Accuracy at radiography and probing for the diagnosis of proximal caries

In 63 teenagers the proximal surfaces of premolars to be extracted for orthodontic reasons and the adjacent surfaces of neighboring teeth, 598 surfaces in all, were examined radiographically and by probing. Direct inspection after extraction revealed that 51% of the surfaces had incipient carious lesions and 5% lesions with cavities. Of the surfaces with cavities 82.1% were correctly diagnosed radiographically if any radiolucency, regardless of its extent, was used as a diagnostic criterion. However, this yielded a false positive rate of 19.6%. If only radioluccncies extending at least into the inner third of the enamel were called positive the true positive rate was 36.7% and the associated false positive rate 1.6%. At a 5% cavity frequency the predictive positive values were 17% and 53%, respectively. Probing yielded a true positive rate of about 29% and a false positive rate of 1.1% with a predictive positive value of 50-57%. All radiolucencies extending into the dentin were associated with cavities. When the most liberal radiographic criterion was used 37.5% of all carious lesions, whether associated with a cavity or not, were detected and 3.8% of sound surfaces were falsely called carious. The corresponding predictive positive value at the actual rate of incipient lesions and lesions with cavities was 92.6%.     

Accuracy at radiography and probing for the diagnosis of proximal caries

In 63 teenagers the proximal surfaces of premolars to be extracted for orthodontic reasons and the adjacent surfaces of neighboring teeth, 598 surfaces in all, were examined radiographically and by probing. Direct inspection after extraction revealed that 51% of the surfaces had incipient carious lesions and 5% lesions with cavities. Of the surfaces with cavities 82.1% were correctly diagnosed radiographically if any radiolucency, regardless of its extent, was used as a diagnostic criterion. However, this yielded a false positive rate of 19.6%. If only radiolucencies extending at least into the inner third of the enamel were called positive the true positive rate was 36.7% and the associated false positive rate 1.6%. At a 5% cavity frequency the predictive positive values were 17% and 53%, respectively. Probing yielded a true positive rate of about 29% and a false positive rate of 1.1% with a predictive positive value of 50-57%. All radiolucencies extending into the dentin were associated with cavities. When the most liberal radiographic criterion was used 37.5% of all carious lesions, whether associated with a cavity or not, were detected and 3.8% of sound surfaces were falsely called carious. The corresponding predictive positive value at the actual rate of incipient lesions and lesions with cavities was 92.6%.     

Radiographic identification of simulated carious lesions in relation to fillings with Adaptic Radiopaque®

The purpose of the present study was to elucidate the possible significance of the radiopacity of a composite restorative material for the radiographic identification of filling deficiencies. Class III cavities of varied size and shape were prepared at 28 proximal surfaces of 14 extracted human canines. All cavities were filled with Adaptic Radiopaque®. Simulated secondary or recurrent carious lesions were produced in 16 of the cavities by insertion of small amounts of radiolucent wax prior to filling. Each tooth was radiographed under standardized conditions using 15 different angulations. The 210 radiographs were interpreted by three observers without knowledge of the distribution of the deficiencies. They made 78.7% correct diagnoses, 18.7% false positive and 2.6% false negative diagnoses. The sensitivity of the method was 95.4, but the specificity was only 56.5. The results indicate that radiopacity of a composite resin is of a certain, although limited, value in detecting secondary and recurrent carious lesions. Regarding the high number of false positive diagnoses the radiographic findings should as far as possible be verified by a clinical examination. A majority of the false positive diagnoses could be explained by an inhomogeneous structure of the fillings.     

Clinical and radiographic appearance of proximal carious lesions at the time of operative treatment in young permanent teeth

Clinical tissue changes were recorded during restorative treatment of proximal carious lesions of young premolars and molars. 60 proximal surfaces with radiolucencies in the inner half of the enamel or the outer half of the dentin were treated. The extent and character of the tissue changes were documented with photographs taken during drilling and evaluated after magnification. The maximum extent for each lesion was correlated to the extent of the radiographically observed lesion. The results showed that 70% of the restored surfaces were associated with a breakdown of the enamel surface. When the radiolucency did not extend deeper than into the inner half of the enamel, cavities were found in 61%; for lesions with a radiolucency extending into the outer half of the dentin the percentage was 78%. In the majority of cases the cavity was limited to the enamel. In all cases discoloration was observed in the enamel. The dentin was soft and discolored in 83%. Severe damage of tooth substance was found in 12% of the teeth.     

