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

Current Approaches to Diagnosis of Early Proximal Carious Lesion: A Literature Review

Integrating technological tools with clinical visual examination for caries detection and diagnosis can improve preventative measures in dentistry, resulting in decreased treatment expenses and reduced time and costs associated with testing potential anticaries agents. This article provides an overview of the conventional and new emerging modern technologies that can assist dental professionals in the early detection and diagnosis of dental caries. These technologies aid in assessing the progression of carious lesions and monitoring them quantitatively or qualitatively over time. Traditional techniques (visual, tactile, and radiographic) have limitations in diagnosing early proximal caries accurately. Novel methods like fluorescence and transillumination, as well as advanced tools like OCT (optical coherence tomography), laser fluorescence, and QLF (quantitative light-induced fluorescence), are effective for early caries detection. Optical methods like fluorescence and transillumination are particularly successful in identifying initial caries stages. Moreover, this review highlights the clinical relevance of these methods and discusses potential future technologies like terahertz imaging and artificial intelligence (AI)-based approaches.

Reversal of Root Caries with Casein Phosphopeptide-Amorphous Calcium Phosphate and Fluoride Varnish in Xerostomia

Different formulas of topical fluoride have been used to manage root carious lesions. This clinical trial aimed to investigate the efficacy of a dental varnish containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and fluoride compared with fluoride alone in reversing/arresting root caries in xerostomic patients over 1 year. A total of 80 patients (age range 45-92 years) with primary root caries (n = 184 root carious lesions) and unstimulated salivary flow rate of <0.2 mL/min were randomly allocated to receive either dental varnish containing CPP-ACP and 5% fluoride (group 1: MI varnish; GC, Japan) (n = 41, 83 lesions), or dental varnish with 5% fluoride alone (group 2: NUPRO White; Dentsply, USA) (n = 39, 101 lesions). Clinical assessments with Severity Index (SI) for root caries, DIAGNOdent measurements, and varnish application were carried out at baseline, 3, 6, and 12 months. Standard oral hygiene instructions with 1,450 ppm fluoride toothpastes were provided for both groups. After 3 months, 63.9% (n = 46) of root caries in group 1 became hard (SI: 0) compared with 39.3% (n = 35) in group 2 (p < 0.01). After 6 and 12 months, the differences in SI were insignificant (group 1, n = 60, 83.3%) (group 2, n = 66, 74.2%) (p = 0.36), and (group 1, n = 60, 89.6%) (group 2, n = 67, 81.7%, n = 1 soft, 1.2%) (p = 0.29), respectively. In both groups, noncavitated leathery lesions were more likely to become hard when compared to the cavitated root caries. A significant decrease in plaque index, surface roughness, lesion dimension, and DIAGNOdent readings with a significant increase in lesion distance from the gingival margin was reported in both groups (p < 0.05). This study has provided evidence that fluoride dental varnish either with or without calcium and phosphate has the potential to arrest/reverse root caries, especially noncavitated lesions for patients with xerostomia.

Electrical conductance for the detection of dental caries

BACKGROUND

Caries is one of the most prevalent, preventable conditions worldwide. A wide variety of management options are available at different thresholds of disease, ranging from non-operative preventive strategies such as improved oral hygiene, reduced sugar diet, and application of topical fluoride, to minimally invasive treatments for early lesions which are limited to enamel, through to selective removal and restoration for extensive lesions. The cornerstone of caries detection is a visual and tactile dental examination, however, an increasing array of methods of caries lesion 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

Our primary objective was to determine the diagnostic accuracy of different electrical conductance devices for the detection and diagnosis of non-cavitated coronal dental caries in different populations (children, adolescents, and adults) and when tested against different reference standards.

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 26 April 2019); Embase Ovid (1980 to 26 April 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 26 April 2019); and the World Health Organization International Clinical Trials Registry Platform (to 26 April 2019). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy studies that compared electrical conductance devices with a reference standard of histology or an enhanced visual examination. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. We included studies using previously extracted teeth or those that recruited participants with teeth believed to be sound or with early lesions limited to enamel. Studies that explicitly recruited participants with more advanced lesions that were obviously into dentine or frankly cavitated 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 was displayed as coupled forest plots, and plotted as summary receiver operating characteristic (SROC) plots, displaying the sensitivity-specificity points for each study. Due to variability in thresholds we estimated diagnostic accuracy using hierarchical summary receiver operating characteristic (HSROC) methods.

