Detection of Approximal Caries with a New Laser Fluorescence Device

An in-vitro evaluation of residual dentin retained after using novel enzymatic-based chemomechanical caries removal agents

To assess the biochemical, mechanical and structural characteristics of retained dentin after applying three novel bromelain-contained chemomechanical caries removal (CMCR) formulations in comparison to the conventional excavation methods (hand and rotary) and a commercial papain-contained gel (Brix 3000). Seventy-two extracted permanent molars with natural occlusal carious lesions (score > 4 following the International Caries Detection and Assessment System (ICDAS-II)) were randomly allocated into six groups (n = 12) according to the excavation methods: hand excavation, rotary excavation, Brix 3000, bromelain-contained gel (F1), bromelain-chloramine-T (F2), and bromelain-chlorhexidine gel (F3). The superficial and deeper layers of residual dentin were examined by Raman microspectroscopy and Vickers microhardness, while the surface morphology was assessed by the scanning electron microscope (SEM). A multivariate analysis of variance followed by Tukey's test (p > 0.05) was performed for data analysis. The novel formulations showed an ability to preserve the partially demineralized dentin that showed a reduced phosphate content with a higher organic matrix. This was associated with lower Vickers microhardness values in comparison to sound dentin and rotary excavation. The collagen integration ratio in all methods was close to sound dentin (0.9-1.0) at the deeper dentin layer. The bromelain-chloramine-T gel (F2) produced the smoothest smear-free dentin surface with a higher number of opened dentinal tubules. In contrast, dense smearing covering the remaining dentin was observed in the manual and rotary methods with obstructed dentin tubule orifices. The bromelain-contained formulations can be considered a new minimally invasive approach for selectively removing caries in deep cavitated dentin lesions.

An in vitro assessment of the residual dentin after using three minimally invasive caries removal techniques

To evaluate the efficiency and effectiveness of three minimally invasive (MI) techniques in removing deep dentin carious lesions. Forty extracted carious molars were treated by conventional rotary excavation (control), chemomechanical caries removal agent (Brix 3000), ultrasonic abrasion (WOODPECKER, GUILIN, China); and Er, Cr: YSGG laser ablation (BIOLASE San Clemente, CA, USA). The assessments include; the excavation time, DIAGNOdent pen, Raman spectroscopy, Vickers microhardness, and scanning electron microscope combined with energy dispersive X-ray spectroscopy (SEM-EDX). The rotary method recorded the shortest excavation time (p < 0.001), Brix 3000 gel was the slowest. DIAGNOdent pen values ranged between 14 and 18 in the remaining dentin and laser-ablated surfaces recorded the lowest reading (p < 0.001). The Ca:P ratios of the remaining dentin were close to sound dentin after all excavation methods; however, it was higher in the ultrasonic technique (p < 0.05). The bur-excavated dentin showed higher phosphate and lower matrix contents with higher tissue hardness that was comparable to sound dentin indicating the non-selectiveness of this technique in removing the potentially repairable dentin tissue. In contrast, the MI techniques exhibited lower phosphate and higher organic contents associated with lower microhardness in the deeper dentin layers. This was associated with smooth residual dentin without smearing and patent dentinal tubules. This study supports the efficiency of using MI methods in caries removal as conservative alternatives to rotary excavation, providing a promising strategy for the clinical dental practice.

Performance of near-infrared light transillumination in the detection of occlusal caries lesions in deciduous teeth

BACKGROUND

This study compared the performance of near-infrared light transillumination (NILT; DIAGNOcam [DC]) in detecting occlusal caries lesions in deciduous molars with the performance of the International Caries Detection and Assessment System (ICDAS), digital radiographic method (RX) and laser fluorescence (DIAGNOdent pen [LFpen]).

METHODS

Fifty-seven extracted deciduous molars with no frank cavitation caries lesions were selected. One site per tooth was evaluated twice each by two examiners using all methods. Then, a histological examination was performed using a stereomicroscope. The performance of the methods was assessed with respect to two thresholds: D1 (all visible caries lesions affecting enamel) and D3 (caries lesions extended into dentin).

RESULTS

A weighted kappa and intraclass correlation coefficients were calculated for intra- and inter-observer reproducibilities, varying from 0.31 (RX) to 0.89 (LFpen). The intra-observer reproducibility at D1 and D3 thresholds varied from 0.51 (ICDAS) to 0.85 (DC) and from 0.30 (ICDAS) to 1.00 (RX), respectively. The inter-observer reproducibility varied from 0.28 (RX) to 0.47 (DC) and from 0.22 (LFpen) to 0.75 (DC), respectively. At the D1 threshold, higher sensitivity and accuracy were found for LFpen (0.76/0.71) and ICDAS (0.65/0.66); and higher specificities were found for RX (0.94), DC (0.79), and ICDAS (0.71). At the D3 threshold, all methods exhibited lower sensitivities (0.13-0.35) and higher specificity, accuracy, and area under the ROC curve values (0.70-1.00). All methods showed a correlation with histological results, especially for ICDAS and DC.

CONCLUSIONS

NILT technology (DC) and LFpen exhibited similar performance for the detection of occlusal caries lesions in deciduous molars when compared with ICDAS criteria.

Caries-preventive effectiveness of two different fluoride varnishes: A randomised clinical trial in patients with multi-bracketed fixed orthodontic appliances

BACKGROUND

Patients with multi-bracketed fixed orthodontic appliances are at a higher risk of developing enamel demineralisation.

AIM

To compare the efficacy of the quarterly application of two varnishes in preventing white spot lesions (WSLs) during multi-bracketed fixed orthodontic treatment.

DESIGN

Ninety-nine patients were randomly allocated into three intervention groups: Group A-standard oral hygiene instructions (OHI); Group B-5% sodium fluoride (NaF) varnish with standard OHI; and Group C-NaF plus tricalcium phosphate varnish with standard OHI. The outcome was assessed at 6-monthly intervals using a quantitative laser fluorescence device, clinical evaluation and photographic evaluation on six maxillary anterior teeth. A logistic regression model using generalised estimating equations with the intervention group, time and their interaction was used to compare the occurrence of WSLs, whereas the independent-samples Kruskal-Wallis test was used to compare the means of fluorescent values among different groups at p = .05.

RESULTS

Generalised estimating equations (with intervention and time as predictors) showed that only the effect of time was found to be significant (p < .001), whereas there was no significant difference among the three intervention groups (p = .305) using clinical assessment or photographic assessment (p = .599). At the 18-month follow-up, sodium fluoride (NaF) varnish with standard OHI was shown to reduce the odds of WSLs by 55% (p = .200), and NaF plus tricalcium phosphate varnish with standard OHI by 42% (p = .327).

