What is an appropriate caries diagnosis?

Australian Dentist's Knowledge and Perceptions of Factors Affecting Radiographic Interpretation

BACKGROUND

Errors of interpretation of radigraphic images, also known as interpretive errors, are a critical concern as they can have profound implications for clinical decision making. Different types of interpretive errors, including errors of omission and misdiagnosis, have been described in the literature. These errors can lead to unnecessary or harmful treat/or prolonged patient care. Understanding the nature and contributing factors of interpretive errors is important in developing solutions to minimise interpretive errors. By exploring the knowledge and perceptions of dental practitioners, this study aimed to shed light on the current understanding of interpretive errors in dentistry.

METHODS

An anonymised online questionnaire was sent to dental practitioners in New South Wales (NSW) between September 2020 and March 2022. A total of 80 valid responses were received and analysed. Descriptive statistics and bivariate analysis were used to analyse the data.

RESULTS

The study found that participants commonly reported interpretive errors as occurring 'occasionally', with errors of omission being the most frequently encountered type. Participants identified several factors that most likely contribute to interpretive errors, including reading a poor-quality image, lack of clinical experience and knowledge, and excessive workload. Additionally, general practitioners and specialists held different views regarding factors affecting interpretive errors.

CONCLUSION

The survey results indicate that dental practitioners are aware of the common factors associated with interpretive errors. Errors of omission were identified as the most common type of error to occur in clinical practice. The findings suggest that interpretive errors result from a mental overload caused by factors associated with image quality, clinician-related, and image interpretation. Managing and identifying solutions to mitigate these factors are crucial for ensuring accurate and timely radiographic diagnoses. The findings of this study can serve as a foundation for future research and the development of targeted interventions to enhance the accuracy of radiographic interpretations in dentistry.

Organization for Caries Research-European Federation of Conservative Dentistry Consensus Report on Clinical Recommendations for Caries Diagnosis Paper II: Caries Lesion Activity and Progression Assessment

INTRODUCTION

This consensus paper provides recommendations for oral health professionals on why and how to assess caries activity and progression with special respect to the site of a lesion.

METHODS

An expert panel was nominated by the executive councils of the European Organization for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD). The steering committee built three working groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity and progression assessment, and (3) obtain individualized caries diagnoses. The experts of work group 2 phrased and agreed on provisional general and specific recommendations on caries lesion activity and progression, based on a review of the current literature. These recommendations were then discussed and refined in a consensus workshop followed by an anonymous Delphi survey to determine the agreement on each recommendation.

RESULTS

The expert panel agreed on general (n = 7) and specific recommendations (n = 6). The specific recommendations cover coronal caries on pits and fissures, smooth surfaces, proximal surfaces, as well as root caries and secondary caries/caries adjacent to restorations and sealants. 3/13 recommendations yielded perfect agreement.

CONCLUSION

The most suitable method for lesion activity assessment is the visual-tactile method. No single clinical characteristic is indicative of lesion activity; instead, lesion activity assessment is based on assessing and weighing several clinical signs. The recall intervals for visual and radiographic examination need to be adjusted to the presence of active caries lesions and recent caries progression rates. Modifications should be based on individual patient characteristics.

A novel deep learning-based perspective for tooth numbering and caries detection

OBJECTIVES

The aim of this study was automatically detecting and numbering teeth in digital bitewing radiographs obtained from patients, and evaluating the diagnostic efficiency of decayed teeth in real time, using deep learning algorithms.

METHODS

The dataset consisted of 1170 anonymized digital bitewing radiographs randomly obtained from faculty archives. After image evaluation and labeling process, the dataset was split into training and test datasets. This study proposed an end-to-end pipeline architecture consisting of three stages for matching tooth numbers and caries lesions to enhance treatment outcomes and prevent potential issues. Initially, a pre-trained convolutional neural network (CNN) utilized to determine the side of the bitewing images. Then, an improved CNN model YOLOv7 was proposed for tooth numbering and caries detection. In the final stage, our developed algorithm assessed which teeth have caries by comparing the numbered teeth with the detected caries, using the intersection over union value for the matching process.

RESULTS

According to test results, the recall, precision, and F1-score values were 0.994, 0.987 and 0.99 for teeth detection, 0.974, 0.985 and 0.979 for teeth numbering, and 0.833, 0.866 and 0.822 for caries detection, respectively. For teeth numbering and caries detection matching performance; the accuracy, recall, specificity, precision and F1-Score values were 0.934, 0.834, 0.961, 0.851 and 0.842, respectively.

CONCLUSIONS

The proposed model exhibited good achievement, highlighting the potential use of CNNs for tooth detection, numbering, and caries detection, concurrently.

CLINICAL SIGNIFICANCE

CNNs can provide valuable support to clinicians by automating the detection and numbering of teeth, as well as the detection of caries on bitewing radiographs. By enhancing overall performance, these algorithms have the capacity to efficiently save time and play a significant role in the assessment process.

Integration of an evidence-based caries management approach in dental education: The perspectives of dental instructors

PURPOSE/OBJECTIVES

Evidence-based caries management (EBCM) has developed into an internationally recognized tool for integration of comprehensive non-surgical caries treatment in dental education. However, uptake of the EBCM approach remains uneven across Canadian dental schools. Our project sought to understand how dental instructors perceive the challenges and solutions to the integration of the EBCM approach in undergraduate clinical education.

METHODS

Using a qualitative descriptive design, we recruited a purposeful sample of clinical instructors supervising undergraduate dental students in caries-related dental care. Semi-structured, online interviews focused on the main characteristics of EBCM. Interviews were analyzed using the awareness, desire, knowledge, ability, and reinforcement (ADKAR) change management model to understand challenges with EBCM implementation in undergraduate education. The analysis process started with verbatim transcription; then, transcripts were coded deductively based on the interview guide and the ADKAR model domains, and inductively to generate emergent codes. Finally, thematic analysis was used to develop themes and subthemes.

RESULTS

We interviewed 11 dental instructors with a wide range of clinical experience. Our results show that participants had sufficient awareness regarding the need for the EBCM approach and portrayed a strong desire to participate in bringing curricular changes. Knowledge and ability of participants depended on their training, experience, and involvement in continuing education courses. A lack of standardized caries management practices, less chairside time, and poor remuneration for instructors were major barriers in EBCM clinical implementation. Potential solutions suggested included providing continuing education courses, credits for students for non-surgical caries management, and remunerating instructors for implementation.

CONCLUSIONS

In conclusion, most participants were aware of the need for a substantive change toward EBCM and demonstrated the desire to participate and improve its implementation. Our analysis showed that to facilitate full integration of the EBCM approach into the undergraduate dental clinics, organizational focus needs to be placed on the individual's knowledge and ability, with tailored efforts toward reinforcement.

