth.

CONCLUSIONS

Microsecond short-pulsed 9.3-μm CO₂ laser irradiation markedly inhibits caries progression in pits and fissures in comparison with fluoride varnish alone.

CLINICAL RELEVANCE

The 9.3-μm CO₂ laser irradiation of pits and fissures enhances caries resistance.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02357979.

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.

Diagnostic Performance of Different Methods in Detecting Incipient Non-Cavitated Occlusal Caries Lesions in Permanent Teeth

Aim: This in vitro study was aimed to investigate the performance of the new caries detection tools on the incipient occlusal caries. Study design: In our study, 100 permanent molar teeth, which were considered to have incipient, enamel caries (D1 and D2 threshold values) according to ICDAS II score. After the visual examination, caries measurements have been applied to all teeth by using DIAGNOdent pen (DP), CarieScan PRO (CP) and SoproLife camera (SC). In addition, in vitro examinations were repeated 2 weeks later. After sectioning and evaluation in stereomicroscope, the lesion depth was determined with histological criteria that are accepted for the gold standard for this research. Sensitivity, specificity, accuracy and area under the ROC curve were calculated at D1 and D2 thresholds. The intra-examiners' reproducibility were analysed using Cohen's kappa statistics and intraclass correlation coefficient (ICC). Results: Intra-examiner repeatability values varied from 0.94 to 0.99 and kappa values ranged from 0.90 to 0.99. While the highest sensitivity and specificity value showed for SC at D1 and D2 thresholds, CP presented the lowest values. The area under ROC curves (Az) varied from 0.70 to 0.99. ICDAS II showed the highest area under ROC curves (Az). Conclusions: ICDAS II, visual diagnostic method by itself is considered to sufficient in order to diagnose incipient occlusal caries. SC may be used as an alternative method for the ICDAS II, since its advantages by displaying caries lesion on the computer monitor, follow-up and motivation of the patients provided.

Performance of Different Methods for Detection of Incipient Occlusal Caries Lesions: An In Vitro Study

OBJECTIVE

The aim of this in vitro study was to evaluate the diagnostic performance of visual inspection (VI), laser fluorescence (LF pen), fluorescence camera (FC), and alternating current impedance spectroscopy technique (ACIST) for detection of incipient occlusal caries lesions. Histology was used as the gold standard to determine the interexaminer reliability of the methods, among three examiners with different levels of experiences (Examiner 1: 5 years; examiner 2: 10 years; and examiner 3: 25 years).

MATERIALS AND METHODS

One hundred two molar teeth were selected. The occlusal surfaces of teeth were evaluated with VI, LF pen, FC, and ACIST devices independently by three examiners. Diagnostic performances of methods were evaluated with binormal receiver-operating characteristics analysis. Interexaminer agreement of detection methods was assessed using Cohen's kappa coefficient values (p < 0.001).

RESULTS

Incipient enamel lesions were determined more successfully with VI by all examiners. All detection methods were presented with statistically acceptable interexaminer agreement (p < 0.001). For D₂ and D₃ thresholds, FC for examiner 1, VI for examiner 2, and both VI and FC for examiner 3 demonstrated statistically high sensitivity and specificity (p < 0.05).

CONCLUSIONS

It can be concluded that diagnostic performance of the methods was insufficient for detecting incipient occlusal caries lesions by itself. Performance can be improved by using them with VI as a traditional caries detection method.

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.

