Performance of diagnostic systems in occlusal caries detection compared

Abstract – Many investigations have been conducted to evaluate existing and new diagnostic systems in the detection of occlusal carious lesions. The performances of these systems are difficult to compare with each other, because of the disadvantages associated with the widely used validity parameters sensitivity and specificity. In this study a meta-analysis was performed to facilitate a comparison between the performances of diagnostic systems which are currently in use in occlusal caries diagnosis. Nine in vitro studies and one in vivo study complied with the selected criteria for inclusion in the analysis. The sensitivity and specificity values obtained from these studies were converted into normal deviate values, and plotted on linearly scaled normal-deviate axes. D_z values, which quantify the performance above chance of a diagnostic test in one single value, were calculated. Averaged D_z values of the diagnostic systems were subsequently compared to each other. The results indicate that electrical resistance measurements and fiber-optic transillumination had a comparatively good, and visual inspection and xeroradiography a poor, performance in occlusal caries diagnosis. All the other radiographic image modalities had intermediate performances.     

(牙合)面可疑龋诊断不同方法比较

目的:比较临床检查(CE),常规X线片(CR),(牙合)翼片(BW)和牙科X线影像诊断系统(RVG)诊断可疑(牙合)面龋的精确性.方法:44个可疑面龋的离体牙作为研究对象,以病理组织学检查为标准,测定计算真、假阳性率(TP,FP)和预测值(TP/FP).结果:TP和FP是:CE=0.63和1.91,CR=0.59T和0.88,BW=0.39和0.58,RVG=0.68和1.85.TP/FP是:CE=1.91,CR=0.88,BW=0.58,RVG=2.06.RVG与CE及CR无显著性差异(P>0.05).结论:RVG可期望增加诊断效果,并可减少X线剂量和产生即刻影像.     

牙合面尚未成洞龋早期诊断方法的进展

近20年来,由于预防工作的广泛展开,特别是氟化物的广泛应用,龋病的发病率明显下降.但牙合面龋所占比例却有所增加,常表现为在表面正常的牙釉质下向深层发展.因此,如何对尚未成洞龋作出早期正确诊断已成为口腔医生日益关注的问题,传统的视诊、探诊法已远远不能满足要求,迫切需要开发新型、有效的龋病诊断技术.本文介绍几种牙合面尚未成洞龋的诊断方法.     

Reliability of the Nyvad criteria for caries assessment in primary teeth

This study assessed the interexaminer and intra-examiner reliability of the Nyvad caries classification system in primary teeth and calculated the mean examination time. The criteria were based on visual and tactile examinations to differentiate active and inactive lesions at cavitated and non-cavitated levels. Eighty children (3-7 yr of age) were examined under standardized conditions by calibrated examiners. At the tooth surface level, reliability was expressed as percentage agreement and kappa coefficient, using four diagnostic thresholds: sound vs. diseased; sound or inactive lesion vs. active lesion; intact surface vs. surface discontinuity; and sound or non-cavitated lesion vs. cavitated lesion. Interexaminer and intra-examiner kappa values were, respectively: 0.82/0.86; 0.80/0.86; 0.90/0.94; and 0.95/0.98. At the individual level, reliability of estimates of the caries prevalence and of the decayed or filled surface (dfs) counts were assessed at three diagnostic thresholds: sound vs. diseased; sound or inactive lesion vs. active lesion; and sound or non-cavitated lesion vs. cavitated lesion. For caries prevalence, interexaminer and intra-examiner kappa values were, respectively: 0.84/0.94; 0.69/0.74; and 0.95/0.97. The mean examination time was 226.5s (SD = 128.5). The use of the Nyvad caries diagnostic criteria in primary teeth showed reliable results. The examination time was acceptable.     

Performance of methods of occlusal caries detection in permanent teeth under clinical and laboratory conditions

OBJECTIVES: To compare performance of visual inspection and Laser fluorescence methods to detect occlusal caries lesions under clinical and laboratory conditions in permanent teeth. METHODS: One hundred and ten sites in 57 third molars scheduled for extraction were examined with visual inspection and laser fluorescence (DIAGNOdent) device by two trained examiners. After the extraction, teeth were re-examined. Then, teeth were sectioned to perform histological validation. Best cut-off points were calculated with ROC analysis, and sensitivity, specificity and accuracy were calculated at D2 and D3 thresholds. Comparisons between the methods and conditions of examination were performed using McNemar test. Inter-examiner agreement in the same conditions and agreement between the methods performed in vivo and in vitro conditions were assessed by Kappa test. Laser fluorescence values obtained in two conditions were compared with Wilcoxon test. RESULTS: No difference was observed with visual inspection in both conditions. Laser fluorescence performed in vitro presented higher specificity and accuracy at D3 threshold. Visual inspection showed higher reproducibility. After adjustment of cut-off points for laser fluorescence method, there was no difference between the evaluated parameters. CONCLUSION: Only slightly differences were observed between the examinations performed under clinical and laboratory conditions in the detection of occlusal caries lesions in permanent teeth.     

