Digital transillumination in caries detection versus radiographic and clinical methods: an in-vivo study

Comparison of near-infrared imaging with cone-beam computed tomography for proximal caries detection in permanent dentition: An in vivo study

OBJECTIVES

This study aimed to evaluate the diagnostic performance of near-infrared imaging (NIRI) and unaided visual examination (UVE) in detecting proximal caries in permanent dentition in comparison with cone-beam computed tomography (CBCT).

METHODS

Patients who underwent NIRI, UVE, and CBCT imaging within 1 week were enrolled. Using CBCT as the reference test, the positive percent agreement (PPA), negative percent agreement (NPA), and overall percent agreement (OPA) of NIRI, UVE, and a combination of the two for detecting proximal caries at different depths and in different tooth locations were assessed. Additionally, the consistency of these diagnostic methods with CBCT was evaluated.

RESULTS

We evaluated 6,084 proximal surfaces and identified 177 CBCT-positive sites. NIRI had a PPA, NPA, and OPA of 68.93 %, 99.09 %, and 98.21 %, respectively, with a substantial agreement with CBCT. When combined with UVE, the PPA increased by approximately 50 % compared with that of UVE alone. Regarding caries at different depths, NIRI outperformed UVE in detecting initial caries (ICDAS 1-2) over moderate-to-advanced caries (ICDAS 3-6). However, the combined use of NIRI and UVE improved the detection of moderate-to-advanced caries. In the anterior teeth region, NIRI exhibited excellent agreement with CBCT, surpassing its performance in the posterior region.

CONCLUSIONS

Although NIRI cannot fully replace radiographic methods, the substantial agreement of NIRI with CBCT in detecting proximal caries highlights its potential as a complementary tool in routine caries screening, especially when combined with UVE.

CLINICAL SIGNIFICANCE

This study highlights the potential of NIRI as a radiation-free method for detecting proximal caries in permanent teeth. Early detection through regular NIRI scanning can lead to timely intervention, improved patient outcomes, and reduced overall disease burden.

Atlas of Dental Near-Infrared Transillumination Images

Technological improvements have introduced significant innovations in dentistry and broadened the array of tools and techniques in dental care. One technological development that has been widely researched over the past 20 years is the use of Near-Infrared Transillumination (NIRT) imaging for the diagnosis of dental caries. This paper aims to introduce a comprehensive collection of NIRT images, intended as a reference tool for routine dental examinations, dental research, pedagogical activities, and forensic odontology. The collection presents pairwise clinical and NIRT images categorized as follows: (a) healthy teeth, (b) carious teeth, (c) restored teeth, (d) enamel defects, and (e) diverse findings. This atlas could be a valuable tool for the dental community as it is designed as an identification guide of NIRT illustrated dental features.

Efficiency of Near-Infrared Technology in the Clinical Detection of Carious Lesions: A Systematic Review

The field of dentistry has seen various technological advances regarding caries detection, some lesions still prove to be difficult to detect. A reasonably new detection method, near-infrared (NIR), has shown good results in caries detection. This systematic review aims to compare NIR with conventional methods in terms of caries detection. Online databases (PubMed, Scopus, ScienceDirect, EBSCO, and ProQuest) were used for the literature search. The search was performed from January 2015 till December-2020. A total of 770 articles were selected, of that 17 articles qualified for the final analysis as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The articles were assessed according to a modified Critical Appraisal Skills Programme checklist, and then synthesis of the review started. The inclusion criteria were clinical trials done in vivo on teeth with active caries of vital or nonvital teeth. This review excluded nonpeer reviewed articles, case reports, case series, opinions, abstracts, non-English written articles, studies of subjects with arrested caries, or teeth with developmental defects of tooth structure and teeth having environmental defects of tooth structure, as well as in-vitro studies. The review compared near-infrared technology with radiography, visual inspection, and laser fluorescence in terms of caries detection, sensitivity, specificity, and accuracy. The sensitivity of NIR ranged from 99.1 to 29.1%. Studies showed that NIR exhibited higher sensitivity for occlusal enamel and dentin caries. The specificity of NIR ranged from 94.1 to 20.0%. In enamel and dentinal occlusal caries, NIR demonstrated lower specificity than that of radiograph. The specificity of NIR in early proximal caries was low. Accuracy was determined in 5 out of 17 studies where the values ranged from 97.1 to 29.1%. The accuracy of NIR was the highest for dentinal occlusal caries. NIR shows promising evidence as an adjunct in caries examination due to its high sensitivity and specificity; however, more studies are required to determine its full potential in different situations.