Tooth demineralization and associated factors in patients on fixed orthodontic treatment

Dental demineralization was determined in patients at three time points during fixed orthodontic treatment. A multiple cross-sectional study included 108 patients divided into three different groups: (1) beginning of orthodontic treatment; (2) one year into treatment; and (3) two years into treatment. Demineralization was estimated using a DIAGNOdent pen. We obtained data from multiple tooth-by-tooth demineralization readings combined with salivary pH and patients' oral hygienic and dietary behaviors. A t-test for independent samples and Spearman´s correlation were performed. No demineralizations differences were found between the initial stage and one year into treatment. Between one and two years small differences were observed, but demineralization increased between the initial stage and second treatment year, predominating in upper right central incisors (p = 0.056), upper left lateral incisors (p = 0.040), both upper canines (p = 0.055 and p = 0.040, respectively) and first left premolars (p = 0.034 and p = 0.053, respectively). We did not find associations between oral hygiene and dietary behaviours or salivary pH. In conclusion, demineralization occurred in first year of treatment and increased during second year, predominating in the upper arch and the left side mainly in upper right central incisors, upper left lateral incisors, both upper canines, and first left premolars.

Efficacy of adjunctive laser in non-surgical periodontal treatment: a systematic review and meta-analysis

To evaluate the efficacy of the adjunctive laser therapy in conventional non-surgical treatment of chronic periodontitis, an electronic search was performed through the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, Scopus, Web of Science, China National Knowledge Infrastructure (CNKI), and China Biology Medicine (CBM) Disc, for relevant randomized controlled trials (RCTs) or quasi-RCTs. All the 12 included studies (11 RCTs and 1 quasi-RCT) were qualified for descriptive and quantitative analysis. Outcomes were divided into two groups according to the length of follow-ups (long term and short term). Subgroup analyses were performed based on the mode of laser (inside and outside mode). Among all included researches, reduction in probing depth (PD) and gain in clinical attachment level (CAL) were presented with the mean value and 95 % confidence interval, while bleeding on probing (BOP) was assessed descriptively. Meta-analysis suggested that adjunctive laser therapy reduced PD at 3 months [mean difference (MD) = -0.26, 95 % confidence interval (CI) range = -0.43 to -0.09, p = 0.003] but did not demonstrate significant effect on the CAL at either 3 months (MD = -0.03, 95 % CI range = -0.25 to 0.19, p = 0.79) or 6 months (MD = -0.11, 95 % CI range = -0.38 to 0.16, p = 0.43). Subgroup analyses indicated that laser therapy would be more effective when the probes were set up outside the periodontal pockets.

Assessment of a new infrared laser transillumination technology (808 nm) for the detection of occlusal caries-an in vitro study

This study aimed to evaluate in vitro performance of near-infrared laser transillumination (NIR-LTI) for detecting early occlusal caries in permanent teeth and compare it with quantitative light-induced fluorescence (QLF), DIAGNOdent Pen (DDPen), and conventional radiography (CR). Ninety-four occlusal surfaces presenting International Caries Detection and Assessment System (ICDAS) scores ranging from 0 to 3 were selected. For the NIR-LTI examination, images were captured using a prototype, which consists of a laser beam (808 nm) and an infrared CCD camera. One occlusal site on each tooth was assessed twice by two examiners. The teeth were prepared histologically and assessed for the presence of early caries. The intraexaminer correlation showed no difference between the NIR-LTI, DDPen, and QLF analytical methods, but all these methods differed from CR. Interexaminer reproducibility was moderate for NIR-LTI, which showed sensitivity (0.68), specificity (0.85), accuracy (0.73), and area under the receiver-operating characteristic (ROC) curve (0.76) similar to those of the fluorescence method and different from those of the CR. In conclusion, the performance of NIR-LTI was comparable to that of DDPen and QLF and may therefore be considered a valid and reliable alternative for the diagnosis of incipient lesions on the occlusal surface of permanent teeth.

Diagnosis of occlusal caries using laser fluorescence versus conventional methods in permanent posterior teeth: a clinical study

OBJECTIVE

The purpose of this in vivo study was to compare three different caries detection methods [laser fluorescence (LFE), visual examination (VE), and radiological examination (RE)] for the detection of occlusal caries in permanent posterior teeth.

BACKGROUND DATA

Early diagnosis of caries is critical in the management of dental caries.