CONCLUSION

The study failed to demonstrate that the quarterly application of both the study varnishes with OHI provided additional benefits compared with standard OHI alone in preventing WSLs, taking the effect of time of follow-up into consideration. There were higher odds of developing WSLs with an increased duration of orthodontic treatment.

Effectiveness of applying proximal enamel caries with fluoride-releasing sealant and fluoride varnish on caries progression in permanent teeth: A 12-month split-mouth randomized clinical trial

BACKGROUND

Few studies report on managing initial proximal caries with sealants, and no reports focus on fluoride-releasing sealants.

AIM

To compare the effectiveness between applications of a fluoride-releasing sealant and fluoride varnish on proximal enamel caries to control caries progression in permanent teeth.

DESIGN

This was a split-mouth randomized controlled trial in forty-four 11- to 16-year-old children with radiographic caries in at least one contralateral pair of teeth with proximal enamel caries. The lesions were evaluated using DIAGNOdent and were also assessed visually after tooth separation. The lesions in each subject were randomly sealed with a fluoride-releasing sealant (Helioseal® F) or applied with fluoride varnish (Duraphat®). The fluoride varnish-treated lesion was reapplied at 3 and 6 months. Clinical examination, bitewing radiograph evaluation, and DIAGNOdent assessment were performed at 6 and 12 months. The caries progression outcome variables were regression, no change, and progression. The data were analyzed with the McNemar-Bowker test.

RESULTS

Radiographic examination and DIAGNOdent assessment demonstrated no significant differences in the percentages of regression, no change, or progression at the 12-month follow-up (p > .05).

CONCLUSION

Applications of a fluoride-releasing sealant and of fluoride varnish three times resulted in a nonsignificant difference in caries progression of initial proximal caries at the 12-month follow-up.

Prevalence of dental caries in children with congenital heart disease

BACKGROUND

Congenital heart defects (CHD) affect about 8 out of 1000 births worldwide. Most of the patients reach adulthood and are exposed to an increased risk of endocarditis. Since bacteria already enter the bloodstream during everyday activities, oral hygiene is given special importance in the prevention of endocarditis.

METHODS

In this study 81 boys (55.1%) and 66 (44.9%) girls with CHD received a dental exam and additionally an assessment using the DIAGNOdent® pen. This study group consisting of patients with CHD was matched with a healthy epidemiological control group in Germany.

RESULTS

Eighty-one boys (55.1%) and 66 (44.9%) girls were examined. The mean age was 11 ± 4 years. 38.8% showed at least one untreated carious lesions. 37.4% had a dmft/DMFT ≥2 and thus represented a group with an increased caries risk. The dmft value was 2.12 ± 1.25 in the age group 3-6 year olds. In the group of the 7-12 year old patients the DMFT/dmft was 2.06 ± 2.27, whereas DMFT in 13-17 year olds was at 2.12 ± 1.58. However, children and adolescents with CHD had a higher DMF index than healthy children in the same age group.

CONCLUSIONS

The present study reveals that more than one third of those examined have a dental condition in need of rehabilitation. In future, close interdisciplinary cooperation between pediatric cardiologists and dentists should ensure regular dental check-ups.

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

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

Systematic review and meta-analysis of diagnostic studies of proximal surface caries

AIM

This systematic review and meta-analysis aimed to assess the diagnostic accuracy and reliability of commonly used caries detection methods for proximal caries diagnostics. Visual examination (VE), bitewing radiography (BWR), laser fluorescence (LF), and fibre-optic transillumination (FOTI) were considered in detail.

MATERIAL AND METHODS

PRISMA guidelines for the reporting of systematic reviews and meta-analyses were applied. The mnemonic PIRDS (problem, index test, reference test, diagnostic and study type) concept was used to guide the literature search. Next, studies that met the inclusion criteria were stepwise selected and evaluated for their quality with a risk of bias (RoB) assessment tool. Studies with low/moderate bias and sufficient reporting were considered for meta-analysis. The pooled sensitivity (SE), specificity (SP), diagnostic odds ratio (DOR), and area under the ROC curve (AUC) were calculated.

RESULTS

From 129 studies meeting the selection criteria, 31 in vitro studies and five clinical studies were finally included in the meta-analysis. The AUC values for in vitro VE amounted to 0.84 (caries detection) and 0.85 (dentin caries detection). BWR ranged in vitro from 0.55 to 0.82 (caries detection) and 0.81-0.92 (dentin caries detection). LF showed higher AUC values for overall caries detection (0.91) and dentin caries detection (0.83) than did other methods. Clinical data are limited.

CONCLUSION

The number of diagnostic studies with low/moderate RoB was found to be low and indicates a need for high-quality, well-designed caries diagnostic studies.

CLINICAL RELEVANCE

BWR and LF showed good diagnostic performance on proximal surfaces. However, because of the low number of includable clinical studies, these data should be interpreted with caution.

Reliability of Class II Bulk-fill Composite Restorations With and Without Veneering: A Two-year Randomized Clinical Control Study

Bulk-fill composites are increasingly used in stress-bearing areas in posterior teeth, with a diversity of reports concerning their effectiveness and clinical reliability. The objective of this randomized clinical control study was to investigate the effectiveness of bulk-fill versus veneered bulk-fill Class II composite restorations. A double-blind split-mouth technique was employed in 80 subjects recruited for restoring Class II caries in one molar bilaterally in the same arch following respective inclusion and exclusion criteria and after obtaining written consent. While one molar was randomly restored with bulk-fill composite using the sealed-envelope technique, Tetric N-Ceram Bulk Fill (TBF), the contralateral was restored with a bulk-fill composite veneered with an increment of a heavy-body microhybrid composite-Tetric-Ceram HB (TBF/V). Box-only cavities were prepared and received etch-and-rinse adhesive bonding and Tetric N-Bond treatment before composite insertion. Restorations were assessed at 24 hours, 2 weeks, 6 months, 12 months, and 24 months for esthetic, functional, and biological quality employing the FDI ranking criteria. Friedman repeated-measures analysis of variance, the McNemar test, and the Cohen's kappa statistical test were used for statistical analysis. Over a 24-month interval, none of the test restorations were ranked as clinically unsatisfactory. In terms of functional criteria, clinically excellent restorations were significantly more prevalent in TBF/V than in TBF (p<0.05). For long-term satisfactory performance of Class II bulk-fill composites, an occlusal veneering increment of conventional heavy body microhybrid composite appears to be favorable.

What is the most accurate method for detecting caries lesions? A systematic review

OBJECTIVE

To perform a systematic review and meta-analysis of the performance of different methods for detecting carious lesions in permanent and primary teeth, considering all types of tooth surface.