[Forensic dentistry for identity verification. A survey at the state police level]

BACKGROUND

In Germany, the identification of unknown dead persons is the responsibility of the police. According to INTERPOL standards, primary (e.g., DNA, fingerprints, and teeth) and secondary (e.g., tattoos) characteristics are examined. Forensic dentistry is already used internationally as an efficient method. In this study, the approach of state police in Germany was analyzed. The methods used for identification, the role of forensic dentistry, the cooperation with dentists, and possible optimization approaches are investigated.

METHODS

By means of a digital questionnaire, police officers competent in all federal states for the discovery of unknown dead bodies were asked about identification methods and specifically about the use of forensic dentistry.

RESULTS

Eighty-five officers from at least 11 federal states participated in the survey. The procedure turned out to be department specific. In 72.6% of the cases, different characteristics are combined in the identification process, most frequently DNA with dental status (37.1%). DNA analysis is used most frequently. Of the respondents, 62.9% agreed that dental identification is used "often." The percentage of identifications using dental status is estimated to be 1.6-8.1%. For forensic dentistry, 19.4% have a fixed point of contact. A digital platform to contact dentists was estimated to be helpful by 56.5%.

DISCUSSION

Forensic dentistry is currently still lagging behind DNA analysis, which could change through increasing digitalization if, for example, ante-mortem data are more reliably available and platforms for interdisciplinary exchange are created.

Harnessing the power of collective intelligence in dentistry: a pilot study in Victoria, Australia

BACKGROUND

In many dental settings, diagnosis and treatment planning is the responsibility of a single clinician, and this process is inevitably influenced by the clinician's own heuristics and biases. Our aim was to test whether collective intelligence increases the accuracy of individual diagnoses and treatment plans, and whether such systems have potential to improve patient outcomes in a dental setting.

METHODS

This pilot project was carried out to assess the feasibility of the protocol and appropriateness of the study design. We used a questionnaire survey and pre-post study design in which dental practitioners were involved in the diagnosis and treatment planning of two simulated cases. Participants were provided the opportunity to amend their original diagnosis/treatment decisions after viewing a consensus report made to simulate a collaborative setting.

RESULTS

Around half (55%, n = 17) of the respondents worked in group private practices, however most practitioners (74%, n = 23) did not collaborate when planning treatment. Overall, the average practitioners' self-confidence score in managing different dental disciplines was 7.22 (s.d. 2.20) on a 1-10 scale. Practitioners tended to change their mind after viewing the consensus response, particularly for the complex case compared to the simple case (61.5% vs 38.5%, respectively). Practitioners' confidence ratings were also significantly higher (p < 0.05) after viewing the consensus for complex case.

CONCLUSION

Our pilot study shows that collective intelligence in the form of peers' opinion can lead to modifications in diagnosis and treatment planning by dentists. Our results lay the foundations for larger scale investigations on whether peer collaboration can improve diagnostic accuracy, treatment planning and, ultimately, oral health outcomes.

A Novel Deep Learning-Based Approach for Segmentation of Different Type Caries Lesions on Panoramic Radiographs

The study aims to evaluate the diagnostic performance of an artificial intelligence system based on deep learning for the segmentation of occlusal, proximal and cervical caries lesions on panoramic radiographs. The study included 504 anonymous panoramic radiographs obtained from the radiology archive of Inonu University Faculty of Dentistry's Department of Oral and Maxillofacial Radiology from January 2018 to January 2020. This study proposes Dental Caries Detection Network (DCDNet) architecture for dental caries segmentation. The main difference between DCDNet and other segmentation architecture is that the last part of DCDNet contains a Multi-Predicted Output (MPO) structure. In MPO, the final feature map split into three different paths for detecting occlusal, proximal and cervical caries. Extensive experimental analyses were executed to analyze the DCDNet network architecture performance. In these comparison results, while the proposed model achieved an average F1-score of 62.79%, the highest average F1-score of 15.69% was achieved with the state-of-the-art segmentation models. These results show that the proposed artificial intelligence-based model can be one of the indispensable auxiliary tools of dentists in the diagnosis and treatment planning of carious lesions by enabling their detection in different locations with high success.

Diagnosis of interproximal caries lesions with deep convolutional neural network in digital bitewing radiographs

Objectives

This study aimed to investigate the effectiveness of deep convolutional neural network (CNN) in the diagnosis of interproximal caries lesions in digital bitewing radiographs.

Methods and materials

A total of 1,000 digital bitewing radiographs were randomly selected from the database. Of these, 800 were augmented and annotated as “decay” by two experienced dentists using a labeling tool developed in Python programming language. The 800 radiographs were consisted of 11,521 approximal surfaces of which 1,847 were decayed (lesion prevalence for train data was 16.03%). A CNN model known as you only look once (YOLO) was modified and trained to detect caries lesions in bitewing radiographs. After using the other 200 radiographs to test the effectiveness of the proposed CNN model, the accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC) were calculated.

Results

The lesion prevalence for test data was 13.89%. The overall accuracy of the CNN model was 94.59% (94.19% for premolars, 94.97% for molars), sensitivity was 72.26% (75.51% for premolars, 68.71% for molars), specificity was 98.19% (97.43% for premolars, 98.91% for molars), PPV was 86.58% (83.61% for premolars, 90.44% for molars), and NPV was 95.64% (95.82% for premolars, 95.47% for molars). The overall AUC was measured as 87.19%.

Conclusions

The proposed CNN model showed good performance with high accuracy scores demonstrating that it could be used in the diagnosis of caries lesions in bitewing radiographs.

Clinical significance

Correct diagnosis of dental caries is essential for a correct treatment procedure. CNNs can assist dentists in diagnosing approximal caries lesions in bitewing radiographs.

Uncertainties around COVID-19 from the perspectives of oral health care workers during the first wave of SARS-CoV-2 infections in British Columbia, Canada

Background

The first wave of COVID-19 infections caused disturbances in all aspects of personal and professional lives. The aim of this study was to explore the ways in which that first wave of novel coronavirus infections resulted in uncertainties, as experienced by members of the oral health care workforce in British Columbia, Canada.

Methods

This qualitative inquiry purposefully recruited frontline oral health care workers, including dentists, dental hygienists, certified dental assistants, and administrative staff, via remote semi-structured interviews between April 20 and May 4, 2020. Coding, categories, and themes were inductively assigned.

Results

A total of 45 interviews, lasting between 39 and 74 minutes each, were conducted involving 18 dentists (6 females), 12 dental hygienists (11 females), 6 certified dental assistants (all females), and 9 administrators/front-desk staff (7 females). Fifty-one hours of audio recordings and more than 650 single-spaced pages of transcripts were produced. Five main themes emerged pertaining to uncertainties surrounding COVID-19, patient care, personal lives and infectiousness, concern for the future, and variations among different pandemics. Certitudes were less evident, but surfaced mostly when considering a potential new normal resulting from the pandemic.

Conclusion

Participants indicated that the uncertainties they felt were dependent upon what is known, and unknown, about the pandemic and the provision of oral health care during the first wave of infections. Future studies are needed to include the viewpoints of oral health care workers from other provinces, as well the perceptions of patients who received oral health care during the height of the first wave of the pandemic.