METHODS

Two examiners assessed the occlusal surfaces of 217 teeth by visual, radiographic, and laser fluorescence (DIAGNOdent Pen) examination methods. After a 1 week interval, randomly selected patients were recalled. Each measurement was repeated by two examiners before the cases were selected for operative intervention to classify lesion depths. Statistical analysis of the data was performed using SPSS and Stata IC. The intra- and inter-examiner reliabilities and reproducibilities of the VE, RE, and LFE were calculated using Cohen's κ statistics. The sensitivities and specificities were plotted in receiver operating characteristic curves. The differences between LFE scores were analyzed using the nonparametric Mann-Whitney U and Wilcoxon tests (α=0.05).

RESULTS

The VE method exhibited the highest sensitivity, accuracy, and κ values among the diagnostic groups in terms of inter-examiner agreement. With regard to the sensitivity, specificity, and likelihood ratios for the two examiners, significant differences were found between sensitivity and specificity for examiner 1, whereas no statistically significant differences were noted between sensitivity and specificity for examiner 2 for the LFE scores.

CONCLUSIONS

The DIAGNOdent pen is useful for the detection of dentinal caries of occlusal surfaces in permanent posterior teeth. Combination with other diagnostic conventional methods may enhance the reliability of this tool.

The use of computer-assisted FACE for minimal-invasive caries excavation

OBJECTIVES

Caries excavation is still a demanding procedure today. In the past years, methods using light-induced fluorescence have proven their ability to detect bacteria remaining in the tooth's hard tissues. However, methods to control the complete removal of infected dentine have not yet been validated. The aim of the present study was to evaluate the degree of dentine removal during caries excavation using a camera- and software-based device as a guide for fluorescence-aided caries excavation (FACE) in comparison to visual-tactile inspection and a dye-staining method.

MATERIALS AND METHODS

One hundred teeth with carious lesions (C3) were randomly allocated to four groups and excavated with the respective method as primary excavation control method. When the first method indicated complete caries excavation, a second method was used to affirm this. Subsequently, dentine samples were taken to determine residual contamination using PCR. After embedding and sectioning the teeth dentine, microhardness was measured perpendicular to the cavity floor.

RESULTS

By using the camera- and software-based device, 94 % of the cavities tested were free of bacterial contamination. All cavities excavated with the dye-staining or visual-tactile control method were free of bacterial contamination but resulted in a significantly higher dentine removal.

CONCLUSION

The camera- and software-assisted caries excavation seems to be an adequate method to remove contaminated dentine without removing affected dentine.

CLINICAL RELEVANCE

Beside its original application to monitor carious, the device is safe, effective, and easy to use for guided caries excavation and is of worth for both everyday practice and undergraduate education.

In vivo performance of two devices for occlusal caries detection

OBJECTIVE

The aim of this in vivo study was to compare the performance of light-emitting diode (LED)- and laser fluorescence (LF)-based devices with that of visual inspection (VI) in the diagnosis of occlusal caries.

METHODS

A total of 156 occlusal surfaces were investigated. Each occlusal surface was assessed with LED- and LF-based devices after a VI was performed. Pit and fissure opening was applied to the occlusal surfaces in which opacity or discoloration was distinctly visible after airdrying. The inter-examiner reliability of caries examination was assessed using the weighted κ statistics. The sensitivity, specificity, and accuracy of occlusal caries diagnosis using these methods were calculated according to the appropriate thresholds.

RESULTS

Acceptable inter-examiner agreement was found for the LED- and LF-based devices and VI (κ=0.61, κ=0.76, and κ=0.87, respectively). Higher specificity values were achieved at a T2 threshold for the LF-based device (0.76 and 0.80) and at a T1 threshold for the LED-based readings (0.60 and 0.62) and VI (0.90 and 0.93) for both observers. With regard to VI, higher sensitivity values were found at both thresholds for the two observers in comparing the three caries detection methods (0.98 at T1 and 0.96 at T2). The accuracy values for T1 were higher than those for the T2 values, for all three caries detection methods.