Value of bitewing radiographs in detection of occlusal caries

A system of diagnosing occlusal caries from bitewing radiographs was developed in an attempt to overcome the problems of clinical diagnosis found in other studies. Standardised bitewing radiographs for 1172 Berkshire schoolchildren aged 11-13 years who were participating in a toothpaste trial, were assessed for occlusal caries under uniform magnification and illumination. The radiographic scores were then compared with the clinical records for these subjects. The radiographic technique proved to be acceptably reproducible at 82.6%. However, only 33.2% of the lesions present were detected on the radiographs. It is concluded that bitewing radiographs for the detection of occlusal caries are of little value in epidemiological studies.     

A longitudinal study of occlusal caries among schoolchildren in Dar es Salaam, Tanzania

OBJECTIVES: To describe the clinical caries status and the radiographic progression of occlusal caries lesions in permanent first and second molars among primary schoolchildren in Dar es Salaam over a 3-year period. METHODS: Clinical and radiographic diagnosis of caries in first and second permanent molars in 223 children aged 8-16 years were carried out annually from 1994 to 1997. The drop-out rates from the baseline in 1994 to the follow-up examinations in 1995, 1996 and 1997 were 16.6%, 22.0% and 35.4%, respectively. Twenty-one percent of the dropouts were picked up during the study. RESULTS: Less that 5% of all occlusal surfaces that were sound at the beginning of the study developed new clinical caries lesions over the 3-year study period. The highest rate of new lesions was found in second molars. The mandibular second molars were most frequently affected by new caries lesions followed by the mandibular first molars. Progression of lesions was generally slow. After 1, 2 and 3 years, 30.0%, 47.9% and 52.8% of lesions in occlusal surfaces of first molars had progressed, compared to 47.9%, 71.3% and 100.0% of lesions in second molars. CONCLUSIONS: Dental caries prevalence was low. New occlusal lesions were more likely to appear in mandibular second molars. Carious lesions were progressing slowly, especially in the first molars. Fissure abrasion may play a role in minimizing the risk of developing new occlusal lesions as well as progression of existing lesions.     

Assessment of diagnostic accuracy in caries detection: an analysis of two methods

Abstract – The quality of a diagnostic tool for caries detection is usually evaluated by quantification of observer performance using sensitivity and specificity values calculated from data obtained from ordinal caries depth rating scales. The application of Receiver Operating Characteristic (ROC) analysis has been restricted to the use of confidence rating scales. The aim of this investigation was to study the appropriateness of ROC analysis using caries depth ratings by comparing sensitivity and specificity values to parameters of diagnostic performance obtained by ROC analysis. In two recent reports, sensitivity and specificity values were utilized to express diagnostic accuracy of observer performance from specified caries diagnostic systems. The raw data from these investigations were subjected to ROC analysis in the current study. The results illustrated that ROC analysis, producing estimates of sensitivities for all specificities, yielded more comprehensive measures of diagnostic performance than single values for sensitivity and specificity. In particular, the area under the ROC curve constituted a clearly interpretable parameter representing the quality of diagnostic performance.     

Clinical performance of a laser fluorescence device for detection of occlusal caries lesions

Children and adolescents must be examined often for occlusal caries. Diagnosis of fissure caries is difficult especially when the tooth surface appears seemingly intact. It has been shown that using traditional clinical methods, as little as 20% of teeth with fissure caries under intact surfaces were correctly recognised as such. Therefore, new methods for increasing the accuracy of diagnosis have been sought for years. Recently, a new device, based on fluorescence measurements, was introduced. The purpose of this study was to test the device under in vivo conditions in order to provide recommendations for its use in the dental office. Seven general dental practitioners examined a total of 332 occlusal surfaces in 240 patients. Caries extent was determined for each site after operative intervention (='gold standard'). Clinical inspection and analysis of bitewing radiographs exhibited statistically significant lower sensitivities (31-63%) than did the DIAGNOdent device (sensitivity > or = 92%). It is recommended that the laser device is used in the decision-making process in relation to the diagnosis of occlusal caries as a second opinion in cases of doubt after visual inspection.     