Caries detection and characterization in pediatric patients using iTero 5D near-infrared technology

INTRODUCTION

Near-infrared imaging (NIRI) has been proposed as an alternative to radiographs and uses nonionizing radiation in the near-infrared spectrum to differentially scatter light off tooth surfaces and generate images allowing interproximal caries detection. The new iTero 5D Element Scanner (Align Technology, Santa Clara, Calif) has integrated NIRI capture and viewing technology but has not been specifically studied in a pediatric population. Therefore, this study aimed to assess clinicians' abilities to detect and characterize caries in pediatric patients using this instrument.

METHODS

Bitewing (BW) radiographs and an intraoral scan were captured on 17 pediatric patients (344 surfaces were analyzed). Data were randomized and graded by 5 calibrated clinicians individually with 2 different rounds of grading.

RESULTS

The reliability of lesion characterization (ie, grade) among examiners was poor to fair in both systems, whereas the reliability of caries detection was moderate. Both systems had a high specificity and low sensitivity. The reliability of the characterization of the combined dataset was moderate to substantial, whereas, for detection, it was substantial.

CONCLUSIONS

When using either BW or NIRI analysis, reliability is relatively poor, and clinicians are more likely to correctly identify a healthy tooth surface when compared with a carious surface. There is a small difference in error rate between BW and NIRI systems that is not likely to be clinically significant. When NIRI and BW data are combined, clinician agreement for both lesion characterization and detection increases significantly.

Detection, Diagnosis, and Monitoring of Early Caries: The Future of Individualized Dental Care

Dental caries remains a significant global health issue. It was highlighted by the World Health Organization's 2022 reports that despite the efforts and scientific advancements in caries detection and management, the situation has only marginally improved over the past three decades. The persistence of this problem may be linked to outdated concepts developed almost a century ago but are still guiding dentists' approach to caries management today. There is a need to reconsider professional strategies for preventing and managing the disease. Contemporary dentistry could benefit from embracing new concepts and technologies for caries detection and management. Dentists should explore, among others, alternative methods for caries detection such as optical-based caries detection. These tools have been established for over a decade and they align with current disease understanding and international recommendations, emphasizing early detection and minimally invasive management. This narrative review presents the current state of knowledge and recent trends in caries detection, diagnosis, monitoring, and management, offering insights into future perspectives for clinical applications and research topics.

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.

Accuracy of high definition near infrared transillumination camera in detection of hidden proximal caries

Background

Early caries detection became mandatory in modern dentistry. However, the traditional methods in caries detection had many limitations. Hence,a novel approach based on Near Infrared technology was introduced to overcome such limitations.

Material and Methods

Proximal surfaces of 102 posterior teeth from 36 adult participants who fulfilled the eligibility criteria were assessed by two examiners using three diagnostic methods. Teeth were examined visually according to the criteria of the International Caries Detection and Assessment System (ICDAS-II) then examined by bitewing digital radiograph (BW) and near infrared light transillumination (NIRT) camera (Vista Proxi iX HD smart). Inter and intra observer agreements were assessed using Kappa test.Dignostic accuracy parameters and Area Under the ROC curve (AUROC) with 95% confidence interval (95% CI) were evaluated for the different caries assessment methods.

