Abstract
The aim of this in vivo study was to evaluate the performance of fluorescence-based devices in detecting occlusal caries lesions in primary molars compared with conventional methods. Two examiners assessed 44 occlusal surfaces of first and second primary molars in 20 patients using two fluorescence devices: DIAGNOdent (LF) and DIAGNOdent pen (LFpen). Teeth were also assessed by visual examination and bitewing radiograph. Histological examination served as the gold standard after extraction. By using the McNemar test, the sensitivity, specificity, accuracy, and area under the receiver operating curve were calculated as outer enamel (D1), inner enamel (D2) and dentine caries (D3) lesion thresholds. The intra- and inter-examiner reproducibility were calculated using the Cohen’s unweighted kappa statistics. At the D1 threshold, the LFpen sensitivity was statistically higher than LF and radiographic examination (P < 0.001), whereas there was no statistically significant difference among the groups at the D2 and D3 thresholds (P > 0.05). All methods demonstrated the highest sensitivity values at D3. At the D1 and D2 thresholds, there were no significant differences between the LFpen specificity and the other methods. All methods presented similar performance in detecting all lesions considering the area under the receiver operating curve. The LFpen showed better performance than LF. Furthermore, visual examination and the LFpen device seem to be sufficient for detection of occlusal caries in primary molars.
Key words: Laser fluorescence, caries diagnosis, DIAGNOdent, primary teeth
INTRODUCTION
Occlusal surfaces are the most susceptible to development of caries. The early diagnosis of caries lesions provides for more efficient arrest thus avoiding operative treatment1., 2., 3.. This process is especially important in deciduous teeth4. Deciduous teeth are more susceptible to demineralisation than permanent teeth5, but permanent teeth have the higher level of caries6. Despite the practical and easily applicable methods available to dentists, visual examination, which is subjective, is most frequently used7. Visual examination has shown high specificity, and low sensitivity and reproducibility for occlusal caries detection8., 9.. Bitewing radiographs are used together with visual examination to aid diagnosis of occlusal caries10 but radiographs only detect demineralisation in dentine and not the enamel lesion11. Thus, detection of dental caries and their early diagnoses is very difficult when conventional diagnostic methods are used12. In view of this, various methods and devices have been developed to detect early caries lesions.
Quantitative detection methods would allow the monitoring of changes in mineral content of caries lesions1., 2., 13.. The laser fluorescence system, DIAGNOdent 2095 (LF) (DD2095; KaVo, Biberach, Germany) was introduced in dentistry for the quantitative determination of occlusal caries. The LF device consists of a diode emitting laser light at a wavelength of 655 nm, which is absorbed by the tooth substance. Some of this light is re-emitted as a near-infrared fluorescent light, and changes in the tooth substance related to the caries process are indicated by an increased amount of fluorescent light. This is detected by the instrument and digitally monitored2., 14.. A new KaVo device the DIAGNOdent pen (LFpen) which has the same physical principles as its predecessor was recently introduced. It allows detection of both occlusal and proximal caries15., 16.. Based on the conventional LF device, new tips had to be developed as a result of the different architecture of the new system15., 17..
In primary teeth, the performance of the LF device was evaluated and has demonstrated high reliability in the detection of occlusal caries; its performance was similar to that of visual and radiographic examinations12., 18.. The aim of this study was to compare the efficiency of the two LF systems with two conventional methods for detection of occlusal caries in primary teeth.
MATERIALS AND METHODS
This study was approved by the Ethics Committee of the Faculty of Dentistry, Gazi University. The study was conducted in full accordance with the World Medical Association Declaration of Helsinki.
The study sample consisted of 9- to 11-year-old children. Twenty children were selected from the patient population at the Gazi University, Faculty of Dentistry, Department of Paediatric Dentistry, Ankara, Turkey. The children were healthy and cooperative. Forty-four occlusal sites were selected for this study from first and second primary molars in the final process of exfoliation or with extraction indicated for orthodontic reasons. Teeth with any restoration, fissure sealants or fissures with brownish pigments were excluded from the study. Written informed consent was obtained from parents or guardians before the start of the examinations.
Teeth were assessed by visual examination, bitewing radiograph and LF devices in the selected sites. Examinations were carried out for each individual from the sample on the same day independently by two experienced paediatric dentists with no communication between them. Digital photographs were taken and selected sites were marked in the photographs.
All assessment with visual examination and LF were performed twice each by the same examiners with a 2-week interval between measurements. Before the visual examination and LF, the teeth were professionally cleaned with non-fluorescent paste (Nupra Fine Mint; Dentsply, York, PA, USA).
Visual examination was performed with the patient positioned in a dental unit with the aid of dental light, oil-free air/water spray and dental mirror using the criteria19 shown in Table 1.