Oral hygiene in the control of occlusal caries

Occlusal pit and fissure caries accounts for a high proportion of the total caries burden among children. Studies from Denmark suggested that oral hygiene measures may be effective in the control of occlusal caries in permanent teeth. This study reports on the findings after 24 months of a controlled field trial comparing the caries-preventive effects of a professional tooth-cleaning and dental health education programme (test) with a standard preventive programme (control), comprising selective fissure sealing and application of topical fluorides. School Dental Service clinics of the Health Department of Western Australia, in Perth, were assigned to four test or four control clinics. Schoolchildren, mean age 6 years, with sound newly erupted first permanent molars were included in the study (207 test, 197 control). After 24 months, 179 test and 156 control children were examined by a calibrated examiner who was 'blind' to the test or control status of the child. Thirty-two test and 31 control children developed occlusal caries on the first permanent molars; the estimated risk ratio was 0.90 (95% CI 0.58–1.41). Children in both groups had an average DMFT score of 0.30. The 24-month results suggest that the two preventive programmes did not differ with respect to the control of occlusal caries in newly erupted molars.     

光学相干断层成像检出早期窝沟龋效能的体外评估

目的 比较光学相干断层成像技术（OCT）与临床探视诊对人牙窝沟早期釉质龋的检出效能。方法 获取77颗人离体恒磨牙面的97个可疑早期龋位点OCT二维图像,由3位临床医师双盲法分别通过OCT图像和探视诊方法对这些位点进行评分,以偏光显微镜获取的组织学图像为金标准,评估OCT、临床探视诊检出早期窝沟龋的敏感度（SE）、特异度（SP）、阳性预测值（PPV）、阴性预测值（NPV）及其与组织学评分结果的相关性;采用Kappa检验分析检测者间评分结果的一致性,采用非参数法Z检验比较受试者工作特征（ROC）曲线下面积（AUC）。结果对于脱矿局限于釉质表层外1/2的窝沟早期龋,OCT检出率（14/25）明显优于探视诊（3/25）。OCT检出窝沟早期釉质龋的SE、SP、PPV、NPV（0.83、0.64、0.87、0.57）均高于探视诊（0.79、0.60、0.85、0.50）。OCT与探视诊检测窝沟早期龋的AUC（95% CI）分别为0.737（0.569~0.822）、0.696（0.614~0.859）,二者间差异无统计学意义。OCT评分与组织学评分呈正相关（r=0.559,P<0.05）,检测者间检测结果的一致性为中等。结论 OCT能够敏感、无创、有效地检出早期窝沟龋,具有辅助临床探视诊检出早期窝沟龋的应用潜能。     

激光荧光法诊断早期龋的研究进展及评价

早期龋的探测及诊断是龋病防治的重要方面.激光荧光法是新型龋诊断方法之一,它是利用龋坏部位激发的荧光强度远高于正常牙齿硬组织,定量分析牙体脱矿程度.激光荧光法灵敏度高、准确度高、可靠性好及无创性,可作为诊断早期龋的有效辅助手段.本文就激光荧光法诊断早期龋的原理、诊断价值、临床应用以及影响因素等研究进展作一综述.     

乳牙菌斑固相钙、磷、氟质量分数与患龋状况及摄糖频率的关系

目的分析乳牙菌斑固相成分中钙、磷、氟质量分数与患龋状况及摄糖频率之间的关系。方法将93名北京城区3~5岁儿童根据患龋情况分为重症婴幼儿龋（ S- ECC）组47人;无龋（ CF）组46人。分别收集集合菌斑,应用原子吸收光谱、分光光度计和氟离子选择性电极法测定受试者乳牙菌斑固相成分中钙、磷、氟质量分数,并进行组间比较;对两组受试者每日摄糖频率进行调查,分析菌斑固相成分中钙、磷、氟质量分数与摄糖频率的关系,并在S- ECC组分析菌斑固相中钙、磷、氟质量分数与dmft、dmfs的关系。结果S- ECC组菌斑固相成分中钙、磷、氟质量分数均值低于CF组,但是差别没有统计学意义;S- ECC组患儿每日摄糖频率高于CF组;乳牙菌斑固相成分中钙、磷、氟质量分数与摄糖频率及dmft、dmfs值之间没有相关关系。结论CF组儿童与S- ECC组患儿相比,并没有显示出其菌斑固相成分中拥有更大的钙、磷、氟储库。     

Establishing quantitative light-induced fluorescence cut-offs for the detection of occlusal dentine lesions

The aims of this in vitro study were, first, to define suitable cut-off values for the detection of occlusal dentine lesions by means of quantitative light-induced fluorescence (QLF), and, second, to compare the validity of light microscopy (LM) and microradiography (MR) as reference standards. Fifty-four third molar occlusal fissures with sound sites or non-cavitated lesions were examined. Standard QLF equipment was used to capture, display, store, and analyze fluorescence images. Each tooth was cut into sections in the bucco-lingual direction using a microtome saw, and the caries levels were subsequently assessed with the two reference methods. The histological examination with LM indicated that 46% of the specimens had carious lesions progressing into the dentine compared with 41% measured using MR (D3-4 level). Using optimal cut-off levels for the detection of dentine lesions, the sensitivity and specificity values were > 80%. The area under the receiver operating characteristic curve was slightly higher for MR (0.91-0.93) than for LM (0.88-0.89). The results of this study give a good idea of suitable cut-off points for the detection of occlusal dentine lesions using QLF. Owing to the small number of specimens in this study, further studies should be carried out before establishing definite cut-offs.     

