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ORIGINAL ARTICLE
Year : 2016  |  Volume : 34  |  Issue : 2  |  Page : 152-158
 

Clinical performance of ICDAS II, radiovisiography, and alternating current impedance spectroscopy device for the detection and assessment of occlusal caries in primary molars


1 Department of Pedodontics and Preventive Dentistry, Vananchal Dental College and Hospital, Garhwa, Jharkhand, India
2 Department of Pedodontics and Preventive Dentistry, Babu Banarasi Das School of Dental Sciences, Lucknow, Uttar Pradesh, India
3 Private Dental Practitioner, Dental Comfort Zone, Patna, Bihar, India

Date of Web Publication14-Apr-2016

Correspondence Address:
Dr. Rohit Singh
Department of Pedodontics and Preventive Dentistry, Vananchal Dental College and Hospital, Garhwa, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.180445

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   Abstract 

Objective: To investigate the clinical performance of International Caries Detection and Assessment System II (ICDAS II) (a ranked visual scale), radiovisiography (RVG) (a digital radiography device), and an alternating current impedance spectroscopy (ACIS) device for the detection and assessment of occlusal caries in primary teeth. Materials and Methods: Twenty-five molars were assessed using all three systems under standardized in vivo conditions. They were then extracted and also assessed by examiners in vitro. Downer's histological scoring criterion was the validation gold standard. Sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver-operator curves were calculated for enamel caries and dentine caries. Repeatability was analyzed using intraclass correlation coefficient (ICC). The performances of the systems between in vivo and in vitro settings by the same examiner were also compared. Statistical Analysis: SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) was used to analyze the data. Comparison of the performance of all three systems for all caries and dentine caries using receiver operating characteristic curves was calculated using a range of cutoffs. Reliability was assessed using ICC method. Results: ICDAS II system showed the highest validity and repeatability for assessing occlusal caries in the primary molars. RVG was less accurate than the ICDAS II for detecting caries lesions confined to enamel. However, when dentine was involved, RVG was found to be as effective as ICDAS II. Conclusion: Within the limitations of the study, the in vivo results of ICDAS II and RVG were satisfactory and comparable to those obtained in vitro, with ICDAS II performing better. The ACIS device was least accurate among the three systems for caries assessment.


Keywords: Alternating current impedance spectroscopy device, caries detection, International Caries Detection and Assessment System II, primary molar, radiovisiography


How to cite this article:
Singh R, Tandon S, Rathore M, Tewari N, Singh N, Shitoot AP. Clinical performance of ICDAS II, radiovisiography, and alternating current impedance spectroscopy device for the detection and assessment of occlusal caries in primary molars. J Indian Soc Pedod Prev Dent 2016;34:152-8

How to cite this URL:
Singh R, Tandon S, Rathore M, Tewari N, Singh N, Shitoot AP. Clinical performance of ICDAS II, radiovisiography, and alternating current impedance spectroscopy device for the detection and assessment of occlusal caries in primary molars. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2021 Mar 8];34:152-8. Available from: https://www.jisppd.com/text.asp?2016/34/2/152/180445



   Introduction Top


Accurate and early detection of occlusal caries and assessment of lesion progression are important, particularly in primary teeth where caries can progress rapidly due to thinner enamel, lower mineral content, and greater porosity than in permanent teeth. However, caries detection research for primary teeth appears to be lacking compared to permanent teeth.

In the past, meticulous visual inspection with a good light, a dry tooth, and a probe has been the backbone of dental caries detection. Currently, three visual systems, Nyvad criteria, International Caries Detection and Assessment System II (ICDAS II), and UniVLSS are commonly in use. The ICDAS II has been designed to assess precavitated lesions. The various studies conducted with this system have yielded favorable accuracy in their results. [1]

Digital radiography is widely used for the detection of occlusal and approximal carious lesions in permanent teeth. A few researchers have also investigated the performance of digital radiography in approximal carious lesions in primary teeth, but its utility in detecting occlusal caries in primary teeth is still unexplored. [1],[2]

Other methods for occlusal caries assessment in primary molars such as the use of electrical impedance measurements have shown some promise. An alternating current device has been reported to yield favorable results. [3] The system comes in the form of a portable handheld rechargeable body with disposable tufted sensors. The device has been designed to assess precavitated lesions. However, the sensitivity, specificity, and validity of alternating current impedance spectroscopy (ACIS) device for occlusal caries detection in primary teeth have not been tested in vivo.