METHODS

Two reviewers searched PubMed, Embase, Scopus and other sources up to November 2020 to identify published and nonpublished studies in English. We focused on three caries detection methods: visual inspection (VI), radiographic (RX) and fluorescence-based (LF). We included studies investigating at least one of these methods which (a) assessed the accuracy of the method in detecting caries lesions; (b) considered occlusal, proximal or free smooth surfaces in primary or permanent teeth; (c) used a reference standard other than one of the three methods; and (d) reported data on sample size and accuracy. Multilevel analyses, meta-regressions and comparisons of bivariate summary receiver operating characteristics curves were undertaken.

RESULTS

Two hundred and forty manuscripts from 14 129 articles initially identified met the inclusion criteria. VI was better than RX on occlusal surfaces at all caries lesion thresholds and proximal surfaces of permanent teeth only at all lesion thresholds in laboratory setting. LF was slightly better than VI for advanced lesions on occlusal surfaces of permanent teeth in the clinical setting and for all lesions on proximal surfaces of permanent teeth in the laboratory setting. Still, LF was worse than VI for advanced occlusal lesions in permanent teeth in the laboratory setting. Although LF showed slightly better performance than VI with advanced lesions, the latter had significantly higher specificity than other methods in all settings.

CONCLUSION

Visual caries detection alone is adequate for most patients in daily clinical practice regardless of tooth type or surface.

Imaging modalities to inform the detection and diagnosis of early caries

BACKGROUND

The detection and diagnosis of caries at the earliest opportunity is fundamental to the preservation of tooth tissue and maintenance of oral health. Radiographs have traditionally been used to supplement the conventional visual-tactile clinical examination. Accurate, timely detection and diagnosis of early signs of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol-generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.

OBJECTIVES

To determine the diagnostic accuracy of different dental imaging methods to inform the detection and diagnosis of non-cavitated enamel only coronal dental caries.

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared a dental imaging method with a reference standard (histology, excavation, enhanced visual examination), studies that evaluated the diagnostic accuracy of single index tests, and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were eligible for inclusion. Studies that explicitly recruited participants with more advanced lesions that were obviously into dentine or frankly cavitated were excluded. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently and in duplicate using a standardised data extraction form and quality assessment based on QUADAS-2 specific to the clinical context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence regions. Comparative accuracy of different radiograph methods was conducted based on indirect and direct comparisons between methods. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

MAIN RESULTS

We included 104 datasets from 77 studies reporting a total of 15,518 tooth sites or surfaces. The most frequently reported imaging methods were analogue radiographs (55 datasets from 51 studies) and digital radiographs (42 datasets from 40 studies) followed by cone beam computed tomography (CBCT) (7 datasets from 7 studies). Only 17 studies were of an in vivo study design, carried out in a clinical setting. No studies were considered to be at low risk of bias across all four domains but 16 studies were judged to have low concern for applicability across all domains. The patient selection domain had the largest number of studies judged to be at high risk of bias (43 studies); the index test, reference standard, and flow and timing domains were judged to be at high risk of bias in 30, 12, and 7 studies respectively. Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies, with sensitivities that ranged from 0 to 0.96 and specificities from 0 to 1.00. For all imaging methods the estimated summary sensitivity and specificity point was 0.47 (95% confidence interval (CI) 0.40 to 0.53) and 0.88 (95% CI 0.84 to 0.92), respectively. In a cohort of 1000 tooth surfaces with a prevalence of enamel caries of 63%, this would result in 337 tooth surfaces being classified as disease free when enamel caries was truly present (false negatives), and 43 tooth surfaces being classified as diseased in the absence of enamel caries (false positives). Meta-regression indicated that measures of accuracy differed according to the imaging method (Chi2(4) = 32.44, P < 0.001), with the highest sensitivity observed for CBCT, and the highest specificity observed for analogue radiographs. None of the specified potential sources of heterogeneity were able to explain the variability in results. No studies included restored teeth in their sample or reported the inclusion of sealants. We rated the certainty of the evidence as low for sensitivity and specificity and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and the observed inconsistency of the results.

AUTHORS' CONCLUSIONS

The design and conduct of studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Low-certainty evidence suggests that imaging for the detection or diagnosis of early caries may have poor sensitivity but acceptable specificity, resulting in a relatively high number of false-negative results with the potential for early disease to progress. If left untreated, the opportunity to provide professional or self-care practices to arrest or reverse early caries lesions will be missed. The specificity of lesion detection is however relatively high, and one could argue that initiation of non-invasive management (such as the use of topical fluoride), is probably of low risk. CBCT showed superior sensitivity to analogue or digital radiographs but has very limited applicability to the general dental practitioner. However, given the high-radiation dose, and potential for caries-like artefacts from existing restorations, its use cannot be justified in routine caries detection. Nonetheless, if early incidental carious lesions are detected in CBCT scans taken for other purposes, these should be reported. CBCT has the potential to be used as a reference standard in diagnostic studies of this type. Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Future research should evaluate the comparative accuracy of different methods, be undertaken in a clinical setting, and focus on minimising bias arising from the use of imperfect reference standards in clinical studies.

Fluorescence devices for the detection of dental caries

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Accurate Detection of Non-Cavitated Proximal Caries in Posterior Permanent Teeth: An in vivo Study

Purpose

This study aimed to compare the sensitivity and specificity of DIAGNOdent versus bitewing radiographs in detecting non-cavitated proximal caries.

Patients and Methods

This observational prospective study included 120 proximal surfaces, without obvious cavitation, on permanent mandibular and maxillary posterior teeth in patients over 16 years old. The DIAGNOdent test was performed, and digital bitewing radiographs were obtained; these were compared with a standard reference method, which comprised a clinical assessment of the proximal surfaces following the application of an orthodontic separator between the teeth for 7 days. Each test was performed by a different investigator blinded to the assessment results of the other examiners.

Results

The DIAGNOdent device exhibited a higher sensitivity in detecting enamel proximal caries (95%) than digital bitewing radiographs (64%), and the specificity of DIAGNOdent (89%) was greater than that of bitewing radiographs (77%). Regarding the detection of dentin caries, the sensitivities of DIAGNOdent and bitewing radiographs were similar (both 62%); however, the specificity of DIAGNOdent was higher (98% versus 88%). The results of the Kruskal–Wallis test revealed a significant difference in DIAGNOdent scores across the three diagnoses (sound tooth surfaces, enamel caries, dentin caries) (p-value <0.001).

Conclusion

The diagnostic accuracy of DIAGNOdent in detecting enamel caries is significantly higher than that of digital bitewing radiography. The routine use of DIAGNOdent can facilitate an accurate diagnosis of early carious lesions and inform the implementation of preventive treatment.