Score system for behaviour of radiologically diagnosed approximal carious lesions

The evolution of systems which monitor changes in the severity of approximal carious lesions diagnosed from serial bitewing radiographs is reviewed. These systems derive a 'score' for each individual lesion based upon the extent of its progression. A new lesion behaviour score system is described which, unlike its predecessors, allows both lesion regression and data from partially overlapped but readable surfaces to contribute to scores. It employs scoring codes from a previously proposed standardized grading system which is compatible with WHO recommendations for grading clinical caries. The score system is designed to be used as a computer program capable of running on a variety of readily available microcomputers; this allows the incorporation of a flexible range of additional options which use the standard data files to calculate scores according to differing conventions. These accommodate variations in: the threshold at which restorative intervention is practiced, the treatment of reversals of caries diagnosis, the threshold of caries diagnosis and the way in which partially overlapped surfaces are scored. These options allow the system to be configured to suit the local needs of different investigations and workers, and also permit the study of the effects of these various methodologies.     

Radiographic display of carious lesions and cavitation in approximal surfaces: Advantages and drawbacks of conventional and advanced modalities

Background. Treatment strategies have changed with efforts on arresting carious lesions suspected to have an intact surface sparing operative treatment for cavitated lesions. Radiography is still the most recommended adjunct method in the diagnosis of clinically inaccessible approximal surfaces. Bitewing radiography. The major drawback of bitewing radiography for caries diagnosis is that the clinical state of the surface cannot be determined; i.e. if cavitation has developed or the demineralized surface is still intact. Based on studies of the relationship between radiographic lesion depth and clinical cavitation in approximal surfaces, a threshold for operative treatment decision has been suggested when a lesion is observed radiographically more than one-third into dentine. However, the results from previous studies are contradictory and the majority of studies are ～25 years old. In addition, there are few longitudinal observational studies on the behaviour of dentinal carious lesions, particularly in adults. Cone beam computed tomography. Cone beam CT is an advanced 3-dimensional radiographic modality, which seems much more accurate than intra-oral modalities for displaying cavitation in approximal surfaces. Nonetheless, there are several drawbacks with CBCT, such as radiation dose, costs and imaging artefacts. Therefore, CBCT cannot be advocated at current as a primary radiographic examination with the aim of diagnosing cavitated carious lesions. Conclusions. Bitewing radiography is, thus, still state-of-the-art as an adjunct in diagnosing carious lesions in clinically inaccessible approximal surfaces. The risk for cavitation is related to lesion depth, but new studies are needed in both child and adult populations to validate current thresholds for the operative treatment decision based on the radiographic lesion depth.     

Computer-automated caries detection in digital bitewings: consistency of a program and its influence on observer agreement

The aim of this study was to evaluate a decision-support, caries detection program and its influence on observer agreement in caries diagnosis. 130 patients were examined by digital bitewing radiography (RVG XL sensor, Trophy Radiologie Inc.). Fifty-four approximal surfaces (27 in premolars and 27 in molars) were selected by the author: 24 surfaces (9 in molars and 15 in premolars) scored as sound, 16 surfaces (9 in molars and 7 in premolars) scored as carious in enamel, and 14 surfaces (9 in molars and 5 in premolars) scored as carious in dentine. The Logicon Caries Detector (LCD) program (Logicon Inc., USA) was assessed by repeating the automated analysis ten times for each surface. The two most varying outcomes for lesion probability (Lp(min) and Lp(max)) were saved. Five observers scored the 54 surfaces independently as sound, caries in enamel or caries in dentine before and after the use of LCD. In more than one third of all surfaces the program indicated different lesion probability, from sound at Lp(min) to the presence of a carious lesion at Lp(max). The 5 observers changed their caries score after the use of LCD in a total of 31 surfaces (only 2 of these were in the same surface). Mean kappa value for inter-observer agreement for caries scores before the use of LCD was 0.47 (range 0. 39-0.61) and after LCD 0.48 (range 0.37-0.69). It was concluded that the automated caries detection program was not very consistent and provided different opinions on the caries status in a surface. Inter-observer agreement in caries diagnosis did not improve using the program.     

