Abstract
目的
评价近红外光透照技术(near-infrared light transillumination,NILT,商品名DIAGNOcam)诊断乳磨牙早期邻面龋的应用价值。
方法
对北京大学口腔医院儿童口腔科4~9岁疑有乳磨牙早期邻面龋的患儿进行视诊、咬合翼片和DIAGNOcam检查,龋齿指数记录为0(无龋)、1(釉质浅层龋)、2(釉质深层龋不超出釉牙本质界)、3(牙本质龋)。相邻2颗乳磨牙中至少1颗牙齿符合侵入性治疗标准方可纳入研究,即要求至少两项检查的龋齿指数≥2。对龋齿指数≥2的牙齿行侵入性治疗,直视下观察相邻乳磨牙的情况,若龋坏成洞,则也行侵入性治疗。将直视下龋洞深度与釉牙本质界的关系作为金标准,比较3种检查方法诊断乳磨牙早期邻面龋的灵敏度、特异度和准确度。
结果
共纳入36例患儿104个乳磨牙邻面,其中,5个牙面最终诊断为无龋,20个牙面诊断为釉质浅层龋,79个牙面进行了侵入性治疗,包括22个牙面龋洞达釉牙本质界,57个牙面龋洞达牙本质层内。视诊、咬合翼片和DIAGNOcam诊断乳磨牙早期邻面龋的灵敏度为68.69%、81.82%、78.79%,特异度为100.00%、100.00%、80.00%,准确度为75.96%、85.65%、78.85%。对于釉质浅层龋,视诊诊断的灵敏度最低,仅为10.00%,DIAGNOcam的灵敏度(60.00%)高于咬合翼片(40.00%);对于釉质深层龋的诊断灵敏度,咬合翼片(86.36%)>DIAGNOcam(72.73%)>视诊(68.18%);对于牙本质龋,3种方法的诊断灵敏度均超过85%,咬合翼片最高为94.74%。
结论
DIAGNOcam诊断乳磨牙早期邻面龋具有接近于咬合翼片的准确度,且使用安全、简便、无辐射,适用于儿童口腔临床。
Keywords: 乳牙, 龋齿, 透照法, 诊断
Abstract
Objective
To evaluate the practical value of near-infrared light transillumination (NILT, DIAGNOcam) on detection of incipient proximal caries in primary molars.
Methods
In this study, 4-9-year-old children with suspicious proximal lesions in primary molars were recruited. The target teeth were examined with clinical examination, bitewing radiograph and DIAGNOcam. And the caries indexes were rated as 0 (no caries), 1 (caries reaching outer 1/2 enamel), 2 (caries reaching inner 1/2 ena-mel), and 3 (dentine caries). Those primary molars with at least one of the adjacent molars according with the criteria of invasive treatment, i.e. the teeth were diagnosed as caries reaching inner 1/2 enamel or dentine with at least two detection methods, were included. The target teeth with caries index ≥2 accepted the invasive treatment. And the caries status of the adjacent teeth was observed under direct vision and those teeth of caries index ≥2 would also accept the invasive treatment. The relationship of lesions to enamel-dentine junction (EDJ) were recorded and used as reference standard to compare the sensitivity, specificity and accuracy of those three methods in detecting the incipient proximal caries in primary molars.
Results
In this study, 36 children with 104 suspicious proximal lesions in primary molars were recruited, of which 5 were diagnosed as no caries, 20 were diagnosed as superficial enamel caries, and 79 accepted invasive treatment, of which 22 were diagnosed as EDJ caries, and 57 as dentine caries. The sensitivity of clinical examination, bitewing radiograph, and DIAGNOcam were 68.69%, 81.82%, 78.79%, respectively. The specificity were 100.00%, 100.00%, 80.00%, and the accuracy were 75.96%, 85.65%, 78.85%, respectively. As for superficial enamel caries, the sensitivity of cli-nical examination was lowest, only 10%, while DIAGNOcam was 60%, higher than 40% of bitewing radiograph. As for EDJ caries, the sensitivity of bitewing radiograph was highest as 86.36%, followed by DIAGNOcam 72.73% and clinical examination 68.18%. As for dentine caries, the sensitivity of the three detection methods were higher than 85%, of which bitewing radiograph was the highest as 94.74%.