Negligible therapeutic impact, false-positives, overdiagnosis and lead-time are the reasons why radiographs bring more harm than benefits in the caries diagnosis of preschool children

Background

To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs.

Methods

This is a secondary analysis of a two-arm randomized clinical trial with parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3–6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up.

Results

4383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias.

Conclusions

Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice.

Trial registration Clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01528-w.

Comparison of novel and established caries diagnostic methods: a clinical study on occlusal surfaces

Background

The purpose of this prospective clinical diagnostic study with validation was to compare the diagnostic accuracy of near-infrared transillumination (NIRT), laser fluorescence measurement (LF), alternating current impedance spectroscopy (ACIS) and their combinations as adjunct methods to visual examination (VE) for occlusal caries detection using a hybrid reference standard.

Methods

Ninety-six first and second non-cavitated permanent molars from 76 individuals (mean age 24.2) were investigated using (VE) (ICDAS) and bitewing radiography (BWR), as well as NIRT, LF and ACIS. The findings of BWR and NIRT were evaluated by two examiners while the other examinations were conducted by one calibrated dentist. The hybrid reference standard consisted of non-operative validation based on the results of VE and BWR and operative validation. Statistical analysis included cross-tabulations, calculation of sensitivity, specificity and area under the receiver operating characteristic curve at three diagnostic thresholds: caries in general, enamel caries and dentin caries.

Results

NIRT, LF and ACIS exhibited high sensitivity for caries in general [1.00 (1.00–1.00), 0.77 (0.65–0.88), 0.75 (0.63–0.87)) and for dentin caries (0.97 (0.91–1.03), 0.76 (0.76–0.90), 0.64 (0.47–0.80)]. Sensitivity values for enamel caries were weak (0.21, 0.11, 0.37). Specificity values did not fall below 0.65 (NIRT) for all categories and methods, except for NIRT at the caries detection threshold (0.27). A combination of LF and ACIS with VE improved the diagnostic performance at the overall and the enamel caries threshold. The other methods showed fair to excellent discrimination at the overall caries threshold (NIRT 0.64, LF 0.89 and ACIS 0.86) and acceptable discrimination at the dentin caries threshold (NIRT 0.82, LF 0.81 and ACIS 0.79). AUROC for enamel caries exhibited the weakest discrimination. Accuracy was 65.6% for VE, 69.8% for BWR, 50.0% for NIRT, 53.1% for LF and 74.0% for ACIS. Reliability assessment for BWR and NIRT showed at least substantial agreements for all analyses.

Conclusions

The methods, NIRT, LF and ACIS, revealed different potential but no impeccable performance for occlusal caries detection. All are suitable instruments to detect hidden carious lesion in dentin. As auxiliaries to VE, LF and ACIS showed an increase in diagnostic performance.

In vitro comparison of two types of digital X-ray sensors for proximal caries detection validated by micro-computed tomography

OBJECTIVES

We aimed to compare the diagnostic accuracy of two intraoral digital X-ray sensors-the charged-coupled device (CCD) and complementary metal-oxide-semiconductor (CMOS)-for proximal caries detection in permanent molar and premolar teeth. Micro-CT served as the reference standard.

METHODS

250 samples were mounted in three-dimensional (3D)-printed phantoms, and their proximal surfaces were evaluated by ICDAS criteria directly to create a balanced sample. Bitewing radiography was conducted using 3D-constructed X-ray phantoms with a CCD sensor at a 0.08 s and a CMOS sensor at 0.12 and 0.16 s exposure time. Two examiners determined the diagnostic decisions twice at appropriate intervals. Three diagnostic thresholds for sound surfaces and enamel and dentin caries were defined and presented in a cross-table. Sensitivity and specificity values and overall accuracy were calculated, and receiver operating curves were generated and compared. Reliability assessment was performed using linear weighted κ statistics.

RESULTS

The overall accuracies between the reference standard and different sensors and exposure times were 63.1% (CCD), 67.1% (CMOS sensor at 0.12 s) and 70.7% (CMOS sensor at 0.08 s). High specificity but low sensitivity values were found for all examination conditions at all thresholds. The area under the curve comparison values revealed no significant difference between sensor types and exposure times. Linear-weighted κ analysis revealed almost perfect agreement for all assessments.

CONCLUSION

No significant difference was found for diagnostic performance of proximal caries detection between the different sensors and exposure times. The increased exposure time did not lead to a significant diagnostic benefit.

What diagnostic strategy performs better for caries lesion detection on proximal surfaces of adolescents?

OBJECTIVE

To evaluate the performance of visual inspection alone and associated to radiographic and laser fluorescence (LF) methods in detecting non-evident caries lesions at adolescents' proximal surfaces.

MATERIALS AND METHODS

Adolescents (12 to 17 years old) were assessed for the presence of caries lesions through visual inspection, radiographic examination, and LF method (DIAGNOdent pen), at non-cavitated (NC) and cavitated lesion (CAV) thresholds. Temporary separation with orthodontic rubbers followed by direct visual inspection was the reference standard method. Two examiners conducted the examinations, and the first examiner reassessed around 20% of the sample, to evaluate inter- and intra-examiner reproducibility, respectively. Sensitivity, specificity, accuracy, and utility values were calculated for the methods alone and combined with visual inspection using two different strategies: simultaneous and sequential combination.

RESULTS

A total of 834 proximal surfaces (51 adolescents) were included. Visual inspection presented higher reproducibility values (higher than 0.98). Moreover, visual inspection presented higher sensitivity (around 0.51) than those obtained with other diagnostic strategies (varying from 0.09 to 0.20) at the NC threshold. For CAV, visual inspection presented higher specificity (0.996) than the sequential association with adjunct methods (around 0.97), but with lower sensitivity. Accuracy and utility values for combined strategies were similar or lower than those achieved with the visual inspection performed alone.

CONCLUSION

Visual inspection alone performs better for detecting caries lesions in premolars and molars of adolescents than other diagnostic strategies.

CLINICAL RELEVANCE

The best diagnostic strategy for caries detection of proximal caries lesions in adolescents is the visual inspection alone.

Study protocol for a diagnostic randomized clinical trial to evaluate the effect of the use of two clinical criteria in the assessment of caries lesions around restorations in adults: the Caries Cognition and Identification in Adults (CaCIA) trial

Background

The assessment of restored teeth in dentistry remains a challenge, mainly related to the detection of caries around restorations. There is a diversity of clinical criteria available to assess the caries lesions, resulting in differences in the dentists’ diagnosis and treatment decisions. In addition, there is a lack of evidence regarding the best criteria to detect caries lesions around the restorations. Thus, the present protocol aims to evaluate the effect of using 2 visual criteria to assess restored teeth on the outcomes related to oral health in adults.