Radiographic diagnosis of incipient proximal caries: an ex-vivo study

The aim of this ex vivo study was to compare visual clinical and radiographic examinations to the histological analysis for proximal caries diagnosis in extracted permanent molars and premolars. The relationship between clinical aspects and carious lesions was also evaluated. Eighty-eight proximal surfaces (44 freshly extracted teeth) were longitudinally sectioned with a 370-microm diamond disk, thinned with wet silicon carbide paper and observed with a stereomicroscope at x40 magnification. Sensitivity and specificity were 65.6% and 83.3% for clinical examination and 29.7% and 95.8% for radiographic examination, respectively. Kappa values ranged from 0.64 to 0.91. The white spots corresponded to lesions restricted to enamel, while the dark spots corresponded to lesions that reached the dentinoenamel junction. In most cases, cavitation corresponded to dentin lesions. It may be concluded that interproximal radiographic examination is not a reliable method for detection of incipient proximal carious lesions.     

Restorative Certainty and Varying Perceptions of Dental Caries Depth Among Dentists

Objective : The question of whether dentists who most frequently identify tooth surfaces for definite restoration perceive dental caries as significantly deeper than other dentists is assessed. Methods : One group of 20 dentists independently examined 145 unrestored approximal tooth surfaces on 16 bitewing radiographs and recorded their restorative and depth decisions. Another group of 15 dentists similarly scored 304 unrestored surfaces on 30 bitewing radiographs. Each group of dentists was later divided into four subgroups according to the number of surfaces designated for definite restoration by each dentist. Results : As the number of tooth surfaces designated for definite restoration increased, mean caries depth (P<.05 for the high vs low subgroups) and the percent of dentinally carious surfaces increased, while the percent of surfaces assessed as sound decreased. Dentists with the lower numbers of surfaces designated for definite restoration came closest to the true histologic mean caries depth of the examined tooth surfaces. Conclusions : Dentists who designated high numbers of approximal tooth surfaces for definite restoration assessed caries as deeper than other dentists, and deeper than was proven histologically.     

Investigation into the relationship between deviations in X-ray angulation and images of proximal overlapping on bite-wing radiographs

Abstract Eleven child skulls were radiographed through a range of 50 degrees by varying the horizontal angulation of the X-ray beam in steps of 2 or 5 degrees. The changes in the width of overlapping contact images and the ranges through which no overlap occurred were measured. A linear relationship between changes in X-ray beam angulation and overlap width was found in all the skulls. Using the data it was calculated that for each increase in overlap width of 0.1 mm, 95% of the deviations in X-ray beam angulation were less than 2.5 degrees. The findings of this study suggested that the positioning of the X-ray beam so as to cause no overlapping is at best difficult, and at worst impossible. They also emphasize the importance of using identical projections in estimating the progress of carious lesions on radiographs since small changes can cause overlaps. The use of methods that reduce the error in repositioning the X-ray beam may be important in reducing methodological errors in clinical research.     

Comparison of three methods for detection of carious lesions in proximal surfaces versus direct visual examination after tooth separation

The present study aimed to compare clinical, fiber-optic transillumination and bite-wing radiographic assessment of carious lesion depth in contacting proximal surfaces with the results obtained by direct visual inspection after tooth separation of the respective surfaces. It is suggested that when a carious lesion is diagnosed as non-cavitated by clinical examination or restricted to enamel by FOTI or radiographic examinations in a population of children with low caries prevalence, dentists should adopt a preventive approach.     

Clinical cavitation and radiographic lesion depth in proximal surfaces in an Indian population

Objectives. To assess the relationship between clinical cavitation and radiographic caries lesion depth in proximal surfaces of permanent posterior teeth in an Indian population. This study also assessed the clinical feasibility of applying ’western guidelines’ to this population from the developing world. Materials and methods. Relationship between clinical cavitation and radiographic caries lesion depth in proximal surfaces in an Indian population was assessed. Proximal surfaces (n = 126) without restorations were examined on bitewing radiographs in patients with suspected caries and lesion depth was recorded by five observers. The radiographic scoring scale was 0 = sound; 1 = lesion in enamel; 2 = lesion in outer 1/3 of dentine and 3 = lesion in inner 2/3 of dentine. Orthodontic separators were placed interdentally and removed after 3 days, where surfaces were recorded as cavitated (yes/no) by two clinical validators (gold standard). Results. Enamel lesions were cavitated in 25.6–38.3%, outer dentinal lesions were cavitated in 83.3–100% and inner dentinal lesions were cavitated in 96.4–100% depending on observer and validator. On applying ‘western guidelines’ for treatment decision to the radiographic findings of lesion depth, 80–100% of the lesions observed in outer dentine would lead to a false (non-operative) treatment decision. Conclusions. Radiographic shallow carious lesions were often cavitated in this population. The threshold for cavitation in this study population is suggested to be set between enamel and outer dentine in contrast to western guidelines.     