Results

The results of inter-observer agreement showed an excellent agreement in the different groups. There was a statistically significant difference in the score distribution between ICDASII and VistaCam modalities (P-value <0.05). While there was no statistically significant difference in the score distribution between bitewing radiography and VistaCam modalities (P-value >0.05). ROC curve analysis revealed that VistaCam when compared with ICDASII had sensitivity (99.0%), specificity (50.0 %), diagnostic accuracy (98.0%) and Area under the ROC curve (AUC) was 0.745 with 95% Confidence Interval (0.649 - 0.826).When VistaCam compared with bitewing radiography, it showed sensitivity (100.0%); specificity (40.0%), diagnostic accuracy (97.1%) and AUC (0.700) with 95% confidence interval (0.601 - 0.787).

Conclusions

NIRT based diagnostic modality is a promising method for detection of hidden proximal lesions overcoming the hazards of radiograph. Key words:Bitewing radiography , ICDAS II , Near-infrared transillumination, proximal caries, VistaCam® iX Proxi.

Near-Infrared Transillumination for Occlusal Carious Lesion Detection: A Retrospective Reliability Study

The aim of this study was to assess the reliability of three diagnostic methods (near-infrared transillumination (NIRT), bitewing radiographs (BW), and clinical images (CI)) to detect occlusal carious lesions in a low caries risk population. This retrospective analysis included one hundred and eighty-eight occlusal surfaces, scored as sound surface, early lesion, or distinct lesion. We evaluated the agreement between and within the methods over time. Kappa statistics tested the correlation between the methods. Examiners detected occlusal early lesions more frequently with visual examination and NIRT and the same lesions were confirmed on the 2-year follow-up. Within the limitations of this study, we were able to establish that early occlusal lesions can be detected and monitored over time using NIRT and visual exam, while BW scores showed mostly sound surfaces at both examinations. NIRT combined with clinical examination can be considered appropriate to detect and monitor early enamel caries on the occlusal surface in low caries-risk populations.

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.

Clinical Analysis of the Diagnostic Accuracy and Time of Execution of a Transillumination Caries Detection Method Compared to Bitewing Radiographs

Purposes: this clinical study evaluated the accuracy and execution time of a digital imaging fiber-optic transillumination (DIFOTI) technique for the detection of approximal caries in posterior teeth compared to intra-oral examination associated with bitewing radiographs. Methods: one hundred patients were selected and submitted to clinical inspection and bitewing radiographs. The outcomes of this process were converted into scores, according to the International Caries Detection and Assessment System (ICDAS): 0—sound tooth; 1, 2, and 3—carious lesion confined within enamel; 4, 5, and 6—dentin carious lesion. Subsequently, an independent investigator acquired digital images of the same teeth using a DIFOTI device (DIAGNOcam, Kavo Dental), which were also converted into ICDAS scores. The time required for executing diagnostic procedures was measured. The clinical sensitivity and specificity of DIFOTI were analyzed by receiver operating characteristic (ROC) curves. The time necessary to perform the diagnostic methods was evaluated by Mann–Whitney U (alfa = 0.05). Results: the overall test accuracy for the DIFOTI-based device ranged from 0.717 to 0.815 (area under the ROC curve) with p < 0.0001 for all ICDAS scores. Bitewing radiographs took almost twice the time required by DIFOTI (p < 0.001). Conclusions: the DIFOTI-based device DIAGNOcam provided accurate detection of approximal caries in posterior teeth, even at early stages. The technique employed for transillumination caries diagnosis by the same device took less time than conventional bitewing radiographs. Clinical Relevance: transillumination devices, such as DIAGNOcam, can be accurately used for caries diagnosis in approximal surfaces of posterior teeth, demanding less clinical time and without radiation-related risks.