Conclusion
The accuracy of DIAGNOcam in detecting incipient proximal caries in primary molars was comparable to that of bitewing radiograph. It was safe, and convenient with no exposure to radiation, which was applicable to be used in pediatric dentistry.
Keywords: Deciduous tooth, Dental caries, Transillumination, Diagnosis
由于乳磨牙的解剖形态、儿童饮食习惯特点和口腔卫生状况,乳磨牙的邻面是4岁以上儿童的好发龋齿部位[1]。乳牙硬组织矿化度明显低于恒牙,一旦发生龋齿,发展速度非常快,很快会波及到牙髓造成较为严重的牙髓炎和根尖周炎。因此,对乳磨牙早期邻面龋进行诊断,进行适时、有效的预防或干预治疗具有十分重要的临床意义。临床上检查乳牙邻面龋最常用的方法是视诊和咬合翼片[2]。咬合翼片可以检查到视诊难以检查到的邻面,可以大致判断出龋损的范围,但是咬合翼片对于拍摄技术的要求比较高,儿童较小的口腔和较浅的口底决定了拍摄咬合翼片较为困难,且不能分辨早期脱矿与龋洞[3],同时,拍摄X线片具有一定的放射剂量,患儿家长对于将此作为常规筛查手段有一定的排斥心理。
1970年,Friedman等[4]首次提出了光纤透照(fiber optic transillumination, FOTI)方法,其基本原理是龋坏组织对光的透照指数低于正常组织,因而显示为一个较周围正常组织色暗的影像。有研究显示,FOTI是一种辅助诊断恒牙早期邻面龋的有效工具[5]。随着技术的发展,产生了数字化摄取照片与FOTI相结合的新型数字化FOTI技术(digital imaging fiber optic transillumination, DIFOTI)[6,7,8]。2012年出现了760 nm波长的近红外光透照技术(near-infrared light transillumination, NILT, 商品名为DIAGNOcam)用以检查早期龋,表现出了良好的实用性[6]。以往的研究基本是基于恒牙,因乳牙的组织结构与恒牙相比存在较大的区别,乳牙的釉质较薄,矿化程度相对较差[9],DIAGNOcam是否可以用于诊断乳磨牙的早期邻面龋存在疑问。本研究拟评价DIAGNOcam诊断乳磨牙早期邻面龋的应用价值。
1. 资料与方法
1.1. 研究对象
选择在北京大学口腔医院儿童口腔科就诊的4~9岁无系统性疾病、可以配合龋齿检查和治疗的儿童患者,要求乳磨牙无临床可判别的牙齿发育异常,乳磨牙区牙列完整,无拥挤和牙齿扭转,牙龈无活动性出血,牙龈乳头无明显红肿和增生,乳磨牙颊舌面色素不超过牙面的1/3,要求相邻两颗乳磨牙均无开放性龋洞及充填体,至少其中1颗牙齿可疑有邻面龋。本研究已获得北京大学口腔医院生物医学伦理委员会批准(PKUSSIRB-201630097),并获得患儿家长的知情同意,共36名患儿104颗乳磨牙的邻面纳入本研究。
1.2. 研究方法
由具备丰富临床经验的接诊医生清洁目标牙面菌斑软垢后进行视诊检查、DIAGNOcam检查、拍摄咬合翼片等3项检查,分别作出相应诊断。相邻2颗乳磨牙中至少1颗牙齿的2项检查结果达到侵入性治疗标准者(诊断指数≥2)纳入本研究,车针打开龋洞,直视下观察并判断相邻两颗牙齿龋齿深度,其结果作为诊断金标准(图1)。
1.