In vivo performance of near-infrared light transillumination for dentine proximal caries detection in permanent teeth

Objective

The purpose of this in vivo study was to confirm the detection of proximal caries using near-infrared light transillumination (NILTI) (DIAGNOcam) device, and to compare the diagnostic performance of the device with other caries detection methods, including visual examination using the International Caries Detection and Assessment System (ICDAS), bitewing radiography (BW), an LED-based device (Midwest Caries I.D.), and a laser fluorescence device (LFpen).

Methods

A total of 974 proximal surface of permanent posterior teeth from 34 patients (19 females and 15 males between the ages of 22–55) were evaluated in the present study. After clinical examination of each proximal surface by an experienced examiner, they were coded according to the ICDAS criteria and subsequently with BW, the NILTI, LED, and LFpen. The proximal dentin caries of 106 were opened based on the combination of visual, NILTI and radiographic assessment and validated; and were treated with restorative materials. The data were analyzed with descriptive statistics and calculation of the sensitivity, specificity, and area under curve (AUC).

Results

The highest sensitivity values were recorded from NILTI readings (99.1%), followed by BW scores (86.8%). The highest specificity values were recorded from ICDAS (100%). The best AUC values were found from the NILTI readings (0.97), followed by BW (0.93) and ICDAS (0.87).

Conclusion

The NILTI device exhibited the best performance in terms of detecting proximal dentin caries.

Clinical performance of clinical-visual examination, digital bitewing radiography, laser fluorescence, and near-infrared light transillumination for detection of non-cavitated proximal enamel and dentin caries

The aim of this study was to compare the clinical performance of clinical-visual examination using the International Caries Detection and Assessment System (ICDAS) II, digital bitewing radiography, near-infrared light transillumination (NIR-LT), and laser fluorescence (LF) for the detection of non-cavitated proximal enamel and dentin caries. The study included 335 patients, aged 12-18 years, with no cavities in the posterior teeth. Clinical-visual inspections of 335 non-cavitated proximal caries were performed by two examiners. For enamel caries, clinical validation included a combination of clinical-visual and digital bitewing radiography assessments. For dentin caries, the clinical validation was opening the cavity. The accuracy rate, sensitivity, specificity, predictive values, and areas under receiver operating characteristic curves were determined. The agreement between the examiners' measurements was calculated using the kappa coefficient. The sensitivity, specificity, and accuracy of the methods were compared using the McNemar test. The significance level was set at p < 0.05. Digital bitewing radiography had the highest sensitivity (0.96) and accuracy (0.96), and LF had the lowest sensitivity (0.38) and accuracy (0.39). After separation of the lesions into enamel and dentin caries, clinical-visual examination had the highest sensitivity (0.98) and accuracy (0.98) for enamel caries, while digital bitewing radiography had the highest sensitivity (0.97) and accuracy (0.97) for dentin caries. The NIR-LT method had a higher sensitivity for enamel caries (0.86). Each method also differed significantly from the others (p < 0.001). Digital bitewing radiography gave the best prediction of proximal enamel and dentin caries. NIR-LT showed good potential for detection of proximal caries.

Assessment of the Depth of Clinically Detected Approximal Caries Lesions Using Digital Imaging Fiber-Optic Transillumination in Comparison to Periapical Radiographs

Objectives

The aim of present prospective clinical trial was to assess the depth of clinically detected approximal caries lesions using digital imaging fiber-optic transillumination in comparison to periapical radiographs.

Material and Methods

One calibrated examiner diagnosed 31 approximal carious lesions in 10 patients with a mean age of 21.8 (SD 1.1) years. The lesions were assessed using digital imaging fiber-optic transillumination (DIFOTI) and digital periapical radiographs (PA). Depending on the depth of the lesions, scores for demineralisation in PA (R) and DIFOTI (F) images were given by two examiners: R0/F0 - no demineralisation, R1/F1 - demineralisation confined to the outer half of the enamel, R2/F2 - into the inner half of the enamel, 3/3 - along the amelodentinal junction, R3/F3 - into the outer half of dentine, R4/F4 - into the inner part of the dentine. Spearman's rank correlation coefficient and kappa were calculated.

Results

Spearman's rank correlation coefficient between DIFOTI and PA was 0.031 (P > 0.05), kappa was 0.077. In 26% of the cases, DIFOTI showed higher scores of demineralisation, relative to PA. In 36% of the cases, PA showed higher scores of demineralisation than DIFOTI. PA showed demineralisation into the outer and inner half of the dentine in 89% of the cases with underlying shadow and in 70% of the cases with opacities.

Conclusions

Digital imaging fibre optic transillumination and periapical radiographs produce evaluations of the depth of approximal caries lesions that do not match.

In vivo validity of proximal caries detection in primary teeth, with histological validation

BACKGROUND

Detection and diagnosis of proximal caries in primary molars are challenging.

AIM

The aim of this in vivo study was to assess the validity and reproducibility of four methods of proximal caries detection in primary molar teeth.

DESIGN

Eighty-two children (5-10 years) were recruited. Initially, 1030 proximal surfaces were examined using meticulous visual examination (ICDAS) (VE1), bitewing radiographs (RE), and a laser fluorescence pen device (LF1). Temporary tooth separation (TTS) was achieved for 447 surfaces, and these were re-examined visually (VE2) and using the LF pen (LF2). Three hundred and fifty-six teeth (542 surfaces) were subsequently extracted and provided histological validation.

RESULTS

At D₁ (enamel and dentine caries) diagnostic threshold, the sensitivity of VE1, RE, VE2, LF1, and LF2 examination was 0.52, 0.14, 0.75, 0.58, and 0.60 and the specificity values were 0.89, 0.97, 0.88, 0.85, and 0.77, respectively. At D₃ (dentine caries) threshold, the sensitivity values were 0.42, 0.71, 0.49, 0.63, and 0.65, respectively, whereas specificity was 0.93 for VE1 and VE2, and 0.98, 0.87, and 0.88 for RE, LF1, and LF2 examinations, respectively. ROC analysis showed radiographic examination to be superior at D₃ .

CONCLUSION

Meticulous caries diagnosis (ICDAS) should be supported by radiographs for detection of dentinal proximal caries in primary molars.

Detection of proximal caries using quantitative light-induced fluorescence-digital and laser fluorescence: a comparative study

PURPOSE

The purpose of this study was to evaluate the in vitro validity of quantitative light-induced fluorescence-digital (QLF-D) and laser fluorescence (DIAGNOdent) for assessing proximal caries in extracted premolars, using digital radiography as reference method.

