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ORIGINAL ARTICLE
Year : 2017  |  Volume : 35  |  Issue : 4  |  Page : 301-306
 

Validation of different diagnostic aids in detection of occlusal caries in primary molars: An in vitro study


Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, M. S. Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India

Date of Web Publication15-Sep-2017

Correspondence Address:
G Shwetha
Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, M. S. Ramaiah University of Applied Sciences, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_54_17

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   Abstract 


Aim and Objective: To estimate the accuracy and assess the sensitivity and specificity of direct visual examination (DVE), computerized radiograph (VISTA SCAN mini), and DIAGNOdent (DD) for caries diagnosis in primary molars as compared to histological examination of the teeth. Materials and Methods: An in vitro comparative study was carried out on 40 freshly extracted primary molars with questionable pit and fissures that yielded 89 examination sites. These samples were mounted on plaster and were subjected to examination methods for caries detection on the occlusal surface by two trained and calibrated examiners. The examination methods used in this study were DVE, computerized radiographic (CR) examination, laser fluorescence examination using DD followed by histological examination which is a gold standard; later, these samples were examined under microscope for caries extent. The scoring criteria given by Nytun et al. were used in this study for scoring the extent of caries. Results: The sensitivity for caries in enamel were 66.10%, 52.86%, and 54.17% for DVE, CR, and DD, respectively, while the specificity for DVE, CR, and DD were found to be 86.67%, 68.42%, and 76.47%, respectively. For dentinal caries, sensitivity for DVE, CR, and DD were 86.67%, 92.86%, and 81.25%, respectively, while the specificity were 66.10%, 56%, and 54.79%, respectively. The accuracy were 73.03%, 61.80%, and 59.55%, respectively, suggesting that the DVE showed highest sensitivity, specificity, and accuracy for enamel caries, whereas for dentinal caries, CR showed highest sensitivity and DVE showed highest specificity and accuracy. Conclusion: The DD exhibited better specificity than sensitivity for enamel lesions and better sensitivity than specificity for lesions into dentin. DD may prove useful as a predictive clinical tool and should only be used in addition to other diagnostic methods such as visual inspection and dental radiographs to avoid false-positive diagnoses.


Keywords: Deciduous teeth, DIAGNOdent, occlusal caries


How to cite this article:
Shwetha G, Chandra P, Anandakrishna L, Dhananjaya G, Shetty AK, Kamath PS. Validation of different diagnostic aids in detection of occlusal caries in primary molars: An in vitro study. J Indian Soc Pedod Prev Dent 2017;35:301-6

How to cite this URL:
Shwetha G, Chandra P, Anandakrishna L, Dhananjaya G, Shetty AK, Kamath PS. Validation of different diagnostic aids in detection of occlusal caries in primary molars: An in vitro study. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jul 23];35:301-6. Available from: http://www.jisppd.com/text.asp?2017/35/4/301/214928





   Introduction Top


Dental caries is an infectious microbiologic disease of the teeth that results in localized dissolution and destruction of the calcified tissues.[1] The early detection of caries and the capacity to discriminate between enamel and dentinal caries enhance the possibility of remineralization and minimal loss of hard substance thus allowing the dentist to take either preventive or minimally invasive measures. The prevalence of caries has decreased drastically during the past three decades. This decrease has mainly been caused by a reduction of free surface caries, the caries lesions on buccal and lingual sites.[2] As a result, there is increase in the prevalence of occlusal caries [3] and with it the importance of early diagnosis.[4] Before 1970, occlusal caries diagnosis was predominantly the domain of visual inspection. Till date, many noninvasive techniques have been introduced, but the identification of appropriate cases remains difficult. The early detection of lesions in and underneath fissures is further hampered by the absence of cavitation due to the frequent use of fluoride, administered in tablets and toothpaste.[5] The relative importance of occlusal caries in the prevalence of caries in societies has stimulated the search for and research into improved diagnostic methods to aid visual inspection.