Table 1.
Criteria used for visual and radiographic examination and actual lesion depth
| Score | Visual examination | Radiographic examination | Lesion depth |
|---|---|---|---|
| 0 | No or slight change in enamel translucency after prolonged air (> 5 s) | No radiolucency visible | No enamel demineralisation or a narrow surface zone of opacity |
| 1 | Opacity or white and brown discoloration hardly visible on the wet surface, but distinctly visible after air drying | Radiolucency visible in the enamel | Enamel demineralisation limited to the outer 50% of the enamel layer |
| 2 | Opacity or white and brown discoloration distinctly visible without air drying | Radiolucency visible in the dentine but restricted to the outer third of the dentine | Demineralisation involving between 50% of the enamel and 1/3 of dentine |
| 3 | Localised enamel breakdown in opaque or discoloured enamel and/or grayish discolouration from the underlying dentine | Radiolucency extending to the middle third of dentine | Demineralisation involving the middle one-third of dentine |
| 4 | Cavitation in opaque or discoloured enamel exposing the dentine | Radiolucency in the pulpal third of dentine | Demineralisation involving the inner one-third of dentine |
Bitewing radiographs were taken for all teeth selected. The radiographic films (Ekstraspeed Plus; Kodak, Rochester, NY, USA) were held by Kwik-biteH film holders (Kwik-bite; Hawe Neos Dental, Bioggio, Switzerland). The X-ray machine was set at 70 kV, 8 mA and the exposure time was set at 0.25 s. Radiographs were developed in an automatic film processor (Velopex, Extra-X; Medivance Instruments, London, UK) with fresh solution. The film radiographs were examined in a masked light box and a 2× magnification x-viewer (Luminosa; CSN Industrie, Cinisello Balsamo, Italy) by examiners independently under constant conditions. The radiographic appearance is classified19 in Table 1.
The test sites were assesed using two laser fluorescence devices: LF (DIAGNOdent 2095; KaVo) and LFpen (DIAGNOdent 2190; KaVo). Devices were calibrated using the ceramic standard provided by the manufacturer. The teeth were isolated with cotton rolls and air-dried. The fluorescence value of a sound spot on the coronal part of the buccal surface (zero value) was then recorded for later subtraction from the peak value. For measurements, tip A (for the LF) and cylindrical sapphire fibre tip for occlusal surfaces (for the LFpen) were used. The device was placed perpendicularly to the test site and turned around until the highest value was recorded. The presence or absence of occlusal caries was determined using the manufacturer’s suggested cut-off points, as shown in Table 2.
Table 2.
Manufacturer’s selected cut-off points for the LF measurements
| Score | LF | LFpen | Criteria |
|---|---|---|---|
| 0 | 0–5 | 0–13 | No demineralisation – sound |
| 1 | 6–14 | 14–20 | Outer enamel demineralisation |
| 2 | 15–20 | 21–29 | Inner enamel demineralisation |
| 3 | 21–99 | >30 | Dentin demineralisation |
LF, DIAGNOdent 2095; LFpen, DIAGNOdent 2190.
After the examinations, the teeth were extracted within a maximum period of 30 days. The teeth were sectioned bucco-lingually in approximately 400 μm thick sections (Mecatome T201; Presi, Grenoble, France) for histological assessment. Sections were serially ground wet on 600–1200 grit silicon carbide paper before being assessed on both sides regarding the presence or absence of caries and the depth of the lesions using a microscope at a magnification of ×16 by two observers. Sites were assessed for caries extension and classified19 in Table 1.
Statistical analysis
Sensitivity, specificity, accuracy, and area under the receiver operating characteristic (ROC) curve Az were calculated for each method at three different thresholds: outer enamel (D1), inner enamel (D2) and dentine (D3).
Data analysis was performed by using spss for Windows, version 11.5 (SPSS Inc., Chicago, IL, USA). The intra- and inter-examiner reproducibility were calculated using Cohen’s unweighted kappa test considering all of the scores of visual examination and radiographic methods or values of the LF and LFpen readings. Coefficients of kappa over 0.75 were considered to be excellent, 0.40–0.75 as fair to good, and below 0.40 as poor. The optimal cut-off point of alternative assessments to discriminate groups regarding histopathology (the gold standard) was evaluated by ROC analysis as giving the maximum sum of sensitivity and specificity for the significance test. Diagnostic performances (i.e. sensitivity, specificity and accuracy) of alternative assessments regarding histopathology were also calculated. Statistical significance of differences between diagnostic methods regarding sensitivity, specificity and accuracy were evaluated by a McNemar test. A P value of < 0.05 was considered statistically significant.