Methods

The design protocol of the Caries Cognition and Identification in Adults trial correspond to a triple-blind randomized, controlled clinical trial with parallel-groups. Two groups will be compared: patients who will receive the diagnosis and treatment decision according to FDI (World Dental Federation) criteria—FDI group; and patients who will receive diagnosis and treatment decision according to the “Caries Associated with Restorations or Sealants” criteria defined by the International Caries Classification and Management System (ICCMS group). The participants will be followed up after 6, 12, 18, 24, and 60 months, and the restoration failure will be the primary outcome. The analysis will be conducted through Cox regression with shared frailty. The impact of oral health on quality of life and the cost-effectiveness of the methods used will be the secondary outcomes. Two-tailed analyzes will be used, considering a level of significance of 5%.

Discussion

This is the first clinical trial to assess the effect of using two visual methods to detect caries lesions around restorations on the outcomes related to oral health in adults. The findings of this study will define what is the best diagnostic strategy for the assessment of caries around restorations in permanent teeth.

Trial registration NCT03108586 (registered 11 April 2017).

Optical magnification has no benefits on the detection of occlusal caries lesions in permanent molars using different visual scoring systems: An in vitro study

Background

Some studies have addressed the influence of optical magnification on the detection of caries lesions using a visual scoring system. However, there is a lack of research related to the use of the CAST and ADA-CCS visual scoring systems. In addition, the reliability and accuracy of ADA-CCS index in permanent teeth were not studied yet. So, the aim of this study was to evaluate, in vitro, the influence of different levels of optical magnification on the detection of occlusal caries lesions in permanent molars using three visual scoring systems.

Material and Methods

One occlusal site per tooth was analyzed in 120 extracted permanent molars. Two trained examiners inspected the teeth using ICDAS (International Caries Detection and Assessment System), CAST (Caries Assessment Spectrum and Treatment), and ADA-CCS (American Dental Association-Caries Classification System) visual criteria, twice with each scoring system, with a one-week interval between examinations. The study was conducted in three phases: (A) without optical magnification, (B) using a binocular lens (3.5× magnification), and (C) using an operating microscope (16× magnification). Then, the teeth were sectioned longitudinally through the center of the selected site and the section with the more severe lesion was histological evaluated considering the D1 (lesions in enamel and dentin) and D3 (dentin lesions) thresholds.

Results

Kappa values for intra- and inter-examiner reproducibility were good to excellent for all systems. At the D1 threshold, sensitivity, accuracy, and area under the ROC curve were high for ICDAS and CAST in all phases. However, this was not the case for the ADA-CCS in phase C (<0.05). At the D3 diagnostic threshold, there was no significant difference between the visual scoring systems during the study phases (>0.05).

Conclusions

The magnification does not improve the accuracy of the visual scoring systems in the detection of occlusal caries lesions in permanent molars. Key words:Dental caries, caries detection, permanent teeth, visual examination, magnification.

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.

General dental practice and improved oral health: is there a win-win for both the professional establishment and government?

General dental practice in the United Kingdom has been in a state of unrest for over two decades, with practitioners having been confronted by two contract changes. The latest contract change of 2006 resulted in much disquiet, and services continue to be piloted in order to develop a contract that satisfies the needs of both government and the profession. Within this context, this paper explores the issues surrounding the present situation. To date, the profession has expanded service provision into the private market which has resulted in an exaggerated inverse care provision. This could be perceived as a move towards a retail philosophy and away from healthcare. In order to restore an equitable balance of care provision, the authors present possible solutions that could satisfy both parties.

Clinical validation of near-infrared light transillumination for early proximal caries detection using a composite reference standard

OBJECTIVES

The aim of this in vivo prospective clinical study was to validate a near-infrared light transillumination (NILT) device for the detection of proximal caries lesions and compare it to the established diagnostic method of bitewing radiography (BWR).

MATERIALS AND METHODS

A total of 116 interproximal posterior teeth/surfaces without gross cavitation were included and assessed with BWR and NILT. After clinical examination, the teeth with sound surfaces or non-cavitated caries lesions were separated with the use of an orthodontic separation rubber for 24h. Upon removal of the separator a silicon impression was obtained and the teeth surfaces were directly investigated. Intra- and inter-examiner reproducibility, sensitivities (SE) and specificities (SP) as well as the area under ROC curves (AUC) were calculated.

RESULTS

The SE of NILT was 0.92 in D₁ lesions and 1.00 in D₂ and D₃ lesions, respectively. BWR showed SE values of 0.81 in D₁ lesions, 0.74 in D₂ and 1.00 in D₃ lesions, respectively. However, NILT showed lower values of SP (D₁ 0.38, D₂ 0.42 and D₃ 0.99) compared to BWR (D₁ 0.65, D₂ 0.88, D₃ 1.00). Intra-examiner reproducibility increased for both examiners from the initial examination (0.68 and 0.62) to the recall appointment (0.89 and 0.76) respectively.

CONCLUSION

The performance of NILT in detection of enamel caries was comparable to BWR. NILT could be considered as a useful and reliable tool in clinical practice. However, monitoring of enamel lesions might not be accurate, since a low specificity of NILT at D_1,2 level and a tendency to false positive ratings have been shown. Therefore, it is recommended that treatment decisions should not be based on NILT alone.

CLINICAL RELEVANCE

This study might indicate that NILT can be used for routine patient screening but the use of BWR is still important for treatment decisions.

In-vitro validation of near-infrared reflection for proximal caries detection

The aim of this study was the in-vitro validation of VistaCam iX HD, which uses near-infrared reflection (NIRR), for proximal caries detection. It was compared with digital bitewing radiography (BWR), and micro-computed tomography (µCT) was used as the reference standard. One-hundred teeth with either sound (n = 54) or carious (n = 46) proximal surfaces were selected using visual-tactile criteria. Images of these surfaces were generated using BWR and NIRR. Evaluation was performed by two examiners, twice, at an interval of 2 weeks. All samples were scanned with a micro-computed tomograph. Thresholds were defined for sound surfaces, and for enamel and dentin lesions, for all methods. Both BWR and NIRR showed moderate sensitivity for the detection of any caries (0.50 for NIRR and 0.53 for BWR). For enamel lesions, sensitivity was lower (0.13 for NIRR and 0.31 for BWR). Specificity was high (≥0.94) in all categories for both methods. Inter-rater reliability ranged from 0.89 to 0.93 and intra-rater reliability from 0.80 to 0.89. Surface evaluation of images generated using NIRR was complicated by overexposed areas; approximately 25% of the images were not clearly interpretable. In conclusion, NIRR and BWR were found to be reproducible methods with comparable diagnostic accuracy. However, NIRR cannot be recommended as a complementary diagnostic method for assessing proximal caries in permanent molars because of problems with image quality and artefacts.

Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document

BACKGROUND

The European Academy of Paediatric Dentistry (EAPD) proposes this best clinical practice guidance to help practitioners decide when and how to prescribe dental radiographs in children and adolescents.