MAIN RESULTS

We included seven studies reporting a total of 719 tooth sites or surfaces, with an overall prevalence of the target condition of 73% (528 tooth sites or surfaces). The included studies evaluated two index tests: the electronic caries monitor (ECM) (four studies, 475 tooth surfaces) and CarieScan Pro (three studies, 244 tooth surfaces). Six studies used histology as the reference standard, one used an enhanced visual examination. No study was considered to be at low risk of bias across all four domains or low concern for applicability or both. All studies were at high (five studies) or unclear (two studies) risk of bias for the patient selection domain. We judged two studies to be at unclear risk of bias for the index test domain, and one study to be at high risk of bias for the reference standard and flow and timing domains. We judged three studies to be at low concern for applicability for patient selection, and all seven studies to be of low concern for reference standard and flow and timing domains. Studies were synthesised using a hierarchical method for meta-analysis. There was variability in the results of the individual studies, with sensitivities which ranged from 0.55 to 0.98 and specificities from 0 to 1.00. These extreme values of specificity may be explained by a low number of healthy tooth surfaces in the included samples. The diagnostic odds ratio (DOR) was 15.65 (95% CI 1.43 to 171.15), and indicative of the variability in the included studies. Through meta-regression we observed no meaningful difference in accuracy according to device type or dentition. Due to the small number of studies we were unable to formally investigate other potential sources of heterogeneity. We judged the certainty of the evidence as very low, and downgraded for risk of bias due to limitations in the design and conduct of the included studies, imprecision arising from the relatively small number of surfaces studied, and inconsistency due to the variability of results.

AUTHORS' CONCLUSIONS

The design and conduct of studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ is particularly challenging. The evidence base to support the detection and diagnosis of caries with electrical conductance devices is sparse. Newer electrical conductance devices show promise and further research at the enamel caries threshold using a robust study design to minimise bias is warranted. In terms of applicability, any future studies should be carried out in a clinical setting to provide a realistic assessment within the oral cavity where plaque, staining, and restorations can be problematic.

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.

DIAGNOdent: An Optical Method for Caries Detection

The onset of caries is characterized by demineralization of dental hard tissues. Optimal fluoridation with respective oral hygiene habits and diet may stop the progression of a lesion and even allow for its remineralization. The aim of modern dentistry must be a preventive approach rather than invasive repair of the disease. This is possible only with early detection and respective preventive measures. Some of today's diagnostic tools are not sensitive enough to detect this early onset of destruction. Tools based on fluorescence could have the possibility to overcome this problem. This overview will focus on today's knowledge of one possible tool, the DIAGNOdent.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

DRKS00004817 on DRKS on 12^th March 2013.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

A fractional electrical impedance model in detection of occlusal non-cavitated carious

Identification of occlusal caries remains a major concern for the diagnosis, which is still highly subjective and presents a considerable variability among clinicians. Dentists have been observed an increase of a specifically type of caries lesion, the hidden caries. Among the available techniques to assess the hidden caries, the measurement of electrical impedance has been shown to be one of the most promising. This paper presents a fractional electrical model for the tooth and uses such a model associated to a BioImpedance Spectroscopy (BIS) method based on the current response to a step voltage excitation. An analytical solution for the current response is presented based on a fractional calculus approach. Estimate parameters of the proposed model achieved using an in vitro data acquired in a protocol performed to collect bioimpedance data showed that it seems possible to detect occlusal non-cavitated caries, and that the principal confounding factor in the diagnosis of the incipient occlusal caries, the pigmented areas, can also be differentiated.

The Use of the International Caries Detection and Assessment System (ICDAS) in a National Health Service General Dental Practice as Part of an Oral Health Assessment

Introduction

The Scottish Dental Clinical Effectiveness Programme (SDCEP) is developing guidance for oral health assessment and review that is intended for use in National Health Service (NHS) general dental practice. One section of this guidance is assessment of the teeth, including their caries status. The detailed caries assessment method identified by the guidance group is the International Caries Detection and Assessment System (ICDAS).