Intraoral scanner featuring transillumination for proximal caries detection. An in vitro validation study on permanent posterior teeth

OBJECTIVES

To assess the validity of an intraoral scanner system featuring near-infrared (NIR) transillumination to aid the detection of proximal caries lesions, and to compare the diagnostic performance of this system with that of conventional caries detection methods and with that of an intraoral camera featuring NIR transillumination (DIAGNOcam).

METHODS

Ninety-five permanent posterior teeth were examined using a prototype tip functioning with TRIOS 4 intraoral scanner system (3Shape TRIOS A/S, Denmark) and emitting NIR light, DIAGNOcam, and visual and radiographic examination employing ICDAS criteria. One or two approximal surfaces per tooth, sound or with caries lesions at different stages, were examined (N₁=158). Histological assessment was used as the reference standard.

RESULTS

All methods showed excellent intra-examiner reliability (κ_intra ≥0.80). Two independent examiners assessed the NIR images obtained with both devices. The first examiner, who obtained and assessed the images, showed improved diagnostic performance than the second examiner, who only had access to the images. The inter-examiner agreement between the two examiners assessing the NIR images was substantial (κ_inter 0.57-0.72). The intraoral scanner and DIAGNOcam showed similar diagnostic performance. Regarding initial caries lesions, the NIR image assessment resulted in equal or improved sensitivity (SE 0.50-0.89) compared to radiographic assessment (SE 0.49-0.51) and higher than visual examination (SE 0.28-0.39). Radiographic and NIR image assessment resulted in similar SE in detecting moderate-extensive dentin caries lesions (SE 0.59-0.70), while visual examination showed an inferior value (SE 0.30).

CONCLUSIONS

The intraoral scanner system featuring NIR transillumination and DIAGNOcam showed an overall good diagnostic performance. The conventional caries detection methods showed inferior sensitivity at initial caries lesion stages.

CLINICAL SIGNIFICANCE

Considering the promising diagnostic performance of the intraoral scanner featuring transillumination and the advantages offered by combining the NIR images with the 3D models of the teeth, this system has the potential to contribute towards more reliable caries detection and monitoring in clinical practice without the use of ionizing radiation.

A comparison of near-infrared imaging with other diagnostic tools for dental caries

Dental caries is one of the most common diseases in the world, and global incidence rates are increasing. The early detection of dental lesions enables a conservative approach to be employed and represents a priority in modern dentistry. Recent studies have suggested that conventional diagnostic methods, such as visual tactile inspection and X-ray examination, exhibit low sensitivity and are not very effective in early diagnoses. Consequently, late detection of decay is associated with an increased loss of tooth structure. New diagnostic systems based on optical properties have been developed to facilitate early detection. Several studies have evaluated the performance of near-infrared imaging (NIRI) as an early diagnostic tool. NIRI using light ranging from 700 to 1700 nm has demonstrated better optical properties compared to conventional optical systems using light in the visible spectra. NIRI enables deeper penetration of the light in the tooth tissue, weak scattering with lower background noise and strong photon absorption with detailed images. Several in vivo studies have demonstrated that NIRI technology has the potential to improve performance compared with current diagnostic methods. NIRI exhibits increased sensitivity compared to radiographs and is more suitable to identify approximal enamel lesions. This paper aims to review these recent advances and their potential applications in daily clinical practice.

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.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Transillumination and optical coherence tomography for the detection and diagnosis of enamel 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 and diagnosis is a visual and tactile dental examination, although alternative approaches are available. These include illumination-based devices that could potentially support the dental examination. There are three categories of illumination devices that exploit various methods of application and interpretation, each primarily defined by different wavelengths, optical coherence tomography (OCT), near-infrared (NIR), and fibre-optic technology, which incorporates more recently developed digital fibre optics (FOTI/DIFOTI).

OBJECTIVES

To estimate the diagnostic test accuracy of different illumination tests for the detection and diagnosis of enamel caries in children or adults. We also planned to explore the following potential sources of heterogeneity: in vitro or in vivo studies with different reference standards; tooth surface (occlusal, proximal, smooth surface, or adjacent to a restoration); single or multiple sites of assessment on a tooth surface; and the prevalence of caries into dentine.