METHODS

Four expert working groups conducted each a systematic review of the literature. The main subjects were radiation protection, intraoral dental radiography (bitewing and periapical radiographs), panoramic radiography (PR) and cone-beam computed tomography (CBCT). In addition, three workshops were held during the corresponding EAPD Interim Seminar in Chania (Crete, Greece) in 2019. On the basis of the identified evidence, all invited experts presented their findings and during the workshops aspects of clinical relevance were discussed.

RESULTS

Several clinical-based recommendations and statements were agreed upon.

CONCLUSION

There is no or low-grade evidence about the efficacy of dental radiographic examinations in young populations. The given recommendations and rationales should be understood as best clinical practice guidance. It is essential to respect the radiological principles of an individualized and patient-specific justification. When a dental radiograph is required, its application needs to be optimized, aiming at limiting the patient's exposure to ionising radiation according to the ALADAIP principle (As Low As Diagnostically Achievable being Indication-oriented and Patient-specific).

Impact of the radiographic method on treatment decisions related to dental caries in primary molars: a before-after study

OBJECTIVES

To evaluate the impact of radiographic examination on changes of treatment decision related to dental caries compared to decisions guided by visual inspection alone in primary molars.

MATERIALS AND METHODS

A total of 126 children aged 3-6 years who had sought dental assistance were randomly selected and examined by two calibrated examiners using visual inspection. A treatment plan regarding dental caries was generated based on this assessment. The same examiners then evaluated two bitewing radiographs, creating an additional treatment plan guided by concurrent assessment of both visual and radiographic methods. Occlusal and proximal surfaces of primary molars received a treatment decision as follows: (i) no treatment, (ii) non-operative treatment, and (iii) operative treatment. The frequency of changes in the treatment decision after radiographic examination was calculated, with subsequent Poisson multilevel regression analysis to evaluate variables influencing such changes.

RESULTS

Changes from "no treatment" decided with visual inspection to "non-operative treatment" after radiographic evaluation occurred in 52 surfaces (3.2%), and changes to "operative treatment" were observed in 46 dental surfaces (2.8%). Furthermore, 50 surfaces (6.2%) had their treatment decision changed from non-operative to operative treatment after radiographic assessment. In addition, changes were significantly more frequent in children with higher caries experience, on proximal surfaces and in 1st primary molars.

CONCLUSIONS

The impact of radiographic examination on changes in the treatment decision of primary molars made with visual inspection is modest. Changes are more frequent in children with higher caries experience and in proximal surfaces.

CLINICAL RELEVANCE

The benefits of the radiographic method for detecting caries in children, as a protocol in the diagnostic process, seem to be overestimated; the impact of this method on changes in treatment decision made by visual examination alone is low. Radiographs could be, however, useful in particular conditions, such as in children with high caries experience.

The effect of bitewing radiography on estimates of dental caries experience among children differs according to their disease experience

BACKGROUND

Radiography is a regularly used and accepted adjunct to visual examination in the diagnosis of dental caries. It is assumed that not using radiographs can lead to underestimation of dental caries experience with most reports having involved studies of young adults or adolescents, and been focused on the permanent dentition. The aim of this study was to determine the relative contributions of bitewing radiography and clinical examination in the detection of dental caries in primary molars and to determine whether those contributions differ according to caries experience.

METHODS

A cross-sectional study was conducted, involving examinations undertaken in dental clinics. Bitewing radiographs taken at the time of the clinical examination were developed and read later, with the data from those used at the analysis stage to adjust the caries diagnosis for the mesial, occlusal and distal surfaces of the primary molar teeth. Children's clinically determined dmfs score was used to allocate them to one of three caries experience groups (0 dmfs, 1-8 dmfs, or 9+ dmfs).

RESULTS

Of the 501 three-to-eight-year-old children examined, nearly three-quarters were younger than six. Caries prevalence and mean dmfs after clinical examination alone and following radiographs were 63.1% and 4.6 (sd, 6.2), and 74.7% and 5.8 (sd, 6.5) respectively. Among children with a dmfs of 1-8, the number of lesions missed during the clinical examination was greater than the number of 106 (25.6%) in children with a dmfs of 9+. In the 185 children with no apparent caries at clinical examination, 124 lesions were detected radiographically, among 58 (46.8%) of those.

CONCLUSIONS

Taking bitewing radiographs in young children is not without challenges or risks, and it must be undertaken with these in mind. Diagnostic yields from bitewing radiographs are greater for children with greater caries experience. The findings of this study further support the need to consider using bitewing radiographs in young children to enhance the management of lesions not detected by a simple visual examination alone.

TRIAL REGISTRATION

ACTRN12614000844640 .

Evaluation of occlusal caries detection and assessment by visual inspection, digital bitewing radiography and near-infrared light transillumination

AIM

This study compared the diagnostic outcomes of visual inspection (VI), digital bitewing radiography (BWR), and near-infrared light transillumination (NIR-LT, DIAGNOcam, KaVo, Biberach, Germany) for occlusal caries detection and assessment of posterior teeth.

PARTICIPANTS AND METHODS

This study included 203 patients (mean age 23.0 years). All individuals received a meticulous VI. Additionally, BWR and NIR-LT images were collected. All BWR and NIR-LT images were blindly evaluated for the presence of enamel caries lesions (ECLs) and dentin caries lesions (DCLs). The descriptive statistical analyses included calculation of frequencies, cross tabulations, and pairwise comparisons using Pearson chi-square tests.

RESULTS

The majority of ECLs/DCLs were detected by VI in this low-risk adult population. The additional diagnostic outcomes in terms of ECLs/DCLs amounted to 5.0% (BWR) and 6.8% (NIR-LT). The combined usage of VI/NIR-LT or VI/BWR identified 95.7 and 94.4% of all ECLs/DCLs on occlusal surfaces, respectively.

CONCLUSION

This comparative diagnostic study showed that VI detected the majority of occlusal caries lesions. Both additional methods showed limited benefits. Due to the valuable features of NIR-LT, i.e., X-ray freeness and clinical practicability, this method might be preferred over X-ray-based methods. Nevertheless, BWRs should be prescribed in clinical situations where insufficient fillings or multiple (deep) caries lesions are diagnosed or where there is a need to assess the caries extension in relation to the pulp.

CLINICAL RELEVANCE

VI has to be understood as caries detection method of choice on occlusal surfaces in low-risk adult population which may help to avoid multiple diagnostic testing, overdiagnosis, and overtreatment.

