Effectiveness of Air Drying and Magnification Methods for Detecting Initial Caries on Occlusal Surfaces Using Three Different Diagnostic Aids

ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I: caries lesion detection and depth assessment

OBJECTIVES

The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection.

MATERIALS AND METHODS

The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey.

RESULTS

Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel.

CONCLUSION

Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations.

CLINICAL RELEVANCE

The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.

Dental Loupe's Role in Detection of Caries of Molars in Children by Student and Dentists

PURPOSE

The objectives of this study were to examine the effectiveness of diagnosing occlusal caries in molar teeth in children under the use of loupes and, secondarily, to examine whether there is a difference in the diagnosis between permanent and primary teeth using dental loupes. In addition, to check whether the student's diagnosis using loupes improves caries diagnosis compared to dentists' diagnosis in both methods.

METHODS

The data were collected from 163 patients aged 6-14 who sought treatment in the Pedodontic Department of the Faculty of Dentistry at Tel-Aviv University during 2020-2021. The first and second permanent molars and second primary molars with deep groves were examined. A student and dentists made the diagnosis with and without loupes while using the ICDAS criteria.

RESULTS

The student's examinations without the loupes detected no caries in 60% of the cases compared to 76.9% in the examinations with the loupes and found initial caries without cavitation (ICDAS1) in only 17.6% of teeth without loupes examination compared to 33% using loupes. The dentist correctly diagnosed no caries (ICDAS0) in 82.1% of cases without loupes and initial caries without cavitation (ICDAS1) in 62.5% of cases. The dentist correctly diagnosed distinct caries without cavitation (ICDAS2) in 90.8% of cases. No differences were observed in caries diagnosis between primary and permanent teeth when the examiner was a specialist/intern using loupes; however, there was a statistically significant difference (p = 0.047) when the diagnosis was made by a student using loupes.

CLINICAL SIGNIFICANCE

The use of dental loupes is an effective method for the correct and early diagnosis of occlusal caries lesions in children's molar teeth by both dentists and students, and this is in accordance with the principle of minimally invasive dentistry. There is a justification for the use of dental loupes for the diagnosis of initial occlusal caries in primary and permanent molars in children in a precise way. Using loupes especially improves the correct diagnosis of initial caries in primary teeth by students.

Visual or visual-tactile examination to detect and inform the diagnosis of enamel caries

BACKGROUND

The detection and diagnosis of caries at the initial (non-cavitated) and moderate (enamel) levels of severity is fundamental to achieving and maintaining good oral health and prevention of oral diseases. An increasing array of methods of early caries detection have been proposed that could potentially support traditional methods of detection and diagnosis. Earlier identification of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol-generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.

OBJECTIVES

To determine the diagnostic accuracy of different visual classification systems for the detection and diagnosis of non-cavitated coronal dental caries for different purposes (detection and diagnosis) and in different populations (children or adults).

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 April 2020); Embase Ovid (1980 to 30 April 2020); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 April 2020); and the World Health Organization International Clinical Trials Registry Platform (to 30 April 2020). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared a visual classification system (index test) with a reference standard (histology, excavation, radiographs). This included cross-sectional studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were considered. Studies that explicitly recruited participants with caries into dentine or frank cavitation were excluded. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.

DATA COLLECTION AND ANALYSIS

We extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on QUADAS-2 specific to the review context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence intervals (CIs) and regions, and 95% prediction regions. The comparative accuracy of different classification systems was conducted based on indirect comparisons. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

MAIN RESULTS

We included 71 datasets from 67 studies (48 completed in vitro) reporting a total of 19,590 tooth sites/surfaces. The most frequently reported classification systems were the International Caries Detection and Assessment System (ICDAS) (36 studies) and Ekstrand-Ricketts-Kidd (ERK) (15 studies). In reporting the results, no distinction was made between detection and diagnosis. Only two studies were at low risk of bias across all four domains, and 15 studies were at low concern for applicability across all three domains. The patient selection domain had the highest proportion of high risk of bias studies (49 studies). Four studies were assessed at high risk of bias for the index test domain, nine for the reference standard domain, and seven for the flow and timing domain. Due to the high number of studies on extracted teeth concerns regarding applicability were high for the patient selection and index test domains (49 and 46 studies respectively). Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies: sensitivities ranged from 0.16 to 1.00 and specificities from 0 to 1.00. For all visual classification systems the estimated summary sensitivity and specificity point was 0.86 (95% CI 0.80 to 0.90) and 0.77 (95% CI 0.72 to 0.82) respectively, diagnostic odds ratio (DOR) 20.38 (95% CI 14.33 to 28.98). In a cohort of 1000 tooth surfaces with 28% prevalence of enamel caries, this would result in 40 being classified as disease free when enamel caries was truly present (false negatives), and 163 being classified as diseased in the absence of enamel caries (false positives). The addition of test type to the model did not result in any meaningful difference to the sensitivity or specificity estimates (Chi²(4) = 3.78, P = 0.44), nor did the addition of primary or permanent dentition (Chi²(2) = 0.90, P = 0.64). The variability of results could not be explained by tooth surface (occlusal or approximal), prevalence of dentinal caries in the sample, nor reference standard. Only one study intentionally included restored teeth in its sample and no studies reported the inclusion of sealants. We rated the certainty of the evidence as low, and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and inconsistency of results.