Caries diagnosis continues to be a challenging task for the dental practitioners. As visual examination is a subjective method, it is difficult to diagnose occlusal caries using this method alone. Visual inspection for occlusal caries detection has shown high specificity and low sensitivity and reproducibility.[6],[7],[8],[9],[10],[11],[12] Several methods have been introduced in recent years to enhance the dentist's capabilities in the diagnostic process. There are a number of relatively new technologies commercially available to help in the precise detection of carious lesions. One such device is DIAGNOdent (DD), which involves fluorescence measurements performed by a laser device. Several studies have been undertaken with the objective of determining the most accurate and precise method for the detection of carious lesions among conventional and new methods, both used separately or in combination. Computerized radiograph is also used as a diagnostic tool in detection of caries wherein the processing errors can be avoided and also the gray scale can be adjusted for better diagnosis.

The null hypothesis is that there is no difference between the diagnostic ability of visual inspection, computerized radiograph (VISTA SCAN mini), and DD as compared to histological section which is the gold standard. Therefore, the aim of this study was to estimate the accuracy and assess the sensitivity and specificity of direct visual examination (DVE), computerized radiograph (VISTA SCAN mini), and DD for caries diagnosis in primary molars as compared to histological examination of the teeth.


   Materials and Methods Top


An in vitro comparative study was conducted in the Department of Pedodontics, Faculty of Dental Sciences, M.S. Ramaiah University of Applied Sciences, Bengaluru, wherein the sample consisted of primary molars with questionable fissures that were extracted for therapeutic and orthodontic reasons between the period of January 2013 and November 2014. Freshly extracted primary molars were collected and cleaned of all pulp remnants and then were stored in fresh tap water.[13] Once the sample was obtained, the tooth was mounted on plaster and then was assigned a number. In 40 sample teeth, 89 examination sites were considered for the study. All primary molar teeth with questionable pit and fissure were included while teeth with pit and fissure sealants, fillings, teeth with occlusal, proximal or lingual cavitated lesion, teeth with stains, and teeth with developmental defects were excluded. The study protocol included the following sequence explained in detail later - examination of the occlusal site using DVE, computerized radiographic (CR) examination, and laser fluorescence (LF) examination using DD. Histological evaluation of the sites was done to check the extent of caries, and this method was used as the reference. All the examination methods were performed by two calibrated examiner.

Calibration of examiners

Once the collection of the sample was done, a pilot study on ten teeth was conducted and the training and calibration of the examiners were done. The inter- and intra-examiner reproducibility could be depicted to be good and are presented in [Table 1].
Table 1: Kappa values of intra. and inter.examiner reproducibility for each diagnostic system

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Visual examination

The caries status was recorded on the basis of criteria given by Nytun et al.[14] as 0 - sound, 1 - caries in enamel, and 2 - caries in dentin by visual inspection which was performed after cleaning the occlusal surfaces using toothbrush and pumice-free paste and then rinsed thoroughly with water spray and air dried for 5 s with compressed air. All sites were evaluated for caries by the examiner under the direct dental operating light.

Radiographic examination

The radiographic examinations were carried out, using Dexcowin portable X-ray machine set at 60 kV and 1 mA with an exposure time of 0.3 s; computerized radiographs were processed for all primary molars using Durr VISTA SCAN mini. The radiographs were evaluated using criteria given by Nytun et al.[14]

Laser fluorescence examination

Then, LF examination was carried out using a DD pen device (Kavo) [Figure 1]. To obtain precise measurements, calibration of the device was performed for each tooth. The tip of the DD pen was placed perpendicular to the examination site and then turned around to record the area where the lesion will be more advanced. Three consecutive readings were recorded for each site, and their mean value was taken for analysis. The readings of the DD pen was then compared to the standards prescribed by the manufacturer and compared with other methods. The readings of the DD were converted into dichotomous data and are mentioned in [Table 2].
Figure 1: Laser fluorescence examination using DIAGNOdent

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Table 2: DIAGNOdent readings given by manufacturer

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Histological examination

Each specimen was then sectioned vertically in buccolingual direction using carborundum disc, and ground sections were prepared manually using Arkansas stone. These sections were dehydrated with isopropyl alcohol, cleared with xylene, and mounted onto the glass slide using dibutyl phthalate xylene and observed under the microscope at a magnification of ×40 [Figure 2]. The evaluation of the caries lesion was assessed according to the extent of demineralization zone into the enamel or dentin, and all the examination sites were classified with the same three-grade caries scoring scale used in the other methods.
Figure 2: Microscopic image of ground section of the tooth showing enamel caries

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Statistical analysis

The data obtained was subjected to statistical analysis using SPSS software Version 16.0 (Chicago, SPSS Inc). Descriptive statistics was done by measurement system analysis.