RESULTS
Histological evaluation revealed that from 44 selected sites, 11 teeth were sound (score 0), 12 had demineralisation limited to the outer 50% of the enamel (score 1), 12 teeth had demineralisation involving 50% of the enamel and one-third of dentine (score 2), eight teeth had demineralisation involving the middle one-third of dentine (score 3) and only one tooth had demineralisation involving the inner one-third of dentine (score 4).
Sensitivity, specificity, accuracy, and Az are shown in Table 3. The highest sensitivity values were observed for LFpen, LF and visual examination at the D3 thresholds. The LFpen also showed the highest sensitivity values at the D2 threshold. While bitewing radiographs presented the lowest values of sensitivity at the D2 and D3 thresholds, LF showed lowest values at the D1 threshold. The LFpen and visual examination showed similar sensitivity and specificity values at the D3 thresholds. The McNemar square test showed that LFpen sensitivity was statistically higher than LF and radiography at the D1 threshold (P < 0.001), and that there was no statistically significant difference compared with all methods at the D2 and D3 thresholds (P > 0.05). There were no statistically significant differences between LFpen specificity compared with the other methods at the D1 and D2 thresholds (P > 0.05). The LFpen showed the highest accuracy values at the D2 thresholds. Considering the AUC, all methods demonstrated similar performance in detecting all lesions (D1, D2, and D3).
Table 3.
Sensitivity, specificity, accuracy and Az values at D1, D2 and D3 thresholds. D1, 0 = sound, 1–4 decayed; D2, 0–1 = sound, 2–4 = decayed; D3, 0–2 = sound, 3–4 = decayed
| Sensitivity | Specificity | Accuracy | Az | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| D1 | D2 | D3 | D1 | D2 | D3 | D1 | D2 | D3 | D1 | D2 | D3 | |
| Visual inspection | 0.848a | 0.857a | 1.000a | 0.818a | 0.870a | 0.400a | 0.841a | 0.864a,b | 0.523a | 0.891a | 0.900a | 0.797a |
| Radiography | 0.697a,b | 0.762a | 0.889a | 0.818a | 0.609a | 0.514a | 0.728a,b | 0.682b | 0.591a | 0.814a | 0.766a | 0.737a |
| LF | 0.545b | 0.952a | 1.000a | 1.000a | 0.783a | 0.743b | 0.659b | 0.864a | 0.796b | 0.836a | 0.913a | 0.871a |
| LFpen | 0.848a | 1.000a | 1.000a | 0.818a | 0.870a | 0.571a,b | 0.841a | 0.932a | 0.660a,b | 0.833a | 0.941a | 0.795a |
Az, area under the receiver operating characteristic curve.
D1, outer enamel; D2, inner enamel; D3, dentine; LF, DIAGNOdent 2095; LFpen, DIAGNOdent 2190.
Different superscript letters show statistically significant differences between diagnostic methods (P < 0.05).
Kappa values for intra- and inter-examiner agreement are shown in Table 4. The reproducibility was excellent for all diagnostic methods by two examiners. In addition, inter-examiner agreement was excellent for all diagnostic methods.
Table 4.
Kappa values of intra- and inter-examiner reproducibility for each diagnostic system
| Visual inspection | Radiography | LF | LFpen | |
|---|---|---|---|---|
| Examiner 1 | 0.97 | 0.81 | 0.80 | 0.88 |
| Examiner 2 | 0.84 | 0.80 | 0.92 | 0.87 |
| Examiner 1 versus examiner 2 | 0.76 | 0.75 | 0.75 | 0.87 |
LF, DIAGNOdent 2095; LFpen, DIAGNOdent 2190.
DISCUSSION
Visual examination and bitewing radiographs have long been used to detect occlusal caries lesions20. The subjectivity of these methods and their limitations in monitoring the progression of the caries process has led to the development of new quantitative technologies20. In this study, fluorescence-based devices were tested in order to compare their findings with those from visual and radiographic examinations in primary teeth. The first LF device used generally in clinical studies has shown similar performance in both primary and permanent teeth18., 21., 22.. Matos et al.22 stated that although the first LF device works using the same principle as the new LFpen, its performance in primary teeth should also be better than in permanent teeth. These differences could be explained in that primary and permanent teeth have different morphological characteristics. The enamel of primary teeth has about half the thickness of permanent teeth. Some areas present prismless enamel, and the mineral content of primary enamel is relatively lower than in permanent teeth. Therefore, the performance of the laser system could be affected by these differences4., 22.. In their study, Rodrigues et al.23 compared the performance of the first LF device for detection of occlusal caries in permanent and primary teeth. They stated that the LF device might be a useful adjunct to conventional methods for the detection of occlusal caries. They also expressed that, for primary teeth, considering their differences from the permanent dentition, further in vitro and in vivo studies should be carried out to fully test this device.