AUTHORS' CONCLUSIONS

Whilst the confidence intervals for the summary points of the different visual classification systems indicated reasonable performance, they do not reflect the confidence that one can have in the accuracy of assessment using these systems due to the considerable unexplained heterogeneity evident across the studies. The prediction regions in which the sensitivity and specificity of a future study should lie are very broad, an important consideration when interpreting the results of this review. Should treatment be provided as a consequence of a false-positive result then this would be non-invasive, typically the application of fluoride varnish where it was not required, with low potential for an adverse event but healthcare resource and finance costs. Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Wherever possible future studies should be carried out in a clinical setting, to provide a realistic assessment of performance within the oral cavity with the challenges of plaque, tooth staining, and restorations, and consider methods to minimise bias arising from the use of imperfect reference standards in clinical studies.

Knowledge and Use of Caries Detection Methods among Dental Students and Dental Practitioners in Riyadh, Saudi Arabia

Aim

Accurate detection and diagnosis of dental caries is an integral part of achieving adequate comprehensive dental care. Furthermore, the high prevalence of caries and generally poor oral health in Saudi Arabia is a public health concern. In addition to necessary preventive programs and awareness initiatives, understanding diagnostic practices plays an important role in garnering broad background knowledge regarding the routine diagnostic means utilized by our targeted respondents. Therefore, this study aimed to assess the methods of caries detection among dental students and dental practitioners in Riyadh using a cross-sectional observational study design.

Methods

The sample comprised 496 dental students, interns, postgraduate residents, general dental practitioners, specialists, and consultants from the Riyadh region of Saudi Arabia. A survey was designed to assess caries detection methods, risk assessment practices, and knowledge of advanced diagnostic methods. The responses were correlated with demographic and educational variables. Regression models were used to predict associations.

Results

42.3% and 32.7% use sharp explorers in diagnosing caries always and most of the time, respectively. When conducting caries risk assessment practices, 64.4% was very likely to review the patient's medical history and lifestyle. In terms of knowledge of advanced diagnostic methods, 47.8% know “much” to “very much” about FOTI. The knowledge of advanced caries diagnostic methods and practices of advanced diagnostic methods were significantly positively correlated (r = 0.388, P < 0.001). Linear regression analysis indicated that higher experience (10+ years) was associated with higher knowledge regarding advanced caries diagnostic methods (β = 0.27, P=0.009). The mean rank for risk assessment practices was significantly lower in GPs compared to consultants (P < 0.05).

Conclusions

The use of traditional and invasive methods of caries detection is prevalent among our respondents, while the usage of advanced diagnostic methods is for the most part low. Therefore, we advocate for more minimally invasive approaches and as such encourage the practice and availability of advanced diagnostic methods.

Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion-Dry and Wet Conditions

Objective

The aim of this study was to assess the effectiveness and reliability of magnification, DIAGNOdent in detection of smooth surface white spot lesions.

Study design

Three hundred children aged 5–10 years were examined by two examiners for presence of smooth surface white spot lesions using naked eye and magnifying loupes in wet and dry conditions followed by DIAGNOdent analysis. Data was analysed using Cohen's kappa coefficient, Friedman test and Paired t test. Accuracy was assessed by sensitivity and positive predicted values.

Results

Significant difference was found between naked eyes and magnifying loupes with and without air drying. While insignificant difference was found between DIAGNOdent and loupes.

Conclusion

Magnifying loupes with air drying is an effective method in detection of smooth surface white spot lesion.

Clinical significance

With the increased knowledge about the pathogenesis of dental caries and its ability to be remineralisable if detected early, makes it all the more important for the clinician to be vigilant in detection of early lesion to prevent the avoidable restorative approach for the same. Incorporation of magnification to routine dental examination by general dentist can help in early diagnosis and treatment of dental decay. This could prevent further progression of dental caries and reduces the incidence of tooth decay

How to cite this article

Gupta N, Sandhu M, et al. Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion—Dry and Wet Conditions. Int J Clin Pediatr Dent 2019;12(1):37–41.