研究过程流程图
Experiment process illustrated in a simplified sequence flow diagram
EDJ, enamel-dentine junction; OHI, oral hygiene introduction.
1.3. DIAGNOcam数字化光纤透照仪
DIAGNOcam数字化光纤透照仪由光纤透照探头、数字化摄像头、图像处理系统(cam系统)组成。光纤透照探头由两个近红外光放射头端组成,可夹持于待测牙的颊舌面,数字化摄像头位于牙合面部位摄取照片。用DIAGNOcam光纤透照探头对纳入牙齿进行探照检查,通过系统的探头从牙合面获取投射结果拍摄照片(图2)。
2.
口外模仿DIAGNOcam在口内检查的情况
DIAGNOcam was taking photos on the occlusal surfaces in vitro
1.4. 相关诊断标准
1.4.1 视诊标准(Ekstrand标准) 0:持续吹干牙齿表面5 s,釉质没有变化或仅有光泽变化;1:在吹干后可以看到釉质白垩或染色,但是在湿润的条件下很难发现;2:在湿润的条件下即可清楚地看到白垩或染色;3:在白垩或染色位置出现部分釉质的缺损和/或其下方的牙本质层出现了墨浸色改变;4:在白垩或染色的釉质处形成龋洞并暴露牙本质。
1.4.2 咬合翼片标准 R0:无X线透影;R1:X线透影区局限于釉质层外1/2;R2:X线透影区位于釉质层内1/2,包括已达到且未超越秞牙本质界的病损;R3:X线透影区在牙本质层外1/2,未累及近髓侧1/2;R4:X线透影区在牙本质层内1/2,累及近髓侧1/2。
1.4.3 DIAGNOcam标准(参考咬合翼片标准分类为D0~D4) D0:无暗影;D1:暗影区局限于釉质层外1/2;D2:暗影区位于釉质层内1/2,包括已达到且未超越秞牙本质界的病损;D3:暗影位于牙本质层外1/2内,未累及近髓侧1/2;D4:暗影达牙本质内层近髓侧1/2内。
1.4.4 直视下诊断(金标准) 对诊断为龋坏的部位行侵入性治疗,去腐中明确龋坏范围并记录与釉牙本质的关系:釉质浅层、釉质深层(不超过釉牙本质界)、牙本质层。腐质去净的标准为中等力度探诊时牙体组织质硬且光滑,视诊形态规则,牙体组织有光泽感[10]。
1.5. 重复性检验
于临床随机选取30颗符合纳入条件的牙齿作为检验对象,由两名检查者分别进行临床视诊、咬合翼片读片及DIAGNOcam检查,1周后再次进行重复检查,计算Kappa值。
1.6. 计算灵敏度和特异度
以直视下的龋坏深度作为金标准计算视诊、咬合翼片及DIAGNOcam 三种检查方法的灵敏度和特异度,并进行串联试验和并联试验比较三种检查方法对于诊断不同程度龋齿的灵敏度和特异度,临床实例见图3。
3.
左下第一乳磨牙远中邻面及第二乳磨牙近中邻面龋
Decay in distal of lower left first primary molar and mesial of lower left second primary molar
A, bitewing; B, DIAGNOcam; C, visual detection before removal of decay; D, after removal of decay.
2. 结果
对于视诊、咬合翼片及DIAGNOcam三种检查方法,检查者之间的Kappa值分别为78.00%、81.30%和76.10%,检查者自身的Kappa值为79.30%、81.10%和81.50%,体现了高度一致性。
共36例患儿104个牙面纳入本研究,其中男孩16例、女孩20例,平均月龄为(72.08±18.20)个月(48~106个月)。纳入不同牙位的牙面数量如表1所示,5个牙面最终诊断为无龋,20个牙面表现为白垩斑或褐斑,诊断为釉质浅层龋,79个牙面龋坏成洞,进行侵入性治疗,其中22个牙面龋洞到达釉牙本质界,而57个牙面深入牙本质层内。
1.