Comparison of two laser fluorescence devices for the detection of occlusal caries in vivo

Laser fluorescence measurements have been shown to be well suited for caries diagnosis. The aim of this study was to compare two laser fluorescence devices and to correlate the respective values with the visual and radiographic assessment and with the extent of the carious lesion. Ninety-four clinically non-cavitated occlusal carious lesions in the premolars and molars of 82 patients were examined. Laser fluorescence values on the surface were measured with a conventional laser fluorescence system and a novel laser fluorescence pen device. When operative intervention at a site was indicated, the extent of caries was determined after its removal. Readings obtained with both systems were significantly different with an interdevice factor of 0.64. Sensitivity and specificity for operative care were 92.6% and 53.7%, respectively, for the conventional, and 88.9% and 53.7%, respectively, for the pen device. For both devices, a correlation between laser fluorescence values and the visual and radiographic assessment and with the extent of the lesion was shown. The study indicates that the novel laser fluorescence device seems to be suitable for occlusal caries diagnosis. However, proposed guidelines for the clinical use of laser fluorescence readings of the conventional device cannot be transferred to the novel pen system.     

Dental caries indices for primary teeth: the need to comply with international recommendations

This paper illustrates inconsistent use of abbreviations in indices employed to assess caries prevalence and incidence in the primary dentition. Possible consequences of this practice are discussed and it is suggested that authors, editoris and referees for dental journals should accept and adhere to internationally agreed upon definitions of these indices. As long as there is disagreement on the use of the dmf and def indices these initials should be defined under "methods".     

A dental caries severity index for primary teeth

Criteria for scoring the caries attack on each surface of an affected primary tooth are described. The score for each carious surface ranges from 1 to 3. The score per tooth is a sum of the surface scores. The caries severity index (csi) is the mean of the scores of all carious teeth in the population examined. Three groups of children aged 5-6.5 yr were examined. In Jerusalem, with a water fluoride concentration of 0.4 ppm, 54 children had a csi of 2.99 and a defs of 10.19. In a semirural African town, Soshanguva, with a 0.2 ppm fluoride concentration, 103 children had a csi of 3.10 and a defs of 5.75. In a nearby rural African area with a water fluoride concentration well above the optimum, 86 children had a csi of 1.93 and a defs of 1.99. Interexaminer and intraexaminer reproducibility of the csi were good. The csi expresses the severity of the caries attack on affected teeth and gives additional information to that of the def indices.     

同一个体乳牙列龋与恒牙列龋的相关性研究

目的：探讨同一个体乳牙龋与其年轻恒牙龋之间是否具有相关性，是否可以通过乳牙龋预见其恒牙龋的发生。方法：对293名5～6岁替牙期的儿童进行4年的跟踪调查，记录其在1999年和2003年时的乳、恒牙患龋情况，并进行统计学分析。结果：乳牙列龋与恒牙列龋之间相关性存在统计学意义。结论：乳牙列患龋严重的儿童，其恒牙患龋的可能性相对增高，可达乳牙列无龋者的4倍。特别是乳磨牙龋对其恒牙龋更具有预见价值。     

Diagnosis of dentin involvement in occlusal caries based on visual and radiographic examination of the teeth

The purpose of the present study was to examine the validity of visual, radio-graphic and combined visual-radiographic examination of occlusal caries, with special reference to the diagnosis of dentin lesions, using the microscopic diagnosis after sectioning the teeth as validating criterion. Thirty extracted permanent molar teeth with signs of occlusal caries were selected and radiographed using a standard method similar to bitewing. Ten dentists, five from the Department of Cariology and Endodontics and five from the Department of Pedodontics, were asked to make a visual, radiographic and combined visual-radiographic caries examination with an interval of at least 1 month between different examinations. The teeth were sectioned bucco-lingually and the caries assessed as enamel or dentin lesion in a stereomicroscope. The sensitivity/specificity of the diagnoses of dentin lesions was 0.72/0.41 for the visual, 0.66/0.50 for the radiographic, and 0.86/0.64 for the combined visual-radiographic examinations. The Receiver Operating Characteristic (ROC) method revealed a statistically significant difference between combined visual-radiographic examination and the two other, but not between the isolated visual or radiographic examination. It is concluded that the combined use of visual and radiographic examination is belter than either visual or radiographic examination alone.