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 15 February 2019); Embase Ovid (1980 to 15 February 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 15 February 2019); and the World Health Organization International Clinical Trials Registry Platform (to 15 February 2019). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared the use of illumination-based devices with a reference standard (histology, enhanced visual examination with or without radiographs, or operative excavation). These included prospective studies that evaluated the diagnostic accuracy of a single index test and studies that directly compared two or more index tests. Both in vitro and in vivo studies of primary and permanent teeth were eligible for inclusion. We excluded studies that explicitly recruited participants with caries into dentine or frank cavitation. 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. The comparative accuracy of different illumination devices 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 24 datasets from 23 studies that evaluated 16,702 tooth surfaces. NIR was evaluated in 6 datasets (673 tooth surfaces), OCT in 10 datasets (1171 tooth surfaces), and FOTI/DIFOTI in 8 datasets (14,858 tooth surfaces). The participant selection domain had the largest number of studies judged at high risk of bias (16 studies). Conversely, for the index test, reference standard, and flow and timing domains the majority of studies were judged to be at low risk of bias (16, 12, and 16 studies respectively). Concerns regarding the applicability of the evidence were judged as high or unclear for all domains. Notably, 14 studies were judged to be of high concern for participant selection, due to selective participant recruitment, a lack of independent examiners, and the use of an in vitro study design. The summary estimate across all the included illumination devices was sensitivity 0.75 (95% confidence interval (CI) 0.62 to 0.85) and specificity 0.87 (95% CI 0.82 to 0.92), with a diagnostic odds ratio of 21.52 (95% CI 10.89 to 42.48). In a cohort of 1000 tooth surfaces with a prevalence of enamel caries of 57%, this would result in 142 tooth surfaces being classified as disease free when enamel caries was truly present (false negatives), and 56 tooth surfaces being classified as diseased in the absence of enamel caries (false positives). A formal comparison of the accuracy according to device type indicated a difference in sensitivity and/or specificity (Chi²(4) = 34.17, P < 0.01). Further analysis indicated a difference in the sensitivity of the different devices (Chi²(2) = 31.24, P < 0.01) with a higher sensitivity of 0.94 (95% CI 0.88 to 0.97) for OCT compared to NIR 0.58 (95% CI 0.46 to 0.68) and FOTI/DIFOTI 0.47 (95% CI 0.35 to 0.59), but no meaningful difference in specificity (Chi²(2) = 3.47, P = 0.18). In light of these results, we planned to formally assess potential sources of heterogeneity according to device type, but due to the limited number of studies for each device type we were unable to do so. For interpretation, we presented the coupled forest plots for each device type according to the potential source of heterogeneity. We rated the certainty of the evidence as low and downgraded two levels in total due to avoidable and unavoidable study limitations in the design and conduct of studies, indirectness arising from the in vitro studies, and imprecision of the estimates.

AUTHORS' CONCLUSIONS

Of the devices evaluated, OCT appears to show the most potential, with superior sensitivity to NIR and fibre-optic devices. Its benefit lies as an add-on tool to support the conventional oral examination to confirm borderline cases in cases of clinical uncertainty. OCT is not currently available to the general dental practitioner, and so further research and development are necessary. FOTI and NIR are more readily available and easy to use; however, they show limitations in their ability to detect enamel caries but may be considered successful in the identification of sound teeth. Future studies should strive to avoid research waste by ensuring that recruitment is conducted in such a way as to minimise selection bias and that studies are clearly and comprehensively reported. In terms of applicability, any future studies should be undertaken in a clinical setting that is reflective of the complexities encountered in caries assessment within the oral cavity.