侵入性治疗获得的龋齿诊断结果
The final diagnosis of teeth included in this study
| Tooth | Intact | Outer enamel |
Inner enamel |
Dentine | Total |
| Upper first primary molar | 0 | 6 | 4 | 15 | 25 |
| Upper second primary molar | 0 | 5 | 8 | 12 | 25 |
| Lower first primary molar | 1 | 1 | 8 | 18 | 28 |
| Lower second primary molar | 4 | 8 | 2 | 12 | 26 |
| Total | 5 | 20 | 22 | 57 | 104 |
按照最终的金标准,三种方法的灵敏度比较,咬合翼片> DIAGNOcam >视诊,而视诊和咬合翼片的特异度均高达100.00%(表2)。
2.
视诊、咬合翼片和DIAGNOcam诊断乳磨牙早期邻面龋的灵敏度、特异度和准确度比较
Comparison of sensitivity, specificity and accuracy among visual, bitewing and DIAGNOcam detection
| Items | Visual | Bitewing | DIAGNOcam |
| Sensitivity | 68.69% | 81.82% | 78.79% |
| Specificity | 100.00% | 100.00% | 80.00% |
| Accuracy | 75.96% | 85.65% | 78.85% |
如表3所示,将龋齿按照釉质浅层、釉质深层和牙本质来划分,比较三种诊断方法的灵敏度,三种方法在诊断釉质深层和牙本质龋的灵敏度排序仍是咬合翼片> DIAGNOcam >视诊,但是诊断牙本质龋的灵敏度都比较高,均超过85%,咬合翼片最高为94.74%;对于釉质深层龋的诊断,咬合翼片(86.36%)要显著高于视诊(68.18%)和DIAGNOcam(72.73%);对于釉质浅层龋,视诊诊断的灵敏度仅10.00%,而DIAGNOcam的灵敏度(60.00%)高于咬合翼片(40.00%)。不过,DIAGNOcam诊断的龋齿深度偏深,将50%釉质浅龋的牙面诊断为了釉质深层龋甚至牙本质层龋。
3.
视诊、咬合翼片及DIAGNOcam诊断乳磨牙邻面不同程度龋齿的灵敏度比较
Comparison of sensitivity among visual, bitewing and DIAGNOcam detection to different caries status
| Items | Visual | Bitewing | DIAGNOcam |
| Outer enamel | 10.00% | 40.00% | 60.00% |
| Inner enamel | 68.18% | 86.36% | 72.73% |
| Dentine | 89.47% | 94.74% | 87.72% |
将三种诊断方法进行串并联试验(表4、5),并联试验的结果是对于釉质浅层龋,DIAGNOcam或咬合翼片组合的灵敏度(70.00%)高于DIAGNOcam或视诊组合(60.00%)以及视诊或咬合翼片组合(40.00%)。而对于釉质深层龋,DIAGNOcam或咬合翼片组合的灵敏度高达100%,视诊或咬合翼片组合的灵敏度也高达95.45%,DIAGNOcam或视诊组合的灵敏度最低。而对于牙本质龋来说,各种组合的灵敏度均很高,接近或等于100%。串联试验的结果是,釉质浅层龋DIAGNOcam或咬合翼片组合的灵敏度最高为30%,釉质深层龋各种组合的灵敏度相差不大,而牙本质龋各种组合的灵敏度均高于80%。
4.