CONCLUSIONS

Caries lesions may be detected more accurately than clinically sound areas by both caries detection devices.

In-vivo occlusal caries prevention by pulsed CO2 -laser and fluoride varnish treatment--a clinical pilot study

BACKGROUND AND OBJECTIVES

High caries prevalence in occlusal pits and fissures warrants novel prevention methods. An 86% reduction in dental enamel smooth surface demineralization in-vivo following short-pulsed 9.6 µm-CO(2) -laser irradiation was recently reported. The objective of this study was to conduct a blinded 12-month-pilot clinical trial of occlusal pit and fissure caries inhibition using the same CO(2) -laser irradiation conditions.

STUDY DESIGN/MATERIALS AND METHODS

Twenty subjects, average age 14 years, were recruited. At baseline, second molars were randomized into test and control groups, assessed by International Caries Detection & Assessment System (ICDAS-II), SOPROLIFE light-induced fluorescence evaluator in daylight and blue-fluorescence mode and DIAGNOdent. An independent investigator irradiated test molars with a CO(2) -laser, wavelength 9.6 µm, pulse-duration 20 µs, pulse-repetition-rate 20 Hz, beam diameter 800 µm, average fluence 4.5 ± 0.5 J/cm(2), 20 laser pulses per spot. At 3-, 6- and 12-month recall teeth were assessed by ICDAS, SOPROLIFE and DIAGNOdent. All subjects received fluoride varnish applications at baseline and 6-month recall.

RESULTS

All subjects completed the 3-month, 19 the 6-month and 16 the 12-month recall. At all recalls average ICDAS scores had decreased for the test and increased for the control fissures (laser vs. control, 3-month: -0.10 ± 0.14, 0.30 ± 0.18, P > 0.05; 6-month: -0.26 ± 0.13, 0.47 ± 0.16, P = 0.001; 12-month: -0.31 ± 0.15, 0.75 ± 0.17, P < 0.0001; mean ± SE, unpaired t-test) being statistically significantly different at 6- and 12-month recalls. SOPROLIFE daylight evaluation revealed at 6- and 12-months statistically significant differences in changes between baseline and recall for test and control molars, respectively (laser vs. control, 6-month: 0.22 ± 0.13, 0.17 ± 0.09, P = 0.02; 12-month: 0.28 ± 0.19, 0.25 ± 0.17, P = 0.03). For SOPROLIFE blue-fluorescence evaluation mean changes in comparison to baseline for the control and the laser treated teeth were also statistically significant for the 6- and 12-month recall.

CONCLUSION

Specific microsecond short-pulsed 9.6 µm CO(2) -laser irradiation markedly inhibits caries progression in pits and fissures in comparison to fluoride varnish alone over 12 months.

Adjunct methods for caries detection: a systematic review of literature

OBJECTIVE

To assess the diagnostic accuracy of adjunct methods used to detect and quantify dental caries.

STUDY DESIGN

A systematic literature search for relevant papers was conducted with pre-determined inclusion and exclusion criteria. Abstracts and full text articles were assessed independently by two reviewers. The study characteristics were compiled in tables and quality graded according to the QUADAS tool. The level of evidence for each diagnostic technology (fiber-optic methods, fluorescence methods, electrical methods) was based on studies of high or moderate quality according to the GRADE approach.

RESULTS

Twenty-five reports fulfilled the inclusion criteria. One study was of high quality, 10 were graded as moderate, while the remaining 14 reports were of low quality. Electrical methods (ECM) and laser fluorescence (DIAGNOdent) displayed sensitivities and specificities around 70-80% regarding occlusal dentin lesions with a mean Youden's index of 0.52-0.54. The mean accuracy of laser fluorescence for detecting enamel and dentin lesions was 0.68 and 0.91, respectively. The heterogeneity of the published reports hampered the analysis.

