Mariana Minatel Braga

Detection activity assessment and diagnosis of dental caries lesions.

This article reviews the current methods for detection and assessment of caries lesions focusing on applicability for daily clinical practice. The end point is to arrive at a diagnosis for each caries lesion. Visual inspection aided by a ball-ended probe is essential for caries lesions assessment and the method must be used for all patients. Use of indices, for example, the International Caries Detection and Assessment System (ICDAS), can improve the performance of this method. Using visual inspection, the clinician must decide about the presence, severity and activity of lesions. After this process, additional methods could aid the dentist in reaching a more appropriate treatment decision in some cases. The ICDAS, including the activity assessment system or the Nyvad system, seems to be the best option to reach final diagnoses for managing lesions. The radiographic method is the most recommended additional method available for daily clinical practice.

Performance of a pen-type laser fluorescence device and conventional methods in detecting approximal caries lesions in primary teeth--in vivo study.

This in vivo study aimed to compare the performance of different methods of approximal caries detection in primary molars. Fifty children (aged 5–12 years) were selected, and 2 examiners evaluated 621 approximal surfaces of primary molars using: (a) visual inspection, (b) the radiographic method and (c) a pen-type laser fluorescence device (LFpen). As reference standard method, the teeth were separated using orthodontic rubbers during 7 days, and the surfaces were evaluated by 2 examiners for the presence of white spots or cavitations. The area under the receiver-operating characteristics curve (Az) as well as sensitivity, specificity and accuracy (percentage of correct diagnosis) were calculated and compared with the McNemar test at both thresholds. The interexaminer reproducibility was calculated using the intraclass correlation coefficient (ICC-absolute values) and the kappa test (dichotomizing for both thresholds). The ICC value of the reference standard procedure was 0.94. At white-spot threshold, no methods tested presented good performance (sensitivity: visual 0.20–0.21; radiographic 0.16–0.23; LFpen 0.16; specificity: visual 0.95; radiographic 0.99–1.00; LFpen 0.94–0.96). At cavitation threshold, both LFpen and radiographic methods demonstrated higher sensitivity (0.55–0.65 and 0.65–0.70, respectively) and Az (0.92 and 0.88–0.89, respectively) than visual inspection sensitivity (0.30) and Az (0.69–0.76). All methods presented high specificities (around 0.99) and similar ICCs, but the kappa value for LFpen at white-spot threshold was lower (0.44). In conclusion, both LFpen and radiographic methods present similar performance in detecting the presence of cavitations on approximal surfaces of primary molars.

In vitro Comparison of Nyvad’s System and ICDAS-II with Lesion Activity Assessment for Evaluation of Severity and Activity of Occlusal Caries Lesions in Primary Teeth

This in vitro study of occlusal surfaces on primary molars aimed to: (1) evaluate the reproducibility of the Nyvad and ICDAS-II visual systems in detecting caries; (2) to test the accuracy of the systems in estimating lesion depth, and (3) to examine the association between the Nyvad system and the Lesion Activity Assessment system, an adjunct to ICDAS-II. Two samples of extracted primary molars (sample 1, n = 38; sample 2, n = 69) were evaluated independently by 2 examiners. In this in vitro study, evaluation of plaque in the Nyvad system was not possible. Histology (sample 2) was used to validate lesion depth. Area under ROC curves (Az), sensitivity, specificity and percent agreement of both systems were calculated at D1, D2 and D3 thresholds. Both systems showed kappa for intra- and inter-examiner agreement >0.86 and good correlation with histology: Spearman ρ = 0.73 (Nyvad) and 0.78 (ICDAS-II). They presented similar performances except that ICDAS-II showed significantly higher sensitivity (Nyvad 0.89; ICDAS 0.92) and Az (Nyvad 0.85; ICDAS 0.90) for the D1 threshold. The correlation between the systems for lesion activity (Cramer’s V) was 0.71. Therefore, both visual systems are reliable and can estimate caries lesion depth on primary teeth. Under in vitro conditions, there is no major difference between the Nyvad system and Lesion Activity Assessment in assessing caries activity.