采用并联试验比较视诊、咬合翼片及DIAGNOcam诊断乳磨牙邻面不同程度龋齿的灵敏度
Comparison of sensitivity among parallel joint detection of visual, bitewing and DIAGNOcam detection to different caries status
| Items | V or B | V or D | D or B | V or D or B |
| V, visual detection; D, DIAGNOcam detection; B, bitewing detection. | ||||
| Outer enamel | 40.00% | 60.00% | 70.00% | 70.00% |
| Inner enamel | 95.45% | 86.36% | 100.00% | 100.00% |
| Dentine | 98.25% | 98.25% | 100.00% | 100.00% |
5.
采用串联试验比较视诊、咬合翼片及DIAGNOcam诊断乳磨牙邻面不同程度龋齿的灵敏度
Comparison of sensitivity among serial joint detection of visual, bitewing and DIAGNOcam detection to different caries status
| Items | V & B | V & D | D & B | V & D & B |
| V, visual detection; D, DIAGNOcam detection; B, bitewing detection. | ||||
| Outer enamel | 10.00% | 10.00% | 30.00% | 10.00% |
| Inner enamel | 59.09% | 54.55% | 59.09% | 45.45% |
| Dentine | 87.72% | 85.96% | 87.72% | 82.46% |
根据不同的牙位来分析,DIAGNOcam诊断上颌和下颌第二乳磨牙和下颌第一乳磨牙邻面龋的灵敏度都非常高,而对上颌第一乳磨牙的诊断灵敏度仅为40.00%(表6,图4)。
6.
视诊、咬合翼片和DIAGNOcam诊断不同牙位乳磨牙邻面龋的灵敏度比较
Comparison of the sensitivity among visual,bitewing and DIAGNOcam detection to different location of teeth
| Tooth | Visual | Bitewing | DIAGNOcam |
| Upper first primary molar | 68.00% | 84.00% | 40.00% |
| Upper second primary molar | 68.00% | 80.00% | 96.00% |
| Lower first primary molar | 85.19% | 92.59% | 92.59% |
| Lower second primary molar | 50.00% | 68.18% | 86.36% |
4.
DIAGNOcam和咬合翼片检查右上第一、第二乳磨牙邻面龋的比较
Comparison of DIAGNOcam and bitewing detection of proximal caries in upper right first and second primary molars
A, DIAGNOcam detection showed no decay in upper right first primary molar and cavity reaching enamel-dentinal junction in upper right second primary molar; B, bitewing showed cavity in upper right first primary molar reaching enamel-dentinal junction while only decay in outer enamel of upper right second primary molar.
3. 讨论
为了保证以直视下诊断作为最终的金标准,本研究的纳入标准要求相邻两颗乳磨牙至少一个邻面的龋齿指数≥2,需要进行侵入性治疗,而那些相邻牙面龋齿指数为0~1的牙齿则未纳入本研究。乳牙龋齿的临床特点是一旦乳磨牙邻面发生龋齿,相邻的乳磨牙很难能“独善其身”,所以本研究纳入的阴性病例相对较少,纳入样本存在一定的偏倚,但是纳入的龋齿均为早期龋,无开放性龋洞,符合本研究探索DIAGNOcam在诊断乳磨牙早期邻面龋应用价值的研究目的。