The Influence of Cognitive Bias on Caries Lesion Detection in Preschool Children

We aimed to evaluate whether children’s caries experience exerts an influence on the performance of visual and radiographic methods in detecting nonevident proximal caries lesions in primary molars. Eighty children (3–6 years old) were selected and classified as having a lower (≤3 decayed, missing, or filled surfaces; dmf-s) or higher (> 3 dmf-s) caries experience. Two calibrated examiners then assessed 526 proximal surfaces for caries lesions using visual and radiographic methods. As a reference standard, 2 other examiners checked the surfaces after temporary separation. Noncavitated and cavitated lesion thresholds were considered and Poisson multilevel regression analyses were conducted to evaluate the influence of caries experience on the performance of diagnostic strategies. Accuracy parameters stratified by caries experience were also derived. A statistically significant influence of caries experience was observed only for visual inspection, with more false-positive results in children with a higher caries experience at the noncavitated lesion threshold, and more false results at the cavitated threshold. The detection of noncavitated caries lesions in children with a higher caries experience was overestimated (specificity = 0.696), compared to children with a lower caries experience (specificity = 0.918), probably due to confirmation bias. However, the examiners underestimated the detection of cavitated lesions in children with a higher caries experience (sensitivity = 0.143) compared to lower-caries-experience children (sensitivity = 0.222), possibly because of representativeness bias. The radiographic method was not influenced by children’s caries experience. In conclusion, children’s caries experience influences the performance of visual inspection in detecting proximal caries lesions in primary teeth, evidencing the occurrence of cognitive biases.

Cariology Education in Canadian Dental Schools: Where Are We? Where Do We Need to Go?

The aim of this study was to document cariology education across Canadian dental schools. Ten faculty members who supervise cariology education at each of the ten Canadian dental schools were invited to participate in the study in 2016. An adapted version of the European Organization for Caries Research-Association for Dental Education in Europe cariology curriculum group questionnaire was used. Representatives of all ten dental schools completed the questionnaire, for a 100% response rate. In four schools, cariology and restorative dentistry were taught by the same department. Five schools had didactic/laboratory courses focusing primarily on cariology as well as a specific written curriculum. Six schools provided cariology-related hands-on workshops/laboratories before students started working with patients. In teaching cariology, seven institutions included dental hard tissues defects. The following caries detection methods were addressed didactically in cariology education: visual (10/10 total schools), tactile (9/10), International Caries Detection and Assessment System criteria (6/10), caries activity assessment (9/10), radiographic (10/10), and other detection tools (8/10). Seven schools charted activity of carious lesions in clinic. Only one school used the concept of caries risk assessment regularly in clinic. Clinical cariology teaching was carried out mostly by private dentists hired as clinical instructors (7/10) and faculty members involved in didactic cariology education (9/10). Calibration of faculty members for caries detection criteria was reported by only one school. The main concern reported by all institutions was the difficulty of implementing didactic instruction on cariology into clinical training. This study found that contemporary cariology concepts are in the process of being implemented in didactic education across Canadian dental schools, but all schools lacked appropriate integration of cariology education into clinical training. These findings suggest a need for harmonization of evidence-based cariology education in Canada.

Oral health and the frailty syndrome

The frailty syndrome is an ever-growing area of study among older adults because of its association with an increased risk of falls, hospitalization, institutionalization, dependency and mortality. Frailty is neither a disease nor a disability but is better understood as a medical syndrome of multisystem dysregulation that results in a diminished ability to overcome everyday stressors. The prevalence of frailty in any given population can vary widely, in part because of the way in which it is defined and measured, but in general it is higher among women and in those with advanced age and declining health. Whilst it is largely understood that older adults will differ biologically, psychologically and socially, and that each of these domains can impact oral health, we are only beginning to investigate how the mouth is affected in frailty. Given that both hard and soft structures contribute to oral health and disease status among older adults with varying degrees of impairment and disability, frailty adds yet another dimension to be considered. This paper will discuss how frailty can influence and be influenced by oral disorders, as well as the potential relationship to oral neglect and the resultant consequences among this vulnerable population.

Caries treatment decisions among undergraduate and postgraduate students supported by visual detection systems

BACKGROUND

The difficulties of caries diagnosis and the level of examiner's experience may influence the treatment decision, resulting excessive and inefficient intervention.

AIM

This randomized experimental study evaluated caries treatment decisions made by undergraduate (UG) and postgraduate (PG) students when examination was performed through conventional visual clinical examination (CVCE) and when supported by ICDAS (IC) or Nyvad's (NY) criteria.

DESIGN

Four UG and four PG initially analyzed, by CVCE, 300 primary incisors and molars surfaces of 25 children aged 5-12 years, and choose between no treatment, non-operative, and operative treatment. Students were randomized between IC (2UG; 2PG) and NY (2UG; 2PG) and, after one week of receiving training, repeated evaluations and treatment suggestions. Reference standard was established by two researchers' consensus. Sensitivity, specificity, ROC analysis, and kappa were calculated. Treatment decisions were analyzed by means of contingency tables.

RESULTS

Only sensitivity showed statistical difference (P < 0.05). Operative treatment had high percentage for initial lesions at first evaluation for both criteria; second evaluation showed higher percentage of non-operative treatments for the same lesions.

CONCLUSIONS

IC and NY present satisfactory performance in primary teeth by UG and PG, and their use may assistance UG to adopt a less interventionist approach for initial enamel lesions.

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.

Examiner's experience and the outcome interpretation of ICDAS and Nyvad's system - a prospective in vitro study

OBJECTIVE

To evaluate, prospectively, the influence of examiner's experience in interpreting and applying the caries detection systems ICDAS (IC) and Nyvad (NY).

MATERIAL AND METHODS

Twelve second-year undergraduate dental students (UG) and 12 postgraduates (PG) MSc level analysed and codified 77 clinical dental caries photographs at three different moments: initially, without any training; after one week of receiving training through a theoretical class; and after two years. Reproducibility and correlation was evaluated; sensitivity, specificity and area under ROC curve (AUC) were dichotomized according to the presence of cavitation (IC) and in relation to disease activity (NY).

RESULTS

IC presented good kappa values for the first two evaluations. Both criteria resulted in good Spearman's correlation after two years (IC = UG: 0.89; PG: 0.93/NY = UG: 0.81; PG: 0.82). Sensitivity, specificity and AUC were statistically higher in the third evaluation by UG for Nyvad.

CONCLUSIONS

ICDAS criteria seem to be instinctively understood by students without clinical experience. Nyvad's concepts performed better after two years where the students deepened their theoretical knowledge and experienced clinical practice, collaborating with the identification of activity signs.

Overtreatment in Caries Management? A Literature Review Perspective and Recommendations for Clinicians

Dentistry, like various branches in the healthcare profession, is susceptible to overtreatment, especially in the management of dental caries, due to the adoption of an aggressive restorative approach. This philosophy provides no actual benefits to the patient in terms of arresting the disease process, which initially led to the carious lesions. Yet practitioners routinely continue to initiate restorative treatment procedures without attempting to understand and alter the biologic factors contributing to the caries process. This paper examines the available scientific literature in this regard and makes recommendations to the clinicians of today based on the available evidence. CPD/Clinical Relevance: The paper provides clinicians an approach to avoiding overtreatment by adhering to established clinical guidelines and accepted operative strategies.