Dental caries and restoration. IV. A six-year longitudinal study of the caries increment of proximal surfaces.

In order to study the progression of proximal caries lesions and the quality of restorations, a sample of individuals in Gothenburg, Sweden was radiographically examined at the ages of 16, 19 and 22. By means of an index system every proximal tooth surface was given a diagnosis and differences between examinations were evaluated by a score system. Of all decayed and filled surfaces observed at the age of 22 more than 70% were already established at the age of 16. During the 16--19 year interval more than twice as many new carious lesions were developed than during the 19--22 year interval. The decrease in the number of new lesions during the last interval was accompanied by a slower progression of already existing lesions. Both factors resulted in a lower mean value with regard to scores during the 19--22 year interval compared with the preceding one. However, great individual differences were noted and 22 percent of the individuals exhibited larger score values during the last interval than during the first. Relatively seen the number of restorations with overhanging margins was lower at the final examination than at the previous ones.     

The sensitivity and specificity of clinical assessment compared with bitewing radiography for detection of occlusal dentin caries.

PURPOSE: This prospective, cross-sectional study examined the sensitivity and specificity of clinical assessment compared to bitewing radiographs in the detection of occlusal dentin caries in permanent molars. METHODS: Subjects were 481 children aged 5-12 years from a school-based dental clinic. Occlusal surfaces of 1929, sealed and unsealed first and second permanent molars were examined clinically and scored using specific criteria. Teeth with any type of restorations or proximal caries, including preventive resin restorations, were excluded from the study. Bitewing radiographs were exposed within 4 weeks of clinical examination and were assessed for dentin radiolucencies beneath the occlusal surface. The results of the clinical examinations were correlated with those of bitewing radiographs. Information provided by the parents on history forms, including systemic fluoride exposure, was also noted. RESULTS: Of the 1833 teeth scored as clinically sound in the study, only 72 (4%) demonstrated a dentin radiolucency on bitewings, and 1761 (96%) were scored as sound. The sensitivity of the clinical examination was determined to be 0.96. In the teeth clinically scored as showing dentin caries, only 56/96 (58%) were found to have dentin radiolucencies on the radiographs. The specificity of the technique was determined to be 0.58. A positive history of a medical condition, or fluoride exposure, in the forms of toothpaste use, or water fluoridation did not affect the examination results. CONCLUSIONS: Clinical examination of cleaned and dried, sealed, and unsealed teeth has a sensitivity of 0.96 and a specificity of 0.58 in the detection of dentin radiolucencies in bitewing radiographs. Dentin radiolucencies beneath clinically sound occlusal surfaces are not significantly associated with gender, medical conditions or fluoride.     

Radiographic versus clinical extension of Class II carious lesions using an F-speed film

This study investigated the difference in the apparent radiographic and true clinical extension of Class II carious lesions. Sixty-two lesions in both maxillary and mandibular premolars and molars were radiographed using Insight bitewing film. Class II lesions were scored independently by two masked examiners using an 8-point lesion severity scale. During the restoration process the lesions were dissected in a stepwise fashion from the occlusal aspect. Intraoperative photographs (2x) of the lesions were made, utilizing a novel measurement device in the field as a point of reference. Subsequently, the lesions were all given clinical scores using the same 8-point scale. Statistical analysis showed a significant difference between the true clinical extension of the lesions compared to the radiographic score. "Aggressive" and "Conservative" radiographic diagnoses underestimated the true clinical extent by 0.66 mm and 0.91 mm, respectively. No statistical difference was found between premolars and molars or maxillary and mandibular arches. The results of this study help to define the parameters for making restorative treatment decisions involving Class II carious lesions.     

Clinical and radiographic appearance of proximal carious lesions at the time of operative treatment in young permanent teeth

Clinical tissue changes were recorded during restorative treatment of proximal carious lesions of young premolars and molars. 60 proximal surfaces with radiolucencies in the inner half of the enamel or the outer half of the dentin were treated. The extent and character of the tissue changes were documented with photographs taken during drilling and evaluated after magnification. The maximum extent for each lesion was correlated to the extent of the radiographically observed lesion. The results showed that 70% of the restored surfaces were associated with a breakdown of the enamel surface. When the radiolucency did not extend deeper than into the inner half of the enamel, cavities were found in 61%; for lesions with a radiolucency extending into the outer half of the dentin the percentage was 78%. In the majority of cases the cavity was limited to the enamel. In all cases discoloration was observed in the enamel. The dentin was soft and discolored in 83%. Severe damage of tooth substance was found in 12% of the teeth.     