Clinical Performance of Two Visual Scoring Systems in Detecting and Assessing Activity Status of Occlusal Caries in Primary Teeth

This study aimed to compare the clinical performance of two sets of visual scoring criteria for detecting caries severity and assessing caries activity status in occlusal surfaces. Two visual scoring systems – the Nyvad criteria (NY) and the ICDAS-II including an adjunct system for lesion activity assessment (ICDAS-LAA) – were compared using 763 primary molars of 139 children aged 3–12 years. The examinations were performed by 2 calibrated examiners. A subsample (n = 50) was collected after extraction and histology with 0.1% red methyl dye was performed to validate lesion depth and activity. The reproducibility of the indices was calculated (kappa test) and ROC analysis was performed to assess their validity and related parameters were compared using McNemar’s test. The association between the indices and with the histological examination was evaluated using Spearman’s correlation coefficient (rs). Visual criteria showed excellent reproducibility both regarding severity (NY: 0.94; ICDAS-II: 0.91) and activity (NY: 0.90; LAA: 0.91). The NY and LAA showed good association in caries activity assessment (rs = 0.88; 95% CI = 0.86–0.89; p < 0.001). Nevertheless, considering only cavitated lesions, this association was not significant (p > 0.05). Concerning the severity, both indices presented similar validity parameters. At D2 threshold, the sensitivity was higher for NY (NY = 0.87; ICDAS = 0.61, p < 0.05). Regarding activity status, NY showed higher specificities and accuracies. In conclusion, NY and ICDAS-II criteria are comparable and present good reproducibility and validity to detect caries lesions and estimate their severities, but the LAA seems to overestimate the caries activity assessment of cavitated lesions compared to NY.

Radiographic and laser fluorescence methods have no benefits for detecting caries in primary teeth.

Clinical guidelines advise that dentists take radiographs in children to detect caries lesions missed by visual inspection; however, due to the current low caries prevalence in most countries, we hypothesized that the adjunct methods of caries detection would not significantly improve the detection of primary molar lesions in comparison to visual inspection alone. We evaluated the performance of visual inspection, alone or in combination with radiographic and laser fluorescence pen (LFpen) methods, in detecting occlusal and approximal caries lesions in primary molars. Two examiners evaluated children who had sought dental treatment with these diagnostic strategies. The reference standard involved the temporary separation of approximal and operative interventions for occlusal surfaces. The sensitivity, specificity, accuracy and utility of diagnostic strategies were calculated. Simultaneous combined strategies increased sensitivities but decreased specificities. Furthermore, no differences were observed in accuracy and utility, parameters more influenced by caries prevalence. In conclusion, adjunct radiographic and laser fluorescence methods offer no benefits to the detection of caries in primary teeth in comparison to visual inspection alone; hence, present clinical guidelines should be re-evaluated.

In vitro performance of methods of approximal caries detection in primary molars

OBJECTIVE The aim was to compare the performance of different methods in detecting approximal caries lesions primary molars ex vivo. STUDY DESIGN One hundred thirty-one approximal surfaces were examined by 2 observers with visual inspection (VI) using the International Caries Detection and Assessment System, radiographic interpretation, and clinically using the Diagnodent pen (LFpen). To achieve a reference standard, surfaces were directly examined for the presence of white spots or cavitations, and lesion depth was determined after sectioning. The area under the receiver operating characteristic curve (A(z)), sensitivity, specificity, and accuracy were calculated, as well as the interexaminer reproducibility. RESULTS Using the cavitation threshold, all methods presented similar sensitivities. Higher A(z) values were achieved with VI at white spot threshold, and VI and LFpen had higher A(z) values at cavitation threshold. VI presented higher accuracy and A(z) than radiographic and LFpen at both enamel and dentin depth thresholds. Higher reliability values were achieved with VI. CONCLUSIONS VI performs better, but both radiographic and LFpen methods also show good performance in detecting more advanced approximal caries lesions.

Visual Inspection for Caries Detection A Systematic Review and Meta-analysis

We aimed to perform a systematic review including a meta-analysis to evaluate the overall accuracy of visual methods for detecting carious lesions and to identify possible sources of heterogeneity among the studies included. Two reviewers searched PubMed, Embase, Scopus, and other sources through July 2014 to identify published and nonpublished studies in English. Studies of visual inspection were included that 1) assessed accuracy of the method in detecting caries lesions; 2) were performed on occlusal, proximal, or free smooth surfaces in primary or permanent teeth; 3) had a reference standard; and 4) reported sufficient data about sample size and accuracy of methods. The data were used to calculate the pooled sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristics curve. Heterogeneity of the studies was also assessed. A total of 102 manuscripts (from 5,808 articles initially identified) and 1 abstract (from 168) met the inclusion criteria. In general, the analysis demonstrated that the visual method had good accuracy for detecting caries lesions. Although laboratory and clinical studies have presented similar accuracy, clinically obtained specificity was higher. We also observed moderate to high heterogeneity and evidence of publication bias in most papers. Moreover, studies employing widely recognized visual scoring systems presented significantly better accuracy as compared to studies that used their own criteria. In conclusion, visual caries detection method has good overall performance. Furthermore, although the identified studies had high heterogeneity and risk of bias, the use of detailed and validated indices seems to improve the accuracy of the method.