The combination of visual examination and bitewing radiography could improve the correct diagnosis of dentine caries in permanent teeth24. The combination of visual examination and bitewing radiography has also led to correct classification of second primary molars as being without either enamel or dentine caries25. However, when compared with careful visual examination, bitewing radiography seems to be inadequate in the detection of enamel caries included within a sound surface26. In our study, bitewing radiography showed lower sensitivity than the visual examination at all thresholds and there was a statistical difference between visual examination and bitewing radiography at the D1 threshold. As expected, detection of enamel caries lesions is very difficult using radiography alone19.
An ideal diagnostic method should offer high sensitivity and high specificity in the detection of caries. However, these conditions are difficult to achieve with available methods4. Visual examination and the LFpen provided a higher sensitivity and specificity in the detection of caries lesions in primary molars. There were no statistical differences between the visual examination and the LFpen. When visual examination is performed in clean and dried teeth, the method can detect early enamel lesions more judiciously20., 27.. Therefore, the LFpen would not have any advantages over visual examination. Novaes et al.20 reported that visual examination presented higher sensitivity than the other methods in detecting initial enamel lesions. At the D1 threshold, the visual examination showed positive performance, as expressed in accuracy (0.841) and Az (0.891). A previous study reported that, similar to our findings, visual examination gave the same values20. Rocha et al.18 stated that the result is probably due to examiners’ training and simpler morphology of primary molars. As our results demonstrated, the LFpen has shown higher values than the LF, and there was a statistical difference between the two LF devices. In contrast to our results, Neuhaus et al.28 and Novaes et al.20 reported that LF and the the LFpen had similar results, showing no significant difference in the values of sensitivity at the D1 thresholds.
The LFpen device showed a good performance at D2 threshold, expressed in accuracy (0.932) and Az (0.941). We observed that the earlier the caries lesions, the worse the performance of the LFpen. Thus, the performance at inner enamel caries was better than at early enamel caries. Mendes et al.3 stated that performance of the first LF device in detecting early enamel caries lesions is worse than detection of advanced enamel caries lesions on the smooth surface of primary teeth. The different optimal cut-off values were used for LF and the LFpen. We found that the LFpen, when measuring only the D2 threshold, had higher specificity values when compared with the LF device. This means that the LFpen gave fewer false positives at the D2 threshold when compared with the LF device. In addition, sensitivity was mostly better with the LFpen. It is obvious that these values are dependent upon the chosen cut-off values. The performance of LF could depend on the cut-off points for device readings. These can potentially explain the different results found in the literature, as there are great variations regarding adopted cut-off points18. In our study, we have chosen to use the manufacturer’s suggested cut-off points. Considering that a rise in the proportion of false positives can be dangerous, as it can lead to overtreatment, a technique that offers high specificity, even at the expense of a reduction in sensitivity, seems to be more appropriate17. At the D2 threshold, the sensitivity and specificity of the LFpen were not significantly different from that of visual examination, radiography and LF.
At the D3 threshold, all methods showed good and similar performances. In general, all methods presented the highest sensitivity values and there were no significant differences among the diagnostic methods. The specificity of the LFpen was not significantly different from that of visual examination, radiography and LF. These results could prove the importance of detailed visual examinations. However, in our study, the specificity values of the LFpen were lower than in other in vivo22 and in vitro studies20.
The Az values confirmed the good performance of all diagnostic methods in detecting occlusal caries in primary molars. The bitewing radiographs showed the lowest values, which was was similar to results in previous studies28. In our study, visual examination and the LFpen device showed the highest Az values at all thresholds when compared with the other methods. However, there were no statistical differences between all diagnostic methods. Burin et al.29 stated that there was no statistical difference in Az among LF, visual examination and radiographic examination.
A diagnostic tool should be reliable and valid and inter-examiner reliability is an important factor in this30. In addition, the experience of examiners may effect intra- and inter-examiner agreement. The values obtained were lower than reported by Kavvadia & Lagouvardos12. The LFpen showed the highest values for inter-examiner reproducibility and kappa values for intra- and inter-examiner agreement were close to the values found by Neuhaus et al.28 and Novaes et al.20.
It can be concluded that, for detection of occlusal caries in primary molars, the LFpen performs better than LF. In addition, the LFpen had similar results when compared with visual examination. Furthermore, visual examination and the LFpen device appear to be adequate for clinical practice.
Acknowledgement
We thank the Scientific Research Foundation of the University of Gazi; Number: 03/2009-01.
Conflict of interest
None declared.
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