Aim

The aim of this study was to investigate the implications of using the ICDAS in an NHS general practice and, in particular, the time taken to use the system.

Method

After online and in-practice training and calibration, 50 adult and 50 child patients were randomly allocated for assessment using the ICDAS detection codes. The ICDAS protocol states that the teeth should be clean and dry. For this study, all patients had their teeth brushed by the dentist before the assessment and the results were recorded on draft ICDAS clinical pro forma sheets. The time taken for the assessment was assessed with a stopwatch and recorded in a spreadsheet program.

Results

The results showed that the mean time for the assessment of an adult was 3.80 minutes, or 4.99 minutes if the time for pre-examination cleaning and drying was included. For a child, the mean time was 2.53 minutes, or 3.99 minutes if pre-examination brushing time was included.

Conclusions

These results indicate that with training and experience, it is possible to carry out an ICDAS assessment in a time that is practical in general dental practice.

Validity of caries detection on occlusal surfaces and treatment decisions based on results from multiple caries-detection methods

The aim of this in vitro study was to evaluate whether having results available from multiple detection methods influences dentist's treatment decisions for incipient caries lesions on occlusal surfaces. The occlusal surface of 96 extracted permanent molars without frank cavitation was examined by three examiners initially by visual examination alone, following which they chose one of three treatment options: (i) no treatment, (ii) preventive or non-invasive treatment (sealants), and (iii) invasive treatment. Four weeks later the examiners again selected one of the three treatment options for the surfaces, but this time were able to refer to the results from additional caries-detection methods [bitewing radiographs, electric conductance measurement (ECM), quantitative light fluorescence (QLF), and DIAGNOdent] that had been performed in the interim time. Stereomicroscopy was used to evaluate sensitivity, specificity, accuracy, and area under the Receiver Operating Characteristic (ROC) curve (AUC) for the detection methods at the D1 diagnostic threshold. Slight improvement was obtained in the percentage of sites correctly diagnosed, and in the AUC, when referring to the results obtained from all detection methods compared with visual examination alone. However, a drastic effect on the selection of treatment options was observed by having results available from multiple methods, with the choice of invasive treatment increasing substantially. In conclusion, having data available from multiple methods did not improve the accuracy of examiners in detecting early occlusal caries lesions, but it had a great influence on the number of surfaces indicated for operative treatment. The potential decrease in overall specificity while using multiple methods of detection may be of concern in populations with a low prevalence of occlusal caries lesions.

The application of ozone in dentistry: a systematic review of literature

OBJECTIVES

(1) To systematically review the clinical application and remineralization potentials of ozone in dentistry; (2) To summarize the available in vitro applications of ozone in dentistry.

SOURCES

Ovid MEDLINE, CINAHL, etc. (up to April 2007).

STUDY SELECTION

In vitro or in vivo English language publications, original studies, and reviews were included. Conference papers, abstracts, and posters were excluded.

RESULTS

In vitro: Good evidence of ozone biocompatibility with human oral epithelial cells, gingival fibroblast, and periodontal cells; Conflicting evidence of antimicrobial efficacy of ozone but some evidence that ozone is effective in removing the microorganisms from dental unit water lines, the oral cavity, and dentures; Conflicting evidence for the application of ozone in endodontics; Insufficient evidence for the application of ozone in oral surgery and implantology; Good evidence of the prophylactic application of ozone in restorative dentistry prior to etching and the placement of dental sealants and restorations. In vivo: Despite the promising in vitro evidence, the clinical application of ozone in dentistry (so far in management of dental and root caries) has not achieved a strong level of efficacy and cost-effectiveness.

CONCLUSIONS

While laboratory studies suggest a promising potential of ozone in dentistry, this has not been fully realised in clinical studies to date. More well designed and conducted double-blind randomised clinical trials with adequate sample size, limited or no loss to follow up, and carefully standardised methods of measurement and analyses are needed to evaluate the possible use of ozone as a treatment modality in dentistry.