In vivo correlation of near-infrared transillumination and visual inspection with bitewing radiography for the detection of interproximal caries in permanent and primary teeth

PURPOSE

To evaluate near-infrared light transillumination (NILT) for interproximal caries detection in children by comparing the correlation between both NILT and visual inspection (ICDAS) with bitewing (BW) radiography and by investigating possible differences in caries detection with NILT between primary and permanent teeth.

METHODS

From 35 patients, 121 and 63 interproximal surfaces in, respectively, primary and permanent teeth were included. NILT images were obtained using DIAGNOcam™ (KaVo) and scored by two calibrated raters. A consensus diagnosis was reached for BW radiography; whereas, the ICDAS scores were obtained by one calibrated rater. Weighted Kappa (wκ) was used to evaluate inter- and intra-rater reliability of NILT and to evaluate the correlation between NILT, ICDAS and BW radiography.

RESULTS

The correlation between NILT and BW radiography was moderate to substantial for primary teeth [Rater 1: wκ = 0.61 (95% CI = 0.49-0.75), Rater 2: wκ = 0.55 (95% CI = 0.41-0.69)] and fair for permanent teeth [Rater 1: wκ = 0.34 (95% CI = 0.15-0.53), Rater 2: wκ = 0.33 (95% CI = 0.08-0.58)]. The correlation between ICDAS and BW radiography was moderate for primary teeth [wκ = 0.49 (95% CI = 0.35-0.63)] and substantial for permanent teeth [wκ = 0.62 (95% CI = 0.32-0.92)]. No significant differences were found between primary and permanent teeth.

CONCLUSION

NILT cannot be recommended as a single diagnostic tool for interproximal caries detection in primary teeth. The number of false negatives for dentine caries, especially in first primary molars, was too high. For the use in permanent teeth, NILT could be more accurate than BW radiography.

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.

Combined Near-Infrarred Light Transillumination and Direct Digital Radiography Increases Diagnostic In Approximal Caries

The objective of this study was to evaluate the clinical ability of Near-Infrared Light-Transillumination (NILT) for approximal dentinal caries detection and to compare with direct digital-radiography (DDR), as well as to determine whether the combination of both techniques improves the diagnostic capacity of the lesions. From 88 patients (over 18 years), 138 posterior teeth (76 molars and 62 premolars), that had approximal caries reached into dentine determined by DDR, were included. Lesion extension and DDR images were scored as follows: D0 = sound surface, D1/D2 = caries restricted to the outer/inner-half of the enamel, and D3/4 = caries restricted to the outer/inner-half of the dentin. Opening of the approximal surface using 0.5 mm-in-diameter diamond-bar was used as gold-standard. The lesion extension was then determined by the following criteria: no dentinal caries (D0/1/2) or dentinal caries (D3/4). Seventy-one lesions were D3 and 67 lesions were D4. Sensitivities of overall/D3/D4 were 98.0/95.7/100.0 (NILT) and 100/100/100 (DDR), respectively. Correlations with gold-standard were 0.92 (NILT) and 0.42 (DDR), respectively. The correlation increased to 0.97 (p = 0.045) on combining NILT and DDR. There was no difference in sensitivity between the methods (p > 0.05); but was differences in the correlation (p < 0.01). It can be concluded that NILT showed sensitivity similar to that of DDR and higher correlation than DDR for approximal dentinal caries detection. Accordingly, it may be used to monitor the progression of caries without exposing the patient to ionizing radiation, this being of particular interest in growing patients and in pregnant women. In this respect, NILT can be an effective diagnostic tool adjunctive to bitewing radiographs in detecting approximal dentinal caries. The combination of NILT and DDR represents an increase in the diagnosis of approximal lesions The proposed diagnostic protocol comprises visual examination, followed by NILT and DDR only if the former technique detects approximal caries.

Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology

AIM

To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures.

METHODOLOGY

A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures.

RESULTS

A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered.