CONCLUSIONS

There was insufficient scientific evidence for diagnostic accuracy regarding fiber-optic methods and quantitative light-induced fluorescence (+OOO). The electrical methods and laser fluorescence could be useful adjuncts to visual-tactile and radiographic examinations, especially on occlusal surfaces in permanent and primary molars, but evidence was graded as limited (++OO). No conclusions could be drawn regarding the cost-effectiveness of the methods. There is an obvious need to standardize study designs for in vitro and in vivo validation of the different methods.

Relationship between laser fluorescence values and visual evaluation of fissure caries in schoolchildren - a field study

BACKGROUND

In our previous study of oral health intervention in children, laser fluorescence (LF) values of occlusal surfaces were reduced after 1 year.

AIM

The aim of this study was to explore the relationship between DIAGNOdent pen values and clinical status of the occlusal surfaces.

DESIGN

The study conducted in 2007 and 2008 in 700 children aged 13-14 included a clinical examination and LFpen measurement of the occlusal surfaces of first and second molars. Four teams consisting of a dental hygienist and a dental nurse performed the examinations on school premises. The dental hygienist scored the surfaces using the Nyvad criteria for caries assessment; the surfaces were then scanned using a DIAGNOdent pen(®) device.

RESULTS

The more severe the visual caries category was, the higher the mean LFpen values were. Correlation coefficients between LF values and NY categories were 0.542 and 0.408 in years 2007 and 2008, respectively (all examiners combined). The LFpen values of active and inactive lesions did not differ significantly.

CONCLUSIONS

The correlation between the mean LFpen values and the NY categories was significant. Fissures can be reliably examined with LF and by visual inspection on school premises if certain special arrangements are made.

The performance of conventional and fluorescence-based methods for occlusal caries detection: an in vivo study with histologic validation

BACKGROUND

The authors conducted an in vivo study to determine clinical cutoffs for a laser fluorescence (LF) device, an LF pen and a fluorescence camera (FC), as well as to evaluate the clinical performance of these methods and conventional methods in detecting occlusal caries in permanent teeth by using the histologic gold standard for total validation of the sample.

METHODS

One trained examiner assessed 105 occlusal surfaces by using the LF device, LF pen, FC, International Caries Detection and Assessment System (ICDAS) criteria and bitewing (BW) radiographic methods. After tooth extraction, the authors assessed the teeth histologically. They determined the optimal clinical cutoffs by means of receiver operating characteristic curve analysis.

RESULTS

The specificities and sensitivities for enamel and dentin caries detection versus only dentin caries detection thresholds were 0.60 and 0.93 and 0.77 and 0.52 (ICDAS), 1.00 and 0.29 and 0.97 and 0.44 (BW radiography), 1.00 and 0.85 and 0.77 and 0.81 (LF device), 0.80 and 0.89 and 0.71 and 0.85 (LF pen) and 0.80 and 0.74 and 0.49 and 0.85 (FC), respectively. The accuracy values were higher for ICDAS, the LF device and the LF pen than they were for BW radiography and the FC.

CONCLUSIONS

The clinical cutoffs for sound teeth, enamel carious lesions and dentin carious lesions were, respectively, 0 through 4, 5 through 27 and 28 through 99 (LF device); 0 through 4, 5 through 32 and 33 through 99 (LF pen); and 0 through 1.2, 1.3 and 1.4 through 5.0 (FC). The ICDAS, the LF device and the LF pen demonstrated good performance in helping detect occlusal caries in vivo. The ICDAS did not seem to perform as well at the D(3) threshold (histologic scores 3 and 4) as at the D(1) threshold (histologic scores 1-4). BW radiography and the FC had the lowest performances in helping detect lesions at the D(1) and D(3) thresholds, respectively.

CLINICAL IMPLICATIONS

Occlusal caries detection should be based primarily on visual inspection. Fluorescence-based methods may be used to provide a second opinion in clinical practice.

A comparative evaluation of DIAGNOdent and caries detector dye in detection of residual caries in prepared cavities

AIM

The objective of this study was to determine the association between DIAGNOdent laser and caries detector dye in detection of the remaining caries in restorative cavities.