Reproducibility of DIAGNOdent 2095 and DIAGNOdent Pen measurements: results from an in vitro study on occlusal sites

The aim of this in vitro study was to investigate the intra- and interdevice reproducibility of the DIAGNOdent 2095 (DD2095) and the new DIAGNOdent Pen (DDPen) on non-cavitated occlusal caries sites. Altogether, 241 sites on 90 molars were inspected twice with both devices and by four examiners. The intra/interdevice reproducibilities were assessed by means of the intraclass correlation coefficient (ICC) as well as by the range of the 95% limits of agreement of Bland & Altman. Additionally, a linear mixed-effects model was fitted with fixed effects for the visual scores and the devices used and random effects for occlusal sites and examiners within each measurement site. In result, the following values were determined for the intradevice reproducibility: DD2095: ICC 0.89, range 42.3; and DDPen: ICC 0.88, range 49.3. The interdevice reproducibility was found to be in the same order of magnitude (ICC 0.82, range 53.7). The comparison between both devices indicated significantly lower mean values for the DDPen. The estimates of the linear model show that there is a high variation between the sites that cannot be explained by the fixed effects. In conclusion, both devices showed an imperfect reproducibility, which indicate the usage as adjunct tool only in clinical practice.

Changes in electrical resistance of sound fissure enamel in first molars for 66 months from eruption

The purposes of this study were to investigate the enamel maturation process in the occlusal pit of sound first molars by measuring electrical resistance. Ninety-nine sound first molars in 34 children (mean age of 6.47 +/- 0.51 years) were measured electrically once every 6 months and were monitored for a maximum of 66 months. Electrical resistance increased during the posteruptive period. However, the results suggest that posteruptive enamel maturation in the occlusal pits may not be completed even 66 months after tooth eruption.

Establishing quantitative light-induced fluorescence cut-offs for the detection of occlusal dentine lesions

The aims of this in vitro study were, first, to define suitable cut-off values for the detection of occlusal dentine lesions by means of quantitative light-induced fluorescence (QLF), and, second, to compare the validity of light microscopy (LM) and microradiography (MR) as reference standards. Fifty-four third molar occlusal fissures with sound sites or non-cavitated lesions were examined. Standard QLF equipment was used to capture, display, store, and analyze fluorescence images. Each tooth was cut into sections in the bucco-lingual direction using a microtome saw, and the caries levels were subsequently assessed with the two reference methods. The histological examination with LM indicated that 46% of the specimens had carious lesions progressing into the dentine compared with 41% measured using MR (D3-4 level). Using optimal cut-off levels for the detection of dentine lesions, the sensitivity and specificity values were > 80%. The area under the receiver operating characteristic curve was slightly higher for MR (0.91-0.93) than for LM (0.88-0.89). The results of this study give a good idea of suitable cut-off points for the detection of occlusal dentine lesions using QLF. Owing to the small number of specimens in this study, further studies should be carried out before establishing definite cut-offs.

Diagnostic tools for early caries detection

BACKGROUND

Management of dental caries demands early detection of carious lesions. This article provides an overview of the state-of-the-art methodologies for the detection and assessment of early carious lesions.

TYPES OF STUDIES REVIEWED

The authors reviewed MEDLINE for available literature on new caries detection methodology and tools, using terms such as "early caries detection," "fluorescence" and "transillumination." Their review was not a systematic review of the literature. They included in their review in vitro, in situ, in vivo and clinical studies, as well as position papers, editorials and consensus conferences statements published in English.

RESULTS

Each early caries detection tool has advantages and disadvantages; some perform better on certain surfaces than others. Therefore, their performance threshold and the operator's influence on performance must be considered. Not all methods accurately detect early lesions, and false positives and false negatives may occur. Detecting early lesions in combination with assessing activity status is essential for establishing the prognosis and threshold required for preventive intervention. Clinically useful tools to help make such decisions are under development.

CLINICAL IMPLICATIONS

Early caries detection methods should be an adjunct to clinical decision making, supporting preventive treatment planning in conjunction with caries risk assessment but not justifying premature restorative intervention.