MATERIALS AND METHODS

A total of 102 extracted premolars with similar lengths and shapes were used. A single operator conducted all the examinations using three different detection methods (bitewing radiography, QLF-D, and DIAGNOdent). The bitewing x-ray scale, QLF-D fluorescence loss (ΔF), and DIAGNOdent peak readings were compared and statistically analyzed.

RESULTS

Each method showed an excellent reliability. The correlation coefficient between bitewing radiography and QLF-D, DIAGNOdent were -0.644 and 0.448, respectively, while the value between QLF-D and DIAGNOdent was -0.382. The kappa statistics for bitewing radiography and QLF-D had a higher diagnosis consensus than those for bitewing radiography and DIAGNOdent. The QLF-D was moderately to highly accurate (AUC = 0.753 - 0.908), while DIAGNOdent was moderately to less accurate (AUC = 0.622 - 0.784). All detection methods showed statistically significant correlation and high correlation between the bitewing radiography and QLF-D.

CONCLUSION

QLF-D was found to be a valid and reliable alternative diagnostic method to digital bitewing radiography for in vitro detection of proximal caries.

In Vitro Comparison of Diagnostic Accuracy of DIAGNOdent and Digital Radiography for Detection of Secondary Proximal Caries Adjacent to Composite Restorations

Introduction: Early detection of secondary proximal caries is critical for the preservation of tooth vitality. This study sought to assess and compare the diagnostic accuracy of DIAGNOdent and digital radiography for detection of secondary proximal caries adjacent to composite restorations. Methods: Sixty extracted molars including 30 teeth with carious lesions and 30 sound teeth were randomly selected. Class II cavities were prepared in all teeth and carious dentin was intentionally left in the gingival floor of cavities in 30 carious teeth. All cavities were restored with composite resin. The teeth were mounted in wax blocks (three teeth per block) and examined for caries using (DIAGNOdent kaVo Dental, Biberach, Germany). Digital radiographs using DIGORA photostimulable phosphor (PSP) plates (Soredex Corporation, Helsinki, Finland) were obtained from all teeth using the parallel technique and were evaluated by 4 observers. Repeated measure analysis of variance (ANOVA) was applied to calculate sensitivity and specificity values of the two diagnostic techniques. Receiver operating characteristic (ROC) curve was plotted for DIAGNOdent results and based on that, the cutoff points were determined. Results: The sensitivity and specificity values at the cut-off point of 10.5 were 0.622±0.038 and 0.822±0.077 for DIAGNOdent and 0.591±0.093 and 0.891±0.083 for digital radiography, respectively. The area under the ROC curve was 0.7 for DIAGNOdent. Weighted kappa revealed moderate to almost perfect intra-observer agreement (0.46-0.99). Intraclass correlation coefficient (ICC) for DIAGNOdent was calculated to be 0.88. Conclusion: No statistically significant difference was noted in diagnostic accuracy of DIAGNOdent and digital radiography for detection of secondary proximal caries adjacent to composite restorations. Thus, DIAGNOdent may be used as an adjunct diagnostic tool for detection of secondary proximal caries beneath composite restorations.

Violet and blue light-induced green fluorescence emissions from dental caries

BACKGROUND

The objective of this laboratory study was to compare violet and visible blue LED light-elicited green fluorescence emissions from enamel and dentine in healthy or carious states.

METHODS

Microscopic digital photography was undertaken using violet and blue LED illumination (405 nm and 455 nm wavelengths) of tooth surfaces, which were photographed through a custom-made stack of green compensating filters which removed the excitation light and allowed green fluorescence emissions to pass. Green channel pixel data were analysed.

RESULTS

Dry sound enamel and sound root surfaces showed strong green fluorescence when excited by violet or blue lights. Regions of cavitated dental caries gave lower green fluorescence, and this was similar whether the dentine in the lesions was the same colour as normal dentine or was darkly coloured. The presence of saliva on the surface did not significantly change the green fluorescence, while the presence of blood diluted in saliva depressed green fluorescence.

CONCLUSIONS

Using violet or blue illumination in combination with green compensating filters could potentially aid in the assessment of areas of mineral loss.

Clinical evaluation of near-infrared light transillumination in approximal dentin caries detection

The objective of this clinical study was to compare conventional caries detection techniques, pen-type laser fluorescence device, and near-infrared light transillumination method in approximal dentin caries lesions. The study included 157 patients, aged 12-18, without any cavity in the posterior teeth. Two calibrated examiners carried out the assessments of selected approximal caries sites independently. After the assessments, the unopened sites were excluded and a total of 161 approximal sites were included in the study. When both the examiners arrived at a consensus regarding the presence of dentin caries, the detected lesions were opened with a conical diamond burr, the cavity extent was examined and validated (gold standard). Sensitivity, specificity, negative predictive value, positive predictive value, accuracy, and area under the ROC curve (Az) values among the caries detection methods were calculated. Bitewing radiography and near-infrared (NIR) light transillumination methods showed the highest sensitivity (0.83-0.82) and accuracy (0.82-0.80) among the methods. Visual inspection showed the lowest sensitivity (0.54). Laser fluorescence device and visual inspection showed nearly equal performance. Near-infrared light transillumination can be used as an alternative method to approximal dentin caries detection. Visual inspection and laser fluorescence device alone should not be used for approximal dentin caries.

Association between quantitative measures obtained using fluorescence-based methods and activity status of occlusal caries lesions in primary molars

BACKGROUND

Fluorescence-based methods (FBM) can add objectiveness to diagnosis strategy for caries. Few studies, however, have focused on the evaluation of caries activity.

AIM

To evaluate the association between quantitative measures obtained with FBM, clinical parameters acquired from the patients, caries detection, and assessment of activity status in occlusal surfaces of primary molars.

DESIGN

Six hundred and six teeth from 113 children (4-14 years) were evaluated. The presence of a biofilm, caries experience, and the number of active lesions were recorded. The teeth were assessed using FBM: DIAGNOdent pen (Lfpen) and Quantitative light-induced fluorescence (QLF). As reference standard, all teeth were evaluated using the ICDAS (International Caries Detection and Assessment System) associated with clinical activity assessments. Multilevel regressions compared the FBM values and evaluated the association between the FBM measures and clinical variables related to the caries activity.

RESULTS

The measures from the FBM were higher in cavitated lesions. Only, ∆F values distinguished active and inactive lesions. The LFpen measures were higher in active lesions, at the cavitated threshold (56.95 ± 29.60). Following regression analyses, only the presence of visible biofilm on occlusal surfaces (adjusted prevalence ratio = 1.43) and ∆R values of the teeth (adjusted prevalence ratio = 1.02) were associated with caries activity.

CONCLUSION

Some quantitative measures from FBM parameters are associated with caries activity evaluation, which is similar to the clinical evaluation of the presence of visible biofilm.