MATERIALS AND METHODS

The sample consisted of 100 cavities prepared in patients referring to the Department of Restorative Dentistry of Mashhad Dental School. After confirming caries absence by tactile examination, the presence of any residual caries was determined by a laser fluorescence (LF) device (DIAGNOdent Pen) and then by caries detector dye. The data were analyzed through McNemar test.

RESULTS

When the cut off value was considered as ≥13, both DIAGNOdent Pen and caries detector dye found 54 cavities as without caries and 12 cavities as carious. There were 32 teeth diagnosed as decayed only by the dye and two cases that were diagnosed as having residual caries only by the DIAGNOdent. The McNemar test revealed a significant difference in the diagnosis of residual caries between the two methods (p < 0.05), as well as significant differences between each method and tactile examination (p < 0.05). When the cut off value was set at ≥25, no significant difference was found between laser fluorescence and tactile examination in residual caries detection (p > 0.05).

CONCLUSION

Both DIAGNOdent Pen and caries detector dye can be considered as adjuncts for detecting residual caries in prepared cavities. However, the use of laser fluorescence device can provide results that are more consistent with tactile examination, while relying on caries detector dye may result in excessive removal of tooth tissue, and thus increase the risk of pulpal exposure.

CLINICAL SIGNIFICANCE

Incomparision with caries detector dye, Residual caries detection by DIAGNOdent Pen is more consistent with tactile examination.

Comparison between a laser fluorescence device and visual examination in the detection of occlusal caries in children

Occlusal surfaces of molars are especially susceptible to the development of caries due to the features, such as pits and deep fissures, of their anatomical structure.

AIM

To evaluate the efficiency of DIAGNOdent laser fluorescence measurements in comparison with visual examination for occlusal caries detection for first permanent molars in children.

METHODS

The study involved 156 permanent molar teeth in 40 children aged 7-12 years. A relatively new technology, the fluorescence laser DIAGNOdent pen, was used for detecting and diagnosing caries on the occlusal surfaces of molars. The visual examination of fissures was based on the Ekstrand classification system.

RESULTS

The results showed a strong relationship between examination with the DIAGNOdent and visual inspection. DIAGNOdent's sensitivity and specificity were 97% and 52%, respectively, indicating that the laser fluorescence DIAGNOdent pen is a reproducible and accurate diagnostic tool that may be very helpful in conjunction with visual examination in the detection of occlusal caries in permanent molars in children.

Performance of laser fluorescence devices and visual examination for the detection of occlusal caries in permanent molars

The aim of this study was to evaluate the diagnostic capabilities of a laser fluorescence tool DIAGNOdent (KaVo, Biberach, Germany) and two light-emitting diode fluorescence tools-Spectra Caries Detection Aid (AIR TECHNIQUES, Melville, NY), and SOPROLIFE light-induced fluorescence evaluator in daylight and blue florescence mode (SOPRO, ACTEON Group, La Ciotat, France)-in comparison to the caries detection and assessment system (ICDAS-II) in detection of caries lesions. In 100 subjects (age 23.4±10.6 years), 433 posterior permanent unrestored teeth were examined. On the occlusal surfaces, up to 1066 data points for each assessment method were available for statistical evaluation, including 1034 ICDAS scores (intra-examiner kappa=0.884). For the SOPROLIFE tool, a new caries-scoring system was developed. Per assessment tool each average score for one given ICDAS code was significantly different from the one for another ICDAS code. Normalized data linear regression revealed that both SOPROLIFE assessment tools allowed for best caries score discrimination followed by DIAGNOdent and Spectra Caries Detection Aid. The area under the receiver operating characteristics curve calculations showed the same grading sequence when cutoff point ICDAS codes 0-1-2 were grouped together. Sensitivity and specificity values at the same cutoff were calculated (DIAGNOdent 87/66, Spectra Caries Detection Aid 93/37, SOPROLIFE 93/63, SOPROLIFE blue fluorescence 95/55.).