In vitro quantification of smooth surface caries with DIAGNOdent and the DIAGNOdent pen

OBJECTIVE

A new generation of the laser fluorescence device, DIAGNOdent, for caries detection and quantification has been introduced recently. It is the DIAGNOdent pen. The aim of this study was to compare the validity and reliability of both laser-based devices, DIAGNOdent and the DIAGNOdent pen, in quantifying smooth surface caries.

MATERIAL AND METHODS

The material comprised a sample of 52 premolar teeth extracted on orthodontic indication. The teeth were visually sound or had various stages of non-cavitated carious lesions on smooth surfaces. All teeth were photographed and measured with both DIAGNOdent and the DIAGNOdent pen by two examiners independently. The teeth were then sectioned into 300-microm slices and analysed under a microscope for verification of lesion depth. Histopathological analyses were performed by two observers to assess lesion depth, which was classified into five categories ranging from sound to dentinal caries. Reliability and validity of the two devices were evaluated in terms of intra-class coefficients and Spearman rank correlation coefficient, respectively. The relation between measurements performed by DIAGNOdent and the DIAGNOdent pen was analyzed using Pearson's correlation coefficient.

RESULTS

Both DIAGNOdent and the DIAGNOdent pen had excellent intra-observer agreement and acceptable inter-observer agreement. The correlation with histology for DIAGNOdent and the DIAGNOdent pen ranged between 0.47 and 0.57, although the correlation between DIAGNOdent and the DIAGNOdent pen was high.

CONCLUSIONS

In this in vitro study, the new laser fluorescence device, the DIAGNOdent pen, showed similar reliability and validity at quantification of smooth surface caries compared to the conventional DIAGNOdent device. Agreement between DIAGNOdent and the DIAGNOdent pen was excellent.

Caries risk assessment: methods available to clinicians for caries detection

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

The influence of toothpastes and prophylaxis pastes on fluorescence measurements for caries detection in vitro

The aim of this study was to test the influence of toothpaste and prophylaxis paste remnants as well as powder remnants on DIAGNOdent readings. A total of 68 sites on the occlusal surface of human molars were used for this study. After a cleaning procedure, saliva was spread on the tooth surface, dried for 3 s, and DIAGNOdent (DD) values were measured. After these measurements were performed, 500 mg of the toothpaste or prophylaxis paste was taken and the occlusal surface was cleaned for 3 s with a slow rotating contra-angle handpiece. The paste was then rinsed off with the 3-in-1 syringe for 3 s using water with air. The DD measurements were taken again and the rinsing for 3 s and fluorescence measurements were repeated. The procedure with the powder using the PROPHYflex 2 was, in principle, the same. Whereas only small differences could be detected on sound surfaces, there was a distinct influence on decayed surfaces. It could be concluded that when the DIAGNOdent device is used in practice and special care in rinsing after cleaning is not taken, it is possible that false readings are registered.

Clinical Study on the Effect of Professional Cleaning of Occlusal Tooth Surfaces on Laser Fluorescence Measurements

Manufacturer's advice is to professionally clean teeth before using a laser fluorescence (LF) device in order to avoid false-positive diagnoses. Professional cleaning is not included in routine dental check-ups in children in Finland because it is time-consuming. The aim of our present study was to evaluate the effect of professional cleaning of teeth on LF in children. A total of 642 occlusal surfaces in permanent molars and premolars in 9- to 16-year-olds (n = 46) were first examined visually. After that the first measurements with LF were made without cleaning the teeth. At the same appointment the second measurements were carried out after professional cleaning using a soft rubber cup and either polishing paste or plain water spray. The differences in LF of uncleaned and cleaned teeth were determined separately for teeth with a visual score of 0 (sound) and > 0. In premolars cleaning had no significant effect on LF. In molars, the values increased when the teeth were cleaned, the difference of the measurements being statistically significant in molars with visual score > 0 cleaned with plain water spray. For molars that were cleaned with paste, the differences were not statistically significant. Sealants did not modify the effect of cleaning. As a conclusion cleaning with a rotating instrument and water spray before LF measurements is recommended in teeth with visible plaque. Also in clean teeth, cleaning is advisable in cases where LF readings approach threshold level for operative intervention. The finding that uncleaned teeth gave lower values than cleaned teeth is opposite to what has been suggested.