Fluorescence-Based Methods for Detecting Caries Lesions: Systematic Review, Meta-Analysis and Sources of Heterogeneity

Background Fluorescence-based methods have been proposed to aid caries lesion detection. Summarizing and analysing findings of studies about fluorescence-based methods could clarify their real benefits. Objective We aimed to perform a comprehensive systematic review and meta-analysis to evaluate the accuracy of fluorescence-based methods in detecting caries lesions. Data Source Two independent reviewers searched PubMed, Embase and Scopus through June 2012 to identify papers/articles published. Other sources were checked to identify non-published literature. Study Eligibility Criteria, Participants and Diagnostic Methods The eligibility criteria were studies that: (1) have assessed the accuracy of fluorescence-based methods of detecting caries lesions on occlusal, approximal or smooth surfaces, in both primary or permanent human teeth, in the laboratory or clinical setting; (2) have used a reference standard; and (3) have reported sufficient data relating to the sample size and the accuracy of methods. Study Appraisal and Synthesis Methods A diagnostic 2×2 table was extracted from included studies to calculate the pooled sensitivity, specificity and overall accuracy parameters (Diagnostic Odds Ratio and Summary Receiver-Operating curve). The analyses were performed separately for each method and different characteristics of the studies. The quality of the studies and heterogeneity were also evaluated. Results Seventy five studies met the inclusion criteria from the 434 articles initially identified. The search of the grey or non-published literature did not identify any further studies. In general, the analysis demonstrated that the fluorescence-based method tend to have similar accuracy for all types of teeth, dental surfaces or settings. There was a trend of better performance of fluorescence methods in detecting more advanced caries lesions. We also observed moderate to high heterogeneity and evidenced publication bias. Conclusions Fluorescence-based devices have similar overall performance; however, better accuracy in detecting more advanced caries lesions has been observed.

Is Atraumatic restorative treatment an option for restoring occlusoproximal caries lesions in primary teeth? A systematic review and meta-analysis.

BACKGROUND Atraumatic restorative treatment (ART) has demonstrated good longevity when used for single-surface restorations, but lower success rates are reported for occlusoproximal surfaces. AIM This systematic review and meta-analysis aimed to verify the pooled success rate of occlusoproximal ART restorations in primary teeth considering the outcomes: longevity, pulp damage, or caries lesion progression. DESIGN Literature searching was carried out on the studies reporting clinical trials indexed in PubMed and in English language, comprising the outcomes. A meta-analysis was undertaken considering the results from reviewed studies. RESULTS An initial search resulted in 126 articles, and three of them were finally selected. The main reasons for excluding articles were the absence of control group, as amalgam, composite resin, or compomer restorations to be compared with ART (hand excavation + high-viscous GIC). The pooled estimate (odds ratio; 95% confidence interval) for ART approach success was 1.04 (0.65-1.66). CONCLUSION Atraumatic restorative treatment restorations performed with high-viscous GIC present similar survival/success rates to conventional approach using composite resin or amalgam for occlusoproximal restorations in primary teeth and can be suggested as a good option for occlusoproximal cavities in primary molars. In addition, further randomized controlled clinical investigations concerning occlusoproximal restorations in primary teeth are still necessary.

Influence of the discomfort reported by children on the performance of approximal caries detection methods.

This in vivo study aimed to evaluate the performance of methods of approximal caries detection in primary molars and to assess the influence of the discomfort caused by these methods on their performance. Two examiners evaluated 76 children (4–12 years old) using visual inspection (ICDAS), radiography and a laser fluorescence device (DIAGNOdent pen, LFpen). The reference standard was visual inspection after temporary separation with orthodontic rubbers. Surfaces were classified as sound, noncavitated (NC) or cavitated (Cav), and performance was assessed at both NC and Cav thresholds. Wong-Baker faces scale was employed to assess the discomfort. Multilevel analysis was performed to verify the influence of discomfort on performance, considering the number of false-positives and false-negatives as outcome. At NC threshold, visual inspection achieved better performance (sensitivities and accuracies around 0.67) than other methods (sensitivities around 0.25 and accuracies around 0.35). At Cav threshold, visual inspection presented lower sensitivity (0.23 and 0.19), and LFpen (0.52 and 0.42) and radiography (0.52) presented similar sensitivities. Concerning the influence of the discomfort, at NC threshold, when discomfort was present, the number of false-negative results was lower with LFpen and the number of false-positive results was higher with visual inspection. At Cav threshold, the number of false-positive results was higher with LFpen. In conclusion, radiography and LFpen achieved similar performance in detecting approximal caries lesions in primary teeth and the discomfort caused by visual inspection and LFpen can influence the performance of these methods, since a higher number of false-positive or false-negative results occurred in children who reported discomfort.