The diagnostic accuracy of a laser fluorescence device and digital radiography in detecting approximal caries lesions in posterior permanent teeth: an in vivo study

The aim of this in vivo study was to test the diagnostic accuracy of a pen-type laser fluorescence (LFpen) device in detecting approximal caries lesions, in posterior permanent teeth, at the cavitation and non-cavitation thresholds, and compare it with that of digital bitewing radiography. Thirty patients (aged 18-37), who attended the Faculty of Dentistry at Damascus University for a dental examination, were consecutively screened. Ninety approximal surfaces of posterior permanent teeth without frank cavitations, enamel hypoplasia or restorations were selected and examined using the LFpen (DIAGNOdent pen) and digital bitewing radiography. The reference standard was the visual-tactile inspection, after performing temporary tooth separation, using orthodontic rubber rings, placed for 7 days. The status of included approximal surfaces was recorded as intact/sound, with white/brown spots or cavitated. One trained examiner performed all examinations. There were statistically significant differences in LFpen readings between the three types of approximal surface status (P < 0.001). The optimal cut-off values for detecting approximal caries lesions in posterior permanent teeth were >16 and 8 at the cavitation and non-cavitation thresholds respectively. The sensitivity, specificity and accuracy (measured by the area under the receiver-operating characteristic curve) were 100, 85 and 95 and 92, 90 and 95% at the cavitation and non-cavitation thresholds respectively. The intra-class correlation coefficient for intra-examiner reliability was 0.95. The diagnostic accuracy of the LFpen was significantly higher than that of digital bitewing radiography (P < 0.001). The LFpen's diagnostic performance was accurate and significantly better than digital bitewing radiography in detecting approximal caries lesions, in posterior permanent teeth.

Control of White Spot Lesions with Use of Fluoride Varnish or Chlorhexidine Gel During Orthodontic Treatment A Randomized Clinical Trial

OBJECTIVE

To compare the effectiveness of fluoride varnish and 2% chlorhexidine gel for controlling active white spot lesions (WSLs) adjacent to orthodontic brackets.

STUDY DESIGN

Thirty-five orthodontic patients (17.2 ± 2.3 years old) presenting 60 WSLs adjacent to orthodontic brackets were enrolled in this randomized, blind, 3-armed and controlled clinical trial. The patients were randomly allocated to 1 of 3 arms: (1) two applications of 5% NaF varnish- F, with one-week interval, (2) two applications of 2% chlorhexidine gel-CHX, with one-week interval and (3) usual home care-control (CO). The WSLs were scored by using a DIAGNOdent pen. An independent examiner scored the surfaces using Nyvad criteria for caries assessment.

RESULTS

A total of thirty patients presenting 51 lesions completed the study. All treatments reduced the fluorescence values during the experimental period; however, F induced faster remineralization than CHX. After 3 months, 70.58 % were inactive considering all groups. DIAGNOdent pen and Nyvad presented a significant correlation.

CONCLUSION

After 3 months of treatment, F, CHX and CO were capable of controlling the WSLs adjacent to the orthodontic brackets. However, the treatment with F was capable of controlling the progression of the WSLs in a shorter period of time.

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.

Evaluation of different Diagnostic Modalities for Diagnosis of Dental Caries: An in vivo Study

AIM

The aim of this study was to compare and evaluate the efficacy of different diagnostic aids for diagnosis of dental caries and to compare the validity in terms of sensitivity and specificity of all four diagnostic modalities for diagnosis of caries.

MATERIALS AND METHODS

Occlusal surfaces of 100 primary and permanent molars were examined using the four diagnostic systems (visual, intraoral camera, DIAGNOdent, and DIAGNOdent with dye). These results were compared with operative intervention gold standard. Sensitivity and specificity were calculated for each diagnostic system for both enamel and dentin caries. Interrater agreement was calculated for each diagnostic system using kappa statistics.

RESULTS

For both enamel and dentin caries, the highest sensitivity values were provided by DIAGNOdent (0.91 and 0.72) and lowest for visual examination on wet surface (0.60 and 0.50). For both enamel and dentin caries, the specificity was found to be highest for intraoral camera on dry surface and lowest for visual examination. The DIAGNOdent gave the highest value of interrater agreement (kappa), i.e., 0.816 as compared with 0.03 for visual examination.

CONCLUSION

The study clearly demonstrated that DIAGNO-dent was the most accurate and valid system tested for the detection of occlusal caries. It has the advantage of quantifying the mineral content, helping to improve the diagnostic efficacy and treatment and accurate assessment of fissures where the visual examination alone is not adequate, thus complementing the traditional dental examination.

HOW TO CITE THIS ARTICLE

Zaidi I, Somani R, Jaidka S, Nishad M, Singh S, Tomar D. Evaluation of different Diagnostic Modalities for Diagnosis of Dental Caries: An in vivo Study. Int J Clin Pediatr Dent 2016;9(4):320-325.

Comparison of different caries detectors for approximal caries detection

Background/purpose

Detection of approximal caries may be difficult using conventional methods including visual inspection (VI) and radiography. The purpose of this in vitro research was to evaluate the efficiency of light-emitting diode (LED) and laser fluorescence (LF) devices, and radiographic and visual examination in approximal caries diagnosis.

Materials and methods

One hundred and fifty-six approximal regions were evaluated. All approximal regions were investigated using LED and LF tools after radiography and VI were performed. Histological evaluation of teeth was performed using stereomicroscopy. The area under the receiver operating characteristic curve and accuracy, specificity, sensitivity values calculated regarding approximal caries diagnose.

Results

The specificity of the bitewing examination was higher for both T1 and T2 thresholds (0.97 and 0.99, respectively), and the LF device showed better sensitivity at each threshold compared with the other devices used for caries diagnosis (0.94 at T1 and 0.79 at T2). The receiver operating characteristic curves presented that the LF device was more successful than the other techniques at T1 threshold and VI was better than the other caries detection methods at T2 threshold. The kappa values for interobserver agreements were 0.43 (LF pen), 0.33 (LED device), 0.55 (VI), and 0.75 (bitewing examination).

Conclusion

The ability of bitewing radiography to identify sound surfaces was better than that of the other methods. The LF device was the most sensitive tool for detecting approximal surfaces with caries, followed by the LED device.

Effect of Different Contact Materials on Approximal Caries Detection by Laser Fluorescence and Light-Emitting Diode Devices

OBJECTIVE

The aim of this in vitro study was to investigate the influence of the adjacent tooth surface on pen type laser fluorescence (LFpen) and light-emitting diode (LED) device readings in detecting approximal caries lesions in permanent teeth.