McNemar's test was used for pairwise comparison of sensitivity and specificity for caries in enamel and dentin among three tests.


   Results Top


A total of 89 samples were subjected to all the examination methods; in histological examination, 43 teeth were shown to have caries in enamel and 46 teeth were shown to have caries in dentin. The data obtained from visual examination, CR examination, and DD examination were compared with that of histological examination for caries in enamel and dentin separately. The sensitivity, specificity, and accuracy for all the three examination methods for caries in enamel and caries in dentin were calculated [Table 3]. DVE showed highest sensitivity, specificity, and accuracy for caries in enamel when compared to all the other diagnostic methods. However, for caries in dentin, DVE showed highest sensitivity and accuracy whereas CR examination showed the highest specificity [Figure 3] and [Figure 4].
Table 3: Validity of three tests for both caries in enamel and dentin

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Figure 3: Comparison of validity of three tests for caries in enamel

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Figure 4: Comparison of validity of three tests for caries in dentin

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On pairwise comparison of sensitivity for caries in enamel among three methods, a nonsignificant result was obtained. However, the specificity for caries in enamel significant results was obtained when DVE was compared with both computerized radiograph (P = 0.004) and DD (P = 0.002), but a nonsignificant result was obtained when computerized radiographs were compared with DD (P = 0.009). On pairwise comparison of sensitivity for caries in dentin, a significant result was obtained between DVE and computerized radiographs (P = 0.004) and also between DVE and DD (P = 0.002); however, a nonsignificant result was obtained when computerized radiographs were compared with DD (P = 0.009). In the specificity for caries in dentin, a non significant results were seen [Table 4].
Table 4: Pairwise comparison of sensitivity and specificity for caries in enamel and dentin among three tests

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In the present study, comparison of DVE, CR, and DD with that of histological examination was done to detect caries in enamel and dentin. The sensitivity for caries in enamel were 66.10%, 52.86%, and 54.17% for DVE, CR, and DD, respectively; the specificity for DVE, CR, and DD were found to be 86.67%, 68.42%, and 76.47%, respectively, and the accuracy was 73.3%, 56.18%, and 58.43%, respectively, for DVE, CR, and DD. For the caries in dentin, the sensitivity for DVE, CR, and DD were 86.67%, 92.86%, and 81.25%, respectively, the specificity were 66.10%, 56%, and 54.79%, respectively. The accuracy were 73.03%, 61.80%, and 59.55%, respectively, suggesting that the DVE showed highest sensitivity, specificity, and accuracy for enamel caries whereas for caries in dentin, CR showed highest sensitivity and DVE showed highest specificity and accuracy. On pairwise comparison of sensitivity between DVE, CR, and DD for caries in enamel, nonsignificant results were obtained ([P = 0.727, 0.999 and 0.727] respectively). On pairwise comparison of specificity between direct DVE, CR, and DD for caries in enamel, significant results were seen for DVE versus CR and DVE versus DD ([P = 0.004 and 0.002]), whereas a nonsignificant result was obtained for CR versus DD (P = 0.999). On pairwise comparison of sensitivity between DVE, CR, and DD for caries in dentin, significant results were obtained for DVE versus CR (p 0.004) and DVE versus DD (P = 0.002) whereas CR versus DD, a nonsignificant (P = 0.999) result was obtained. Similarly, the pairwise comparison of specificity between direct DVE, CR, and DD for caries in dentin showed a nonsignificant result for DV versus CR, DV versus DD, and CR versus DD (P = 0.250, 0.999, 0.625).