Abogazalah等[11]的离体牙实验发现,对于早期邻面龋的检查,DIAGNOcam的灵敏度/特异度为0.68/0.93,甚至要高于咬合翼片的0.50/0.64,对于尚未成洞的邻面早期龋,两者具备相似的准确度。本研究中,咬合翼片检查邻面龋的灵敏度最高为81.82%,DIAGNOcam的灵敏度接近于咬合翼片为78.79%,视诊的灵敏度最低为68.69%。
对于釉质浅层龋,本研究中视诊的灵敏度仅为10%, DIAGNOcam的灵敏度为60%,高于咬合翼片的40%。并联试验的结果显示,对于釉质浅层龋,DIAGNOcam或咬合翼片组合以及DIAGNOcam或视诊组合的灵敏度分别为70%和60%,提示在临床实际工作中,对于局限于釉质浅层的脱矿,绝大多数仅通过视诊检查不出来,会出现漏诊。这种情况和乳磨牙邻面的解剖形态有关,邻面接触为面接触,接触紧密,当龋坏脱矿面积较小局限于接触面之内时,很难凭借肉眼检查出来,而DIAGNOcam对釉质浅层龋的检出率相对较高,这有利于早期的预防干预,如指导患者进行牙线的清洁、氟化物的应用、密切的随诊观察等。Kühnisch等[12]对恒牙早期邻面龋的临床研究发现,DIAGNOcam检查不超过釉牙本质界的早期龋的准确度为99.2%,牙本质龋的准确度较低为29.1%。本研究中随着龋损范围的扩大,咬合翼片的灵敏度逐渐增高,当到达牙本质层时,灵敏度高达94.74%。对于达釉质深层及牙本质层即成洞的龋坏,DIAGNOcam亦表现出较高的灵敏度,分别是72.73%和87.72%。并联试验各组合的灵敏度均接近100%,串联试验各组合的灵敏度均超过80%。
需要注意的是,对于检查不同牙位的乳磨牙邻面龋,DIAGNOcam的灵敏度表现出了很大差异。对于上颌第二乳磨牙和下颌第一、第二乳磨牙,其灵敏度接近和超过90%,甚至优于咬合翼片,而对于上颌第一乳磨牙邻面龋检出的灵敏度却仅为 40.00%。如图4所示,咬合翼片显示右上第一乳磨牙的远中邻面龋坏达釉牙本质界,而DIAGNOcam却没有显示出代表龋坏的暗影。
乳牙的釉质矿化程度较低且薄,釉质与牙本质无论是在咬合翼片还是DIAGNOcam上的显影,其区别都不如恒牙明显,对拍摄咬合翼片的技术人员和DIAGNOcam的检查者都有一定的要求。在龋洞深度的判断方面,咬合翼片的读片结果和其他研究一样,邻面龋在咬合翼片上显示的龋坏深度往往要浅于实际洞深[13]。如图3所示,咬合翼片中左下第一、第二乳磨牙的龋坏局限于釉质层内,而DIAGNOcam则显示超出釉牙本质界,侵入性治疗打开龋洞后发现实际洞深已经到达牙本质层内。于江利等[14]发现,使用DIAGNOcam系统体外检测恒牙龋坏深度与龋洞去腐后的实际深度基本一致,提示临床上可以使用DIAGNOcam 系统来辅助评估恒牙龋洞深度。但是本研究发现,对于釉质浅层龋,DIAGNOcam检查邻面龋的深度偏深,将50%釉质浅层龋的牙面诊断为釉质深层龋甚至牙本质层龋,因此考虑侵入性治疗时需慎重,因视诊的特异度较高,在临床上可以结合DIAGNOcam和视诊的检查结果综合考量,必要时可以考虑分牙后直视下观察龋坏情况。
使用DIAGNOcam检查的过程中,需要探头紧紧环抱牙冠,方向与牙齿长轴平行,才能避免光纤的散射对成像的影响,呈现较清晰的图像,但是乳牙的牙冠体积较小,DIAGNOcam的探头相对较大,为了避免光纤的散射对成像的影响,保证成像效果,有时候探头不能保持与牙体长轴的平行而出现倾斜,对使用者有一定的技术要求。DIAGNOcam作为一种无创、无辐射的新技术,同时具备实时成像的优点,结合视诊检查诊断乳磨牙早期邻面龋的准确度近似于咬合翼片,在4岁以上儿童的龋齿检查中具有一定的应用价值。
Funding Statement
北京大学口腔医院临床新技术新疗法项目（PKUSSNCT-16B10）
Supported by the Program for New Clinical Techniques and Therapies of Peking University School and Hospital of Stomatology (PKUSSNCT-16B10)
Footnotes
The authors have declared that no competing interests exist.
作者已声明无竞争性利益关系。
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