Comparative in vitro validation of VistaProof and DIAGNOdent pen for occlusal caries detection in permanent teeth

PURPOSE

Current caries diagnostic tools are neither very accurate nor very reliable for the detection of carious lesions of different depths. Thus, the development of new devices and techniques is needed. The aim of this in vitro study was to validate a newer fluorescence device VistaProof (VP), and compare it with DIAGNOdent Pen (DP), direct visual (DV) and indirect visual methods (IDV), with respect to accuracy and reliability for the detection of occlusal caries in permanent teeth.

METHODS AND MATERIALS

One hundred seven sites on 41 occlusal surfaces of recently extracted premolars were selected and classified into lesion categories according to Ekstrand's clinical criteria, by direct and indirect visual examination. The fluorescence of the sites was also measured by the two devices, and the teeth were ground through the sites for histological evaluation of their lesion depth. One calibrated examiner of high reliability (intraclass correlation coefficient [ICC]>0.85) made all of the evaluations. Sensitivity, specificity, and accuracy of each detection method were estimated based on histological examination as the reference method, estimated using cutoff limits calculated on the basis of best agreement between the devices' values and histological examination. McNemar tests and receiver operating characteristic (ROC) curve analyses were used to compare the validity measures of all detection methods at α=0.05, while the ICC was used to test the reproducibility of the methods based on a second measurement one week after the first.

RESULTS

There was no statistically significant difference (p>0.05) between the accuracy of DP and VPs for both enamel and dentin lesions. The areas under the ROC curves (AUC) for the two devices were also found not to be different (p>0.05). The reliability of DP was statistically significantly better than VP (p<0.05).

CONCLUSION

The validity of both fluorescence devices were not found to be significantly different and not better than visual methods for the detection of noncavitated carious lesions.

A novel LED-based device for occlusal caries detection

The aim of this in-vitro study was to compare the performance of laser-based (DIAGNOdent, KaVo, Biberach, Germany) and LED-based (Midwest Caries I.D., DENTSPLY Professional, New York, USA) caries detectors in the detection of occlusal caries in permanent molars. The study consisted of 129 visually sound or non-cavitated pits or fissures in 82 extracted permanent human molar teeth. Two trained examiners used the laser-based and LED-based caries detectors to examine the fissures for caries. The teeth were then sectioned at the surfaces suspected of containing occlusal caries and histologically evaluated using stereomicroscopy as a gold standard. Inter-examiner reliability of the caries detector examination was assessed using Cohen's Kappa statistics. The sensitivity, specificity, and accuracy in diagnosing occlusal caries using the two devices were calculated according to appropriate cut-off scores. Receiver operating characteristic (ROC) curves were also determined to compare the diagnostic performance of the devices in occlusal caries diagnosis. The cut-off level of significance was taken as p = 0.005. Cohen's Kappa showed substantial agreement for the laser-based caries detector (0.74), and almost perfect agreement for the LED-based (0.89) caries detector. The specificity of the laser-based device varied from 0.49 to 0.97 at T1 and T2. Its sensitivity varied from 0.33 to 0.65 at T1 and T2. The specificity of the LED-based device varied from 0.48 to 0.56 at T1 and T2. Its sensitivity varied from 0.65 to 0.84 at T1 and from 0.80 to 0.84 at T2. Taking the limitations of the current study into consideration, the DIAGNOdent laser pen was more accurate in determining when teeth were free of occlusal caries than was the Midwest Caries I.D. LED-based device, although the Midwest Caries I.D. device more often revealed the presence of occlusal caries than did the DIAGNOdent pen.