Clinical performance of DIAGnodent in the detection of secondary carious lesions

The diagnostic value of DIAGNOdent in detecting primary occlusal caries has been investigated in many studies, although its use in in vivo detection of secondary caries remains unclear. The aim of this study was to investigate the ability of DIAGNOdent in in vivo detection of secondary caries on teeth with amalgam restorations. The material comprised 51 posterior teeth restored with amalgam material. Bitewing radiographs were taken of all teeth, in accordance with the standard clinical protocol, and analysed by five observers with respect to secondary caries. The restoration margins of each tooth were carefully scanned with DIAGNOdent and the site of the highest reading and its value were registered in a digital picture. The color (stained/unstained) of the restoration margins was also documented. The restoration material was removed and all cavities were examined carefully by two observers together, both visually and by probe. The results showed that the sensitivity and specificity of DIAGNOdent and conventional radiography in detecting secondary caries were 0.60/0.81 and 0.56/0.92, respectively. For DIAGNOdent, 100% of the teeth in the false-positive fraction had stains. Regarding receiver operating characteristic analyses, the Az values were 0.78 and 0.69 for DIAGNOdent and radiography, respectively. We conclude that DIAGNOdent may be used only as an adjunct to conventional methods in detecting secondary caries on teeth with amalgam restorations.

A systematic review of the performance of a laser fluorescence device for detecting caries

BACKGROUND

The DIAGNOdent, or DD (KaVo America, Lake Zurich, Ill.), a device for detecting caries using laser fluorescence, has been growing in popularity during the past three years. Although several evaluations of its diagnostic performance have appeared in the literature, the range of reported performances is extensive.

TYPES OF STUDIES REVIEWED

The authors conducted a systematic review of the literature to assess the diagnostic performance of the DD. Of 115 articles identified in the search, 25 studies were included in the review according to criteria requiring histologic validation and outcomes expressed as sensitivity and specificity values.

RESULTS

For detection of dentinal caries, sensitivity values ranged widely (0.19 to 1.0), although most tended to be high. Specificity values exhibited a similar pattern, ranging from 0.52 to 1.0. In comparison with visual assessment methods, the DD exhibited a sensitivity value that was almost always higher and a specificity value that was almost always lower. The body of evidence is characterized largely by in vitro studies, so that generalization to the clinical setting is uncertain. Because caries thresholds varied substantially across the studies, synthesized estimates of performance were not possible.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The DD clearly is more sensitive than traditional diagnostic methods; however, the increased likelihood of false-positive diagnoses compared with that with visual methods limits its usefulness as a principal diagnostic tool.

A follow-up study of the use of DIAGNOdent for monitoring fissure caries in children

OBJECTIVES

The aim of this study was to evaluate the utility of the laser fluorescence device DIAGNOdent for monitoring occlusal caries longitudinally as part of a routine dental check-up in a public dental clinic.

METHODS

Children aged 7-8 and 13-14 years at baseline participated in the study. As part of two consecutive dental check-ups with a mean interval of 1,19, years, 423 permanent molars and 315 primary molars in 81 children were examined visually and using DIAGNOdent by one dentist. In teeth where, as judged by visual examination, caries had emerged or progressed during the follow-up, the DIAGNOdent values had increased significantly from the baseline.

RESULTS

In permanent teeth with a change in visual score from sound to enamel or dentin caries, the mean DIAGNOdent value increased from 24 to 37 and in primary teeth from 8 to 40. The increase in DIANGOdent values correlated positively with the increase in visual score. The mean DIAGNOdent value at baseline was significantly higher in teeth that became carious than in those that remained sound during the follow-up. For permanent teeth with a visual reversal from inactive or active enamel caries to a sound surface, the mean DIAGNOdent value decreased from 36 to 24.

CONCLUSIONS

These results suggest that DIAGNOdent is useful in monitoring occlusal caries in both permanent and primary molars.