Clinical relevance of studies on the accuracy of visual inspection for detecting caries lesions: a systematic review

Although visual inspection is the most commonly used method for caries detection, and consequently the most investigated, studies have not been concerned about the clinical relevance of this procedure. Therefore, we conducted a systematic review in order to perform a critical evaluation considering the clinical relevance and methodological quality of studies on the accuracy of visual inspection for assessing caries lesions. Two independent reviewers searched several databases through July 2013 to identify papers/articles published in English. Other sources were checked to identify unpublished literature. The eligible studies were those which (1) assessed the accuracy of the visual method for detecting caries lesions on occlusal, approximal or smooth surfaces, in primary or permanent teeth, (2) used a reference standard, and (3) reported data about sample size and accuracy of the methods. Aspects related to clinical relevance and the methodological quality of the studies were evaluated. 96 of the 5,578 articles initially identified met the inclusion criteria. In general, most studies failed in considering some clinically relevant aspects: only 1 included study validated activity status of lesions, no study considered its prognosis, 79 studies did not consider a clinically relevant outcome, and only 1 evaluated a patient-centred outcome. Concerning methodological quality, the majority of the studies presented a high risk of bias in sample selection. In conclusion, studies on the accuracy of the visual method for caries detection should consider clinically relevant outcomes besides accuracy; moreover, they should be conducted with higher methodological quality, mainly regarding sample selection.

Impact of the radiographic examination on diagnosis and treatment decision of caries lesions in primary teeth--the Caries Detection in Children (CARDEC-01) trial: study protocol for a randomized controlled trial

BACKGROUND

Although most clinical guidelines throughout the world indicate that clinicians take two bitewings for detecting caries lesions in primary molars of all children, evidence for this recommendation is essentially based on cross-sectional studies performed in laboratory settings or using convenience samples. The benefits and impact of performing radiographs on diagnosis and treatment decision of caries lesions in primary teeth, mainly considering relevant outcomes for patients, have not been evaluated yet. Thus, the aim of this randomized clinical trial will be to evaluate the impact of performing radiographic examination adjunct to the visual inspection for detecting and making treatment decision regarding caries lesions in primary teeth compared with visual inspection performed alone. We will consider different outcomes related to children's health and welfare.

METHODS/DESIGN

To reach this objective, 250 children ages 3 to 6 years who sought dental treatment in our dental school will be randomly allocated in two groups according to the diagnostic strategy used for caries detection: visual inspection performed alone or visual inspection associated to radiographic examination. Two trained and calibrated examiners will carry out the examinations and elaborate the treatment decision plan. Then, children will be treated and followed up for 2 years, with evaluations after 12 and 24 months after the inclusion of children in the study. Children will also return after 6 and 18 months to reinforce the preventive orientations. Primary outcome will be the number of dental surfaces in need of dental treatment at the follow-up. Secondary outcomes will be the components of the primary outcome separately, as well as, proportion of false-positive results, the oral health-related quality of life, cost-efficacy, cost-adjusted life years, and number of new lesions in the first permanent molars.

DISCUSSION

Our working hypothesis is that radiographic examination would actually exert little influence on patient-centered outcomes, and visual inspection would be enough as diagnostic strategy for caries detection in primary teeth.

TRIAL REGISTRATION

NCT02078453. Registered 4 March 2015.

Ex vivo evaluation of new 2D and 3D dental radiographic technology for detecting caries

OBJECTIVES

Proximal dental caries remains a prevalent disease with only modest detection rates by current diagnostic systems. Many new systems are available without controlled validation of diagnostic efficacy. The objective of this study was to evaluate the diagnostic efficacy of three potentially promising new imaging systems.

METHODS

This study evaluated the caries detection efficacy of Schick 33 (Sirona Dental, Salzburg, Austria) intraoral digital detector images employing an advanced sharpening filter, Planmeca ProMax(®) (Planmeca Inc., Helsinki, Finland) extraoral "panoramic bitewing" images and Sirona Orthophos XG3D (Sirona Dental) CBCT images with advanced artefact reduction. Conventional photostimulable phosphor images served as the control modality. An ex vivo study design using extracted human teeth, ten expert observers and micro-CT ground truth was employed.

RESULTS

Receiver operating characteristic analysis indicated similar diagnostic efficacy of all systems (ANOVA p > 0.05). The sensitivity of the Schick 33 images (0.48) was significantly lower than the other modalities (0.53-0.62). The specificity of the Planmeca images (0.86) was significantly lower than Schick 33 (0.96) and XG3D (0.97). The XG3D showed significantly better cavitation detection sensitivity (0.62) than the other modalities (0.48-0.57).

CONCLUSIONS

The Schick 33 images demonstrated reduced caries sensitivity, whereas the Planmeca panoramic bitewing images demonstrated reduced specificity. XG3D with artefact reduction demonstrated elevated sensitivity and specificity for caries detection, improved depth accuracy and substantially improved cavitation detection. Care must be taken to recognize potential false-positive caries lesions with Planmeca panoramic bitewing images. Use of CBCT for caries detection must be carefully balanced with the presence of metal artefacts, time commitment, financial cost and radiation dose.

Confronting dental uncertainty in old age

OBJECTIVE

To provide an overview of the literature about uncertainty in health care and how it relates to the oral health care of older people.

BACKGROUND

The medical literature describes uncertainty in health care from the initial informed-consent to its impact on a patient's ability to cope with undesirable outcomes.

METHODS

A narrative review of the medical, dental and psychological literature was conducted to identify pertinent information on the theory and implications of uncertainty in healthcare. The findings are infused into a case-report illustrating the recurrence of uncertainty experienced by an older woman who had multiple treatments over several years to restore her dentition damaged severely by dental caries.

RESULTS

Uncertainty originates from inadequate understanding, incomplete information and undifferentiated alternatives leading to unnecessary diagnostic tests and healthcare costs. A conceptual taxonomy clarifies the characteristics of uncertainty in the context of scientific, practical or personal sources and offers management possibilities through effective communications to identify choices and probabilities that help patients to adapt and cope with adverse events.

CONCLUSIONS

Uncertainty pervades healthcare. It can lead patients to self-blame, anger and withdrawal from care unless it is communicated effectively so that they can adapt and cope with the disappointment of adversity and continue with alternative approaches to care.

Caries management by risk assessment: A review on current strategies for caries prevention and management

The current trend in treating dental caries is using nondestructive risk-based caries management strategies rather than focusing on the restorative treatment alone. Currently, there have been many changes in understanding of the multifaceted nature of caries process and its management. Caries Management by Risk Assessment (CAMBRA) which is an evidence-based approach focuses on determining many factors causing the expression of disease and take corrective action. The clinicians can ascertain what behaviors are increasing a patient's risk for disease and disease progression by evaluating the current caries risk of a patient. With this modern CAMBRA protocol, a novel treatment plan can be designed to arrest dental caries thereby decreasing the chance of cavitation. After the recognition of the multi factorial nature of caries involving the biofilm, the contemporary approaches focused mainly on the various options to cope with the locally out-of-balance oral biofilm and stop the progression of the disease. The initial caries lesions can be diagnosed with modern diagnostic aids and with the help of CAMBRA, reestablishment of the integrity of the tooth surface early on in the caries process will bring great rewards for patients. This review focuses on the repair of hard tooth tissues using noninvasive strategies.