CONCLUSIONS

Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

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

OBJECTIVES:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

In vitro visual and visible light transillumination methods for detection of natural non-cavitated approximal caries

OBJECTIVES

The objective was to evaluate a visible-light-transillumination (using Digital Imaging Fiber-Optic Transillumination machine: DIFOTI) method using occlusal view (DIFOTI-occl), axial view (buccal and lingual: DIFOTI-axial), and combination of all views (DIFOTI-all) for detecting non-cavitated approximal caries and to compare its performance to visual examination (International Caries Detection and Assessment System: ICDAS).

MATERIALS AND METHODS

Thirty extracted human premolars were selected (sound to lesions into the outer one-third of the dentine) based on micro-computed tomography (μ-CT). Teeth were mounted in a custom-made device to simulate approximal contact. DIFOTI (Electro-Optical Sciences Inc., Irvington, NY, USA) images were obtained from the occlusal, buccal, and lingual views. DIFOTI image and ICDAS examinations were performed and repeated by three trained/calibrated examiners. Sensitivity, specificity, area under receiver operating characteristics curve (A_z), inter- and intra-class correlation coefficients (ICCs), and correlation were determined.

RESULTS

Sensitivity/specificity was for DIFOTI-occl: 0.42/0.75, DIFOTI-axial: 0.86/0.93, DIFOTI-all: 0.91/0.69, and for ICDAS: 0.89/0.83. A_z for DIFOTI-occl was significantly lower than that of DIFOTI-axial (p < 0.001), DIFOTI-all (p = 0.002), and ICDAS (p = 0.005). Spearman correlation coefficients with μ-CT for DIFOTI-occl (r = 0.39) showed weak association, while DIFOTI-axial (r = 0.80), DIFOTI-all (r = 0.91), and ICDAS (r = 0.90) showed moderate association. ICCs for intra-examiner repeatability/inter-examiner agreement were for DIFOTI-occl (0.64/0.58), DIFOTI-axial (0.92/0.89), DIFOTI-all (0.85/0.83), and ICDAS (0.79/0.72).

CONCLUSIONS

The results of the current in vitro study suggest that, for detection of non-cavitated approximal caries lesions, DIFOTI performs better using axial than occlusal view.

CLINICAL RELEVANCE

Approximal non-cavitated caries detection is challenging. DIFOTI can observe images from occlusal-, buccal-, and lingual views. DIFOTI and visual (ICDAS) examinations of buccal- and lingual- and all-views are more suitable than those of occlusal view for a detection of non-cavitated approximal caries.

Validity of Digital Imaging of Fiber-Optic Transillumination in Caries Detection on Proximal Tooth Surfaces

OBJECTIVE

The aim of our study was to evaluate the validity of the digital imaging fiber-optic transillumination (DIFOTI) method in comparison with clinical visual examination (CV) and bitewing (BW) radiography on detecting caries lesions on proximal surfaces of teeth.

MATERIALS AND METHODS

Proximal tooth surfaces of premolars and molars (n = 2,103) of 91 voluntary university students aged from 18 to 30 years were examined with CV, BW radiography, and the DIFOTI method.

RESULTS

DIFOTI detected more initial and manifested caries lesions compared with CV and BW. Of the analyzed tooth surfaces, 69.8% were classified as sound by DIFOTI, 80.3% by BW, and 91.6% by CV. Initial caries lesions were found in 21.2% of the surfaces by DIFOTI, in 14.1% by BW, and in 6.2% by CV, whereas the proportions for manifested dental caries lesions were 9.0%, 5.6%, and 2.2%, respectively. The interexaminer agreement regarding the DIFOTI findings between an experienced clinician and a fifth-year dental student was high: κ = 0.67 for initial and κ = 0.91 for manifested caries lesions.

CONCLUSIONS

The noninvasive DIFOTI method seems to offer a potential tool for everyday clinical practice. In clinical use, DIFOTI finds well even initial caries lesions on proximal surfaces, thus providing an instrument for detecting lesions potential for arresting as well as for monitoring the outcome after preventive measures.

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

OBJECTIVES/AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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