Effect of alteration in organic material of the occlusal caries on DIAGNOdent readings

DIAGNOdent is a laser fluorescence device used for dental caries diagnosis in occlusal and smooth surfaces. Despite the promising preliminary results, the molecules involved in the increase of fluorescence in carious lesions remain unclear. The aim of this study was to compare the laser fluorescence readings before and after changes in the organic material of occlusal carious lesions in primary teeth. Twenty-four primary molars stored in saline solution with at least one site with occlusal caries were divided into two groups. The control group had 17 sites with caries and the experimental one had 16 sites. The carious lesions were measured with laser fluorescence. The experimental samples were then removed from the storage solution and immersed in a 2% sodium hypochlorite solution for 24 hours. After washing with water, the teeth were measured again with the laser fluorescence device. The teeth of the control group were submitted to the same procedures, but saline solution was used instead of the sodium hypochlorite solution. A statistically significant reduction in the mean of the readings after immersion in the two tested solutions compared with the initial readings was observed in both groups, but the decrease was statistically higher in the experimental group (p < 0.0001). In this study, the data indicate that changes in the fluorescence of carious lesions measured by the laser fluorescence are mainly due to the organic content alterations rather than to the mineral loss.

Diagnostic comparison of three groups of examiners using visual and laser fluorescence methods to detect occlusal caries in vitro

BACKGROUND

To evaluate the accuracy of the DIAGNOdent laser device (DD) for detecting occlusal fissure caries when used by three groups of examiners.

METHODS

Three final-year dental students (S), three General Dental Practitioners (G), and three Academic Clinicians (A) individually examined the non-cavitated occlusal surfaces of 25 extracted permanent molars using visual inspection (VI) then DD assessments. The presence of caries was confirmed following tooth sectioning. A cut-off limit of 30 was used for the DD to avoid over-treatment in a low caries-risk situation.

RESULTS

For VI, individual examiner sensitivity (caries correctly diagnosed) ranged from 53 to 86 per cent, and specificity (sound teeth correctly diagnosed) ranged from 76 to 95 per cent, with low Kappa agreements. Group S achieved the highest sensitivity (80 per cent) and Groups G and A achieved the highest specificities (88 per cent). For DD, individual examiner sensitivity ranged from 19DD, individual examiner sensificity ranged from 19 to 77 per cent, and specificity from 71 to 97 per cent, with generally moderate Kappa agreements. Group A achieved the highest (67 per cent) and Group G the lowest (44 per cent) sensitivities, and Group G achieved the highest specificity (94 per cent).

CONCLUSIONS

There were similar widely varying results for the two diagnostic methods and for the three groups of examiners. However, the relatively high sensitivities found with VI and specificities found with DD should avoid over-treatment in low caries-risk populations.

Effects of Drying Time and the Presence of Plaque on the in vitro Performance of Laser Fluorescence in Occlusal Caries of Primary Teeth

The diode laser fluorescence device was introduced to diagnose caries lesions in occlusal and smooth surfaces. Despite promising results, much variation has been found in the protocol of utilization. The goal of this study was to evaluate the influence of dental plaque and drying time on the laser fluorescence (DIAGNOdent) performance in occlusal sites of primary molars. For the drying time study, 63 suspected occlusal sites in primary molars were used. The same sites were evaluated in four different conditions: (1) moist teeth, (2) teeth dried for 3 s with a 3-in-1 syringe, (3) teeth dried for 15 s, and (4) dehydrated teeth. For the plaque experiment, we selected 28 occlusal sites. After the baseline laser fluorescence readings, plaque collected from children was placed on the suspected site. New laser fluorescence measurements were performed. For both studies, we compared the laser fluorescence values, as well as sensitivity, specificity, accuracy, and area under ROC curve. For different drying times, the more dehydrated the teeth, the higher the values. Nevertheless, the performance of the method did not change significantly, except for dehydrated teeth. In the presence of plaque, the laser fluorescence values were reduced, and the evaluated parameters were worse than with no plaque. In conclusion, the hydration state of the teeth did not change the results significantly, but the presence of plaque worsened the performance of the laser fluorescence method.