Comparison of Clinpro Cario L-Pop estimates with CIA lactic acid estimates of the oral microflora

Clinpro Cario L-Pop (CCLP) is a semiquantitive test claimed to determine the general potential for caries development and to monitor the individual caries risk. This test translates the capacity of the tongue microflora to produce lactic acid into a score of 1-9, indicating a low, medium or high risk for caries development. The aim of this randomized crossover, clinical trial was to evaluate the CCLP on its variation over time and its capacity to monitor the effect of three different oral hygiene procedures. The CCLP readings were compared with measurements of lactic acid in tongue biofilm and plaque samples by capillary ion electrophoresis (CIA). After four washout periods, the distribution of scores in the low-, medium-, and high-risk categories was 10%, 16%, and 74%, respectively. Out of 30 subjects, 11 scored consistently in the same category. The coefficients of variance of lactic acid concentrations were 31% for tongue samples and 25% for plaque samples. After using antimicrobial toothpaste and mouthwash, the number of high-risk scores was reduced to 33%; reduced acidogenicity was also found in tongue and plaque samples. We conclude that CCLP can be used to monitor and stimulate compliance to an antimicrobial oral hygiene protocol.     

Caries risk reduction in patients attending a caries management clinic

Background: A Caries Management Clinic was established for patients at high risk of caries aiming to reduce caries incidence to close to zero. That is, to prevent new lesions on existing sound surfaces, along the susceptible restoration margins, and to remineralize existing cavitated and non‐cavitated lesions. Twenty patients attended the clinic every two weeks from April to December 2005. Methods: The Caries Management System is a ten‐step non‐invasive strategy to arrest and remineralize early lesions and includes consideration of the patient at risk, the status of each individual lesion, patient management, clinical management, and monitoring. Results: After six months, there was a 42 per cent increase in gingival sites having Gingival Index scores of zero, and a 21 per cent decrease in sites having Gingival Index scores of 2 compared to baseline (χ² = 137.67, 4 df, p = 0.00001). Ready to change (RTC) patients had significantly fewer sites scored GI ≤ 2 compared to not‐RTC patients (p = 0.01). Compared with the not‐RTC patients, RTC patients were more than twice as likely to have fewer sites scored GI ≤ 2 (RR = 2.43, 95% CI (1.24, 4.71), p = 0.01). A total of 100 out of 146 smooth non‐cavitated carious surfaces at baseline have remineralized after six months, 99 per cent of sound surfaces remained sound, and 23 new lesions were observed in six of the 20 patients (α² = 292, 7 df, p = 0.00001). About half of proximal surfaces showing bitewing scores of grade 1 or 2 had regressed (α² = 86.66, 56 df, p = 0.0001) and 95 per cent of proximal sound surfaces at baseline, as diagnosed via bitewing radiographs, remained sound. Conclusions: This audit revealed that the implementation of the non‐invasive approach to caries management which combined intensive coaching in oral hygiene maintenance, special home care and intensive monitoring in a clinic for high‐risk patients was able to reduce gingival inflammation and maintain low plaque levels, at least within the scope of this short‐term review.     

Validity of MicroCT for in vitro detection of proximal carious lesions in primary molars

Objective

This study aimed to validate the MicroCT for detection of proximal carious lesions in primary molars, using histology as the gold standard.

Methods

Forty-eight proximal surfaces of primary molars were examined. Two calibrated examiners conducted the examinations independently. Proximal surfaces were visually scored, using ICDAS. Bitewing radiographs, Micro-CT and histological analyses used caries scores: 0 = sound; 1 = outer enamel; 2 = inner enamel; 3 = not spread dentine; 4 = outer dentine; 5 = inner dentine. Axial and sagital images were used for Micro-CT analysis, whilst for histology, tooth sections (400 μm) were analyzed stereomicroscopically (×15).

Results

Inter-examiner agreement ranged from 0.87 to 0.93 kappa coefficient (k). Histological analysis revealed a frequency of sound tooth surfaces (18.8%) enamel carious lesions (E1) (48%) and dentine carious lesions (D1) (33.3%). MicroCT showed high correlation with histology (r_s0.88). At both diagnostic thresholds (E1 and D1), sensitivity and accuracy were higher for MicroCT. Inter-device agreement between MicroCT and histology was k = 0.81. No difference was found between MicroCT and histology as gold standards for detecting carious lesions using ICDAS.

Conclusion

MicroCT can be used as a gold standard for detecting carious lesions in proximal surfaces in primary molars.