Impact of measuring multiple or single occlusal lesions on estimates of diagnostic accuracy using fluorescence methods

Carious lesions can occur at different sites on the occlusal surfaces of teeth and may differ in appearance and severity. This study aimed to evaluate how scoring several lesions on occlusal surfaces, as opposed to only one representative lesion, affects estimates of reproducibility and accuracy of fluorescence-based devices. Thirty-six permanent teeth with 2-3 investigation sites (n = 82) were examined by two examiners using the laser fluorescence device DIAGNOdent pen (LF) and the fluorescence camera VistaProof (FC). Lesion depth was then assessed histologically in serial sections of the teeth. Intra-class-correlation coefficients (ICC) and areas under the ROC-curves were calculated for all investigation sites and for one randomly selected site per tooth. Comparing the reproducibility and the performance for the whole sample and the independent sites showed only a small effect or no effect. Measuring multiple sites on teeth with fluorescence devices only moderately influences performance compared to one site being investigated.

Effects of different fissure sealant applications on laser fluorescence measurements

OBJECTIVE

The aim of this in vitro study was to evaluate the effects of using only phosphoric acid or a self-etch bonding agent under clear and opaque fissure sealants on laser fluorescence (LF) readings and the reproducibility of the laser device.

METHODS

Eighty extracted permanent molars, ranged from sound to carious, were randomly divided into four groups: phosphoric acid + opaque sealant (group I), Clearfil S3 Bond (Kuraray, Kurashiki, Japan) + opaque sealant (group II), phosphoric acid + clear sealant (group III), and Clearfil S3 Bond + clear sealant (group IV). The teeth were measured using an LFpen device, before and after sealing. Data were analysed using the Spearman's correlation, Wilcoxon signed rank, and Mann-Whitney U-test.

RESULTS

Except group IV, there was a statistically significant decrease in fluorescence after the application of sealants (P < 0.05). The decrease of LFpen readings in the opaque sealant groups was more significant than the clear sealant groups (P < 0.05). But for both sealants, the difference between phosphoric acid and Clearfil S3 Bond groups was nonsignificant (P > 0.05).

CONCLUSIONS

There was a statistically significant decrease in fluorescence for both clear and opaque sealant groups. However, clear sealant with Clearfil S3 Bond does not influence the LFpen readings.

Demineralization Depth Using QLF and a Novel Image Processing Software

Quantitative Light-Induced fluorescence (QLF) has been widely used to detect tooth demineralization indicated by fluorescence loss with respect to surrounding sound enamel. The correlation between fluorescence loss and demineralization depth is not fully understood. The purpose of this project was to study this correlation to estimate demineralization depth. Extracted teeth were collected. Artificial caries-like lesions were created and imaged with QLF. Novel image processing software was developed to measure the largest percent of fluorescence loss in the region of interest. All teeth were then sectioned and imaged by polarized light microscopy. The largest depth of demineralization was measured by NIH ImageJ software. The statistical linear regression method was applied to analyze these data. The linear regression model was Y = 0.32X + 0.17, where X was the percent loss of fluorescence and Y was the depth of demineralization. The correlation coefficient was 0.9696. The two-tailed t-test for coefficient was 7.93, indicating the P-value = .0014. The F test for the entire model was 62.86, which shows the P-value = .0013. The results indicated statistically significant linear correlation between the percent loss of fluorescence and depth of the enamel demineralization.

Caries Detection Methods Based on Changes in Optical Properties between Healthy and Carious Tissue

A conservative, noninvasive or minimally invasive approach to clinical management of dental caries requires diagnostic techniques capable of detecting and quantifying lesions at an early stage, when progression can be arrested or reversed. Objective evidence of initiation of the disease can be detected in the form of distinct changes in the optical properties of the affected tooth structure. Caries detection methods based on changes in a specific optical property are collectively referred to as optically based methods. This paper presents a simple overview of the feasibility of three such technologies for quantitative or semiquantitative assessment of caries lesions. Two of the techniques are well-established: quantitative light-induced fluorescence, which is used primarily in caries research, and laser-induced fluorescence, a commercially available method used in clinical dental practice. The third technique, based on near-infrared transillumination of dental enamel is in the developmental stages.