BACKGROUND DATA

Early detection of noncavitated dental caries is important, because disease progression can be easily halted at this stage with certain applications, such as fluoride therapy, antibacterial therapy, dietary changes, or low-intensity laser irradiation.

MATERIALS AND METHODS

A total of 87 permanent molars with 156 approximal surfaces were assessed with LED- and LF-based devices in contact with sound tooth surfaces (the control group) as well as approximal amalgam, composite, zirconia, and full ceramic restorations. All teeth were assessed once by one trained examiner. After the LF and LED assessments, the teeth were histologically evaluated using stereomicroscopy as the gold standard. The sensitivity, specificity, accuracy, and area under the receiver operating characteristics (ROC) curve were calculated according to the appropriate thresholds (T1, sound surface or enamel caries; T2, dentin caries).

RESULTS

For the LFpen device, higher sensitivity and accuracy was found when the adjacent surface was sound at the T1 threshold and no significant differences were found among accuracy at the T2 threshold. For the LED-based device, no significant differences were found among sensitivities at the T1 threshold. At the T2 threshold, specificity was higher when the adjacent tooth had a zirconia restoration.

CONCLUSIONS

It was found that both devices could be used effectively for evaluating approximal surfaces with adjacent restored teeth, regardless of the different kinds of restorative materials.

Detection of Caries Around Amalgam Restorations on Approximal Surfaces

To evaluate the in vitro performance of the International Caries Detection and Assessment System (ICDAS) visual examination, bitewing radiography (BW), and the DIAGNOdent 2190, a pen-type laser fluorescence device (LFpen), in detecting caries around amalgam restorations on approximal surfaces. Approximal surfaces (N=136) of permanent posterior teeth (N=110) with Class II amalgam restorations were assessed twice by two experienced examiners using ICDAS, BW, and LFpen. The occurrence of proximal overhangs was also evaluated. The teeth were histologically prepared and assessed for caries extension. Different cutoff limits for the LFpen were used. Intraexaminer and interexaminer reproducibility showed moderate to good agreement for all the methods (weighted κ/intraclass correlation coefficient=0.40 to 0.87). The specificities at D1 (all visible lesions affecting enamel) and D3 (lesions extended into dentin) were, respectively, 0.41 and 0.82 for ICDAS, 0.70 and 0.82 for BW, and 0.77-0.89 and 0.88-0.94 for LFpen. The sensitivities were 0.80 and 0.52 for ICDAS, 0.56 and 0.51 for BW, and 0.04-0.23 and 0.01-0.02 for LFpen at D1 and D3, respectively. At the D1/D3 thresholds, the accuracy and the area under the receiver operating characteristic curve (Az) values were similar and statistically higher for ICDAS (0.65/0.68 and 0.633/0.688) and BW (0.64/0.68 and 0.655/0.719), respectively; whereas, LFpen presented lower accuracy (0.37-0.44/0.49-0.52) and Az (0.390-0.454/0.345-0.395) values. The occurrence of overhangs (26.8%) was shown to be irrelevant in determining the presence of secondary caries. The ICDAS and BW methods presented the best performance in detecting caries lesions affecting enamel and dentin on approximal surfaces of amalgam restorations.

Evaluation of caries in deciduous second molar and adjacent permanent molar in mixed dentition

AIM

This study was done to evaluate association of caries in deciduous second molar and adjacent permanent first molar, tooth surface more involved in permanent first molar and to assess the parental awareness regarding the eruption of permanent first molar.

SUBJECTS AND METHODS

Three hundred and ten children (160 boys, 150 girls) of mixed dentition aged between 6 and 11 years were included. Presence or absence of paired association of caries in primary second molar and adjacent permanent first molar, of both the jaws, were noted. Parental awareness regarding the child's dentition was asked by pointing the maxillary and mandibular permanent first molar.

RESULTS

Pearson Chi-square test was used. Significance was noted in both sexes between paired nonassociation of caries in mandibular primary second molar and mandibular permanent molar (P =0.01) and paired nonassociation of caries in primary maxillary second molar and maxillary permanent first molar in girls only (P =0.04). Parental awareness that permanent first molar has erupted was 24.83% and not to be exfoliated and replaced was 22.9% for both the sexes. In permanent teeth of both the sexes, the occlusal surface was more involved with caries in maxillary teeth; the buccal surface was more involved in mandibular teeth. About 10% of the sample did not have caries in both maxillary and mandibular permanent first molar.

CONCLUSIONS

Paired association of caries of primary second molar and permanent first molar though found in large number of cases was not significant. It is clear that parental awareness is less regarding the child's oral health. Thus, community-based awareness program has to be conducted to emphasize on pediatric oral health status and care.

Influence of contact points on the performance of caries detection methods in approximal surfaces of primary molars: an in vivo study

This in vivo study aimed to evaluate the influence of contact points on the approximal caries detection in primary molars, by comparing the performance of the DIAGNOdent pen and visual-tactile examination after tooth separation to bitewing radiography (BW). A total of 112 children were examined and 33 children were selected. In three periods (a, b, and c), 209 approximal surfaces were examined: (a) examiner 1 performed visual-tactile examination using the Nyvad criteria (EX1); examiner 2 used DIAGNOdent pen (LF1) and took BW; (b) 1 week later, after tooth separation, examiner 1 performed the second visual-tactile examination (EX2) and examiner 2 used DIAGNOdent again (LF2); (c) after tooth exfoliation, surfaces were directly examined using DIAGNOdent (LF3). Teeth were examined by computed microtomography as a reference standard. Analyses were based on diagnostic thresholds: D1: D 0 = health, D 1 –D 4 = disease; D2: D 0 , D 1 = health, D 2 –D 4 = disease; D3: D 0 –D 2 = health, D 3 , D 4 = disease. At D1, the highest sensitivity/specificity were observed for EX1 (1.00)/LF3 (0.68), respectively. At D2, the highest sensitivity/ specificity were observed for LF3 (0.69)/BW (1.00), respectively. At D3, the highest sensitivity/specificity were observed for LF3 (0.78)/EX1, EX2 and BW (1.00). EX1 showed higher accuracy values than LF1, and EX2 showed similar values to LF2. We concluded that the visual-tactile examination showed better results in detecting sound surfaces and approximal caries lesions without tooth separation. However, the effectiveness of approximal caries lesion detection of both methods was increased by the absence of contact points. Therefore, regardless of the method of detection, orthodontic separating elastics should be used as a complementary tool for the diagnosis of approximal noncavitated lesions in primary molars.

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.

Fluorescence-based methods for detecting caries lesions: systematic review, meta-analysis and sources of heterogeneity

BACKGROUND

Fluorescence-based methods have been proposed to aid caries lesion detection. Summarizing and analysing findings of studies about fluorescence-based methods could clarify their real benefits.