   Discussion Top


The occlusal surface is the area most susceptible to dental caries. It is also the most difficult surface for reliable detection of caries. Sensitivity is the proportion of true disease identified correctly, and specificity is the proportion of true nondisease identified correctly.[6] A diagnostic tool should be reliable (reproducible) and valid. When evaluating a diagnostic method, it is very important to test whether it provides a reliable and minimal diagnostic variability between measurements to assure consistency and reproducibility along time.[15] In the present study, the DD device was tested in vitro on primary molars in occlusal caries diagnosis, to estimate its validity using the histological examination as the gold standard. The simplified scoring scale (0, 1, 2) was used for all examination methods as reported by Kavvadia and Lagouvardos.[16] The same caries scoring scale has been proposed by the manufacturer to be used in permanent teeth.[17] The results obtained in our study are similar to the results obtained by Apostolopoulou et al.[18] In a study done by Attrill and Ashley,[6] to compare the accuracy and repeatability of three diagnostic systems (visual, DD, and conventional radiograph) for occlusal caries diagnosis in primary molars, the highest sensitivity values were seen in DD (0.77 and 0.80, examiners 1 and 2, respectively); however, this was offset by a lower specificity (0.82 and 0.85) than all other systems. The DD gave the highest values of kappa for intra- and inter-examiner repeatability with the exception of intraexaminer repeatability for examiner 2 where visual diagnosis had the highest value of kappa. A similar in vitro study done by Lussi and Francescut [12] showed no statistically significant difference between visual inspection with magnification and DD in detecting caries confined to enamel. A study was done by Sridhar et al.[19] to determine the clinical efficacy of DD in detecting occlusal caries; a total number of fifty teeth were subjected for visual inspection, conventional radiograph, and DD examination and were compared to histological examination which is a gold standard; results showed that DD is superior to visual and radiographic methods in diagnosing occlusal caries. Anttonen et al.[20] observed a sensitivity of 92% and specificity of 82% with employment of a cutoff point of 30. Similarly study done by Heinrich-Weltzien et al[21] revealed sensitivity values of 93% and specificity values of 63%, on the contrary the specificity values was 20% lower than other investigations. This was probably due to the exclusion of caries-free molars, which were assessed but not operatively validated. A study by Zaidi et al.[15] demonstrated that the DD device is capable of obtaining high sensitivity on the occlusal sites of deciduous teeth with macroscopically intact surfaces. The performance was similar to that found in a recently published in vitro study in deciduous teeth. An in vitro study by Kühnisch et al.[22] on occlusal sites to assess the intra-/inter-examiner reproducibility of the new DD pen revealed a wide measuring range. However, a invitro study done by Burin,[23] to compare the effectiveness of a LF device with visual and radiographic scoring system for detection of occlusal caries and also to evaluate the effect of 1% NaOCl immersion on the LF readings, A significant reduction of the LF reading was found after immersion in 1% of NaOCl. A study by Pinelli et al.[24] verified the drying effect on the reproducibility of DD devices to detect caries-like lesions and showed that reproducibility increased under dry condition, drying is advised to detect caries-like lesions on free smooth surfaces.

A systematic review was conducted by Pinheiro et al.[25] to assess the accuracy of LF (DIAGNOdent ®) for diagnosis of occlusal caries in permanent teeth, using any sort of gold standard. DIAGNOdent ® was found to be an accurate method for diagnosis of occlusal caries, mainly if employed simultaneously with visual inspection.[20] Thus, the null hypothesis is rejected as the three diagnostic aids used in the present study fall short of accuracy when compared to histological examination which is the gold standard.


   Conclusion Top


The present study demonstrated the following:

  • The DD exhibited better specificity than sensitivity for enamel lesions and better sensitivity than specificity for lesions in dentin
  • DVE and LF examination (DD) were superior to computerized radiographic examination in terms of sensitivity for enamel caries
  • Computerized radiographic examination exhibited higher sensitivity than DVE and LF examination for caries in dentin
  • DD may prove useful as a predictive clinical tool by virtue of its accuracy and repeatability and should only be used in addition to other diagnostic methods such as visual inspection and dental radiographs to avoid false-positive diagnoses
  • However, DD may be a useful adjunct in the caries diagnosis and treatment planning process. Nevertheless, further research seems to be necessary to investigate reasons for the observed deviations.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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