Performance of undergraduate dental students on ICDAS clinical caries detection after different learning strategies

AIM

This study aimed to evaluate the effect of a digital learning tool on undergraduate dental students' performance in detecting dental caries using ICDAS.

METHODS

An experimental digital learning tool (DLT) was created using digital photographs of sound and carious teeth. Thirty-nine students were divided into three groups (n = 13) and each assessed 12 randomly allocated patients before and after learning strategies: G1, ICDAS e-learning program; G2, ICDAS e-learning program plus DLT; G3, no learning strategy. Students (n = 32) reassessed patients 2 weeks after training.

RESULTS

Comparing before and after the learning strategies, any difference in the values of specificity and area under the ROC curve for all groups was found. Sensitivity was statistically significantly higher for G1 and G2. Comparing the groups, G2 showed a significant increase in sensitivity at the D2 and D3 thresholds. Spearman's correlations with the gold standard before and after the learning strategy were 0.60 and 0.61 for G1, 0.57 and 0.63 for G2, and 0.54 and 0.54 for G3, respectively. The Wilcoxon test showed a statistically significant difference between the values obtained before and after learning strategies for G1 and G2.

CONCLUSIONS

Use of the DLT after the ICDAS e-learning program tended to increase the sensitivity of ICDAS used by undergraduate dental students. The DLT appeared to improve dental students' ability to use ICDAS.

In vivo validation of near-infrared light transillumination for interproximal dentin caries detection

OBJECTIVES

The aims of this clinical study were to investigate the diagnostic accuracy of near-infrared light transillumination (NILT) as a novel X-ray-free method for proximal dentin caries detection and to compare this method to established diagnostic methods.

MATERIALS AND METHODS

A total of 127 interproximal dentin caries lesions without any cavity within visible dentin in posterior teeth from 85 consecutively selected patients were included. Visual and radiographic diagnoses and laser fluorescence measurements were available. NILT images were obtained, and a dentin lesion was predicted if a demineralisation involved the enamel-dentin junction (NILT-EDJ) or a shadow in dentin was detectable (NILT-dentin). Included lesions were opened and validated (reference standard). The statistical analyses included descriptive analyses and calculations of sensitivity, specificity and Az values.

RESULTS

The diagnostic accuracy with respect to the reference standard was 1.6% for visual inspection, 66.7% for laser fluorescence, 96.1% for digital radiography, 29.1% for NILT-dentin and 99.2% for NILT-EDJ. Bitewings (Az 0.984) and NILT-EDJ (Az 0.992) performed equally.

CONCLUSION

Given the lack of true negatives in the study, the diagnostic accuracy of NILT achieved the same level as bitewings for the detection of proximal dentin caries.

CLINICAL RELEVANCE

This study might indicate that NILT could reduce the usage of bitewings.

Impact of different magnification levels on visual caries detection with ICDAS

OBJECTIVES

The aim of this in vitro study was to examine the effect of different levels of magnification on the accuracy and reliability of visual caries detection using ICDAS criteria.

METHODS

Occlusal surfaces of 100 extracted molars were assessed by 14 examiners (3rd and the 4th year dental students and dentists) using no magnification aids, a 2.5× Galilean loupe, a 4.5× Keplerian loupe, or a surgical microscope with 10× magnification. The assessments were repeated on a different day. Sensitivity, specificity, AUC and reliabilities were calculated according to the gold standard of histology.

RESULTS

We found that with increasing magnification, the number of surfaces rated as "sound" (ICDAS code 0) decreased, while the number of surfaces with a localized enamel breakdown (ICDAS code 3) increased. While the sensitivities increased, the values of the specificities decreased to an unacceptably low level irrespective of the clinical experience of the examiners.

CONCLUSIONS

ICDAS seems to be optimized for natural vision up to 2.0× magnification and not for high magnifications. The use of powerful magnification in visual caries detection involves the risk of unnecessary and premature invasive treatment.

CLINICAL SIGNIFICANCE

This paper discusses when it does and does not make sense to use magnification devices for visual caries detection using ICDAS criteria. Strong magnifications should be refrained from for this purpose.

Proximal caries lesion detection in primary teeth: does this justify the association of diagnostic methods?

The aim of this clinical study was to evaluate and compare the performance of visual exam with use of the Nyvad criteria (visual examination - (VE)), interproximal radiography (BW), laser fluorescence device (DIAGNOdent Pen-DDPen), and their association in the diagnosis of proximal lesions in primary teeth. For this purpose, 45 children (n = 59 surfaces) of both sexes, aged between 5 and 9 years were selected, who presented healthy primary molars or primary molars with signs suggestive of the presence of caries lesions. The surfaces were clinically evaluated and coded according to the Nyvad criteria and immediately afterwards with the DDPen. Radiographic exam was performed only on the surfaces coded with Nyvad scores 2, 3, 5, or 6. Active caries lesions and/or those with discontinuous surfaces were restored, considering the depth of lesion as reference standard. Sensitivity, specificity, accuracy, and area under ROC curve were calculated for each technique and its associations. Visual exam with Nyvad criteria presented the highest specificity, accuracy, and area under ROC curve values. The DDPen presented the highest sensitivity values. Association with one or more methods resulted in an increase in specificity. The performance of visual, radiographic, and DDpen exams and their associations were good; however, the clinical examination with the Nyvad criteria was sufficient for the diagnosis of interproximal lesions in primary teeth.

How much dentists are ethically concerned about overtreatment; a vignette-based survey in Switzerland

BACKGROUND

Overtreatment (or unnecessary treatment) is when medical or dental services are provided with a higher volume or cost than is appropriate. This study aimed to investigate how a group of dentists in Switzerland, a wealthy country known to have high standards of healthcare including dentistry, evaluated the meaning of unnecessary treatments from an ethical perspective and, assessed the expected frequency of different possible behaviors among their peers.

METHODS

A vignette describing a situation that is susceptible for overtreatment of a patient was presented to a group of dentists. The vignette was followed by five options. A questionnaire including the vignette was posted to 2482 dentists in the German-speaking areas of Switzerland. The respondents were asked to rate each option according to their estimation about its prevalence and their judgment about the degree to which the behavior is ethically sound.

RESULTS

732 completed questionnaires were returned. According to the responses, the most ethical and the most unethical options are considered to be the most and the least prevalent behaviors among dentists practicing in Switzerland, respectively.

CONCLUSIONS

Suggesting unnecessary treatments to patients seems to be an ethically unacceptable conduct in the eyes of a sample of dentists in Switzerland. Although the respondents believed their colleagues were very likely to behave in an ethical way in response to a situation that is susceptible to overtreatment, they still seemed to be concerned about the prevalence of unethical behaviors in this regard.