OBJECTIVE

We aimed to perform a comprehensive systematic review and meta-analysis to evaluate the accuracy of fluorescence-based methods in detecting caries lesions.

DATA SOURCE

Two independent reviewers searched PubMed, Embase and Scopus through June 2012 to identify papers/articles published. Other sources were checked to identify non-published literature. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND DIAGNOSTIC METHODS: The eligibility criteria were studies that: (1) have assessed the accuracy of fluorescence-based methods of detecting caries lesions on occlusal, approximal or smooth surfaces, in both primary or permanent human teeth, in the laboratory or clinical setting; (2) have used a reference standard; and (3) have reported sufficient data relating to the sample size and the accuracy of methods.

STUDY APPRAISAL AND SYNTHESIS METHODS

A diagnostic 2×2 table was extracted from included studies to calculate the pooled sensitivity, specificity and overall accuracy parameters (Diagnostic Odds Ratio and Summary Receiver-Operating curve). The analyses were performed separately for each method and different characteristics of the studies. The quality of the studies and heterogeneity were also evaluated.

RESULTS

Seventy five studies met the inclusion criteria from the 434 articles initially identified. The search of the grey or non-published literature did not identify any further studies. In general, the analysis demonstrated that the fluorescence-based method tend to have similar accuracy for all types of teeth, dental surfaces or settings. There was a trend of better performance of fluorescence methods in detecting more advanced caries lesions. We also observed moderate to high heterogeneity and evidenced publication bias.

CONCLUSIONS

Fluorescence-based devices have similar overall performance; however, better accuracy in detecting more advanced caries lesions has been observed.

Can the individual calibration be modified when laser fluorescence method is used for caries detection?

BACKGROUND

Individual calibration (IC) for caries detection methods based on fluorescence is time-consuming, especially for paediatric dentists, if the calibration has to be performed tooth-by-tooth. However, it is not clear how this calibration actually interfere in laser fluorescence (LF) readings.

AIM

This in vivo study was to verify the influence of different modes of IC on laser fluorescence (LF) readings.

DESIGN

Ninety six occlusal and 95 buccal surfaces of 1st permanent molars were examined using LF device after IC performed on control (no IC), the examined teeth, a permanent incisor, a 1st primary molar or a 2nd primary molar. All modes of IC were performed in the same child. Wilcoxon test and Bland-Altman analysis were used to compare the readings. Intraclass correlation coefficients (ICC) were calculated.

RESULTS

Laser fluorescence readings without prior calibration were higher than readings performed after any mode of IC and resulted in different values of ICC. After other IC modes, the LF readings were statistically similar.

CONCLUSION

The absence of IC influences LF readings and LF reproducibility, but different IC methods can be considered in clinical practice.

Performance of fluorescence-based and conventional methods of occlusal caries detection in primary molars - an in vitro study

AIM

This in vitro study aimed to test the performance of fluorescence-based methods in detecting occlusal caries lesions in primary molars compared to conventional methods.

DESIGN

Two examiners assessed 113 sites on 77 occlusal surfaces of primary molars using three fluorescence devices: DIAGNOdent (LF), DIAGNOdent pen (LFpen), and fluorescence camera (VistaProof-FC). Visual inspection (ICDAS) and radiographic methods were also evaluated. One examiner repeated the evaluations after one month. As reference standard method, the lesion depth was determined after sectioning and evaluation in stereomicroscope. The area under the ROC curve (Az), sensitivity, specificity, and accuracy of the methods were calculated at enamel (D1) and dentine caries (D3) lesions thresholds. The intra and interexaminer reproducibility were calculated using the intraclass correlation coefficient (ICC) and kappa statistics.

RESULTS

At D1, visual inspection presented higher sensitivities (0.97-0.99) but lower specificities (0.18-0.25). At D3, all the methods demonstrated similar performance (Az values around 0.90). Visual and radiographic methods showed a slightly higher specificity (values higher than 0.96) than the fluorescence based ones (values around 0.88). In general, all methods presented high reproducibility (ICC higher than 0.79).

CONCLUSIONS

Although fluorescence-based and conventional methods present similar performance in detecting occlusal caries lesions in primary teeth, visual inspection alone seems to be sufficient to be used in clinical practice.

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.

Children's discomfort in assessments using different methods for approximal caries detection

Because discomfort caused by different approximal caries detection methods can influence their performance, the assessment of this discomfort is important. Thus, this study aimed to evaluate the discomfort reported by children after the use of different diagnostic methods to detect approximal caries lesions in primary teeth: visual inspection, bitewing radiography, laser fluorescence (DIAGNOdent pen - LFpen) and temporary separation with orthodontic rubbers. Seventy-six children aged 4 to 12 years were examined using these methods. Their discomfort was assessed using the Wong-Baker scale and compared among the methods. Visual inspection caused less discomfort than did other methods. Radiography and the LFpen presented similar levels of discomfort. Older children reported higher discomfort using temporary separation, whereas younger children reported less discomfort with the LFpen. In conclusion, radiographic, temporary separation and LFpen methods provoke higher discomfort than visual inspection.

Detection of proximal secondary caries at cervical class II-amalgam restoration margins in vitro

OBJECTIVES

To compare the performance of LFpen (DIAGNOdent pen) with two different wedge-shaped tips to conventional bitewing radiography (BW) for detecting proximal secondary caries at the cervical margin of amalgam restorations in vitro.

METHODS

Seventy-five molars with class II amalgam restorations were selected. Depending on the marginal filling extension, data was subdivided into a crown group (C), when the filling ended in enamel, and into a root group (R), when the filling ended beyond the cementum-enamel junction. Bayesian analysis including calculation of the area under the receiver operating curve (AUC) was performed. Furthermore, Spearman correlations between caries and cofactors, such as presence of plaque or stain, occlusal ditching, marginal gap size, filling overhangs, and shortfalls, were calculated. Additionally, for group R the correlation coefficient between LFpen measurements and lesion depth was calculated. Histology served as gold standard.

RESULTS

In group C both at the D1 and D3 levels, LFpen with two different tips showed a better performance than bitewing radiography (AUC at D1: 0.83/0.79 (LFpen) and 0.63 (BW); at D3: 0.66/0.66 (LFpen) and 0.53 (BW)). In group R, the respective AUC values were 0.53/0.56 (LF) and 0.59 (BW). A significant medium correlation was observed for occlusal ditching and proximal caries. Stain accumulation at the restoration margins especially in combination with filling overhangs interfered with LFpen readings, resulting in false positive measurements.

CONCLUSIONS

Compared to BW, LFpen enhances the detection of secondary caries lesions at the cervical margin of amalgam restorations that do not extend below the cementum-enamel junction.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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