Although various methods have been reported for early detection of dental caries in permanent dentition, there is relatively very less literature regarding the diagnosis of early carious lesions in primary teeth. Therefore, the present study was undertaken with an aim to have a comparative evaluation of clinical performance of ICDAS II, radiovisiography (RVG), and ACIS device for the detection and assessment of occlusal caries in primary molar teeth. The null hypothesis for the current study was that there is no difference in the three systems with respect to the caries detection.


   Materials and Methods Top


The present study was conducted after obtaining the approval from Institutional Ethical Committee. Signed and informed consent was obtained from the children's parents or guardians before the examination.

The sample consisted of primary molar teeth with dental caries from both maxillary and mandibular arches of healthy children aged 8-11 years. In total, 25 teeth were included and tested both in vivo and in vitro.

Study design

The present study was conducted in two phases:

  1. In vivo phase: The 25 teeth were examined by ICDAS II, RVG, and ACIS device for caries detection in primary molars.
  2. In vitro phase: The 25 examined teeth were extracted and retested in vitro, and validity of caries detection assessment was determined by histological evaluation. 20 teeth out of the sample were retested after 1 week for intra-examiner reliability.


Inclusion criteria

  1. Primary molar teeth having carious lesions.
  2. Carious primary molars on the verge of exfoliation.


Exclusion criteria

  1. Primary molar teeth with restorations.
  2. Primary molar teeth with pulpal involvement.
  3. Primary molar teeth with dental anomalies.


Caries assessment in vivo

The following procedures were carried out per tooth:

  1. The tooth was cleaned with pumice and a bristle brush, and then rinsed thoroughly with water and dried for 5 s. One site per tooth was selected and recorded.
  2. ICDAS II assessment was carried out first. The tooth was initially viewed wet to determine whether caries was visible, then air-dried for 5 s to desiccate the tooth surface before visual assessment.
  3. For the ACIS device (Cariescan Pro, Caries Scan Ltd., Dundee, Scotland), the tooth was rehydrated with water from a syringe for 5 s to enable electrical conductance of the device. The tooth was dried for 3 s, and the activated device was placed directly on the area to be tested [Figure 1].
  4. For the RVG, the images were obtained with a charge-coupled device sensor (Dixi 3; Planmeca, Helsinki, Finland), using an exposure time of 0.2 s.
Figure 1: Detection of occlusal caries with alternating current impedance spectroscopy device

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Caries assessment in vitro

For the in vitro phase, the tested teeth were extracted and stored in 0.1% thymol solution. Each tooth was scored according to the earlier recorded reference area from the in vivo phase.

For this stage, the detection tests were carried out under standard conditions in a dental light. The two systems (ICDAS, RVG) were applied to the teeth in the same manner as described in vivo. Only modification being done that for the CarieScan PRO, each tooth was held in an ungloved hand with the lip connector in contact with the root to facilitate electrical conductance by completing the circuit between tooth and device.

One week after all the testing were completed, 20 teeth were selected. On a separate score sheet, these teeth were re-assessed by the examiner using each system in the same way and the results recorded for later analysis of in vitro intra-examiner reliability.

Histological validation

The teeth were mounted in sticky wax holders before hemi-section from the mesial to distal surface of each tooth, using a 0.1-mm-thick band saw under running tap water. No teeth were lost during sectioning. Wet sections were viewed at ×15 magnification (Olympus SZ-PT, Olympus Optical Co., Japan) for the presence or absence of caries in enamel or dentine. The results were classified using Downer's criteria, which allowed for comparison with previous work. [4] One week later, 20 teeth were selected randomly, and their sections were re-examined to determine the repeatability of the histological assessment [Figure 2].
Figure 2: Histological tooth section showing D2 score

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Statistical tools employed

SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) was used to analyze the data. Comparison of the performance of all three systems for all caries and dentine caries using receiver operating characteristic (ROC) curves was calculated using a range of cutoffs. Reliability was assessed using intraclass correlation coefficient (ICC) method. The values were represented in number (%) and mean ± standard deviation.

Outcome variables and standardization

All the three methods assessed were compared with the following outcome variables:

  1. Sensitivity for all three caries detection systems both in vivo and in vitro by examiner.
  2. Specificity for all three systems both in vivo and in vitro by examiner.
  3. Positive and negative likelihood ratios for all three systems both in vivo and in vitro by examiner.
  4. ROC curves for all three systems both in vivo and in vitro by examiner.
  5. Intra-examiner repeatability between the in vivo and in vitro testing.


Cut-offs grading criteria

Since the Downer's histological classification offered a distinct cut-off for dentinal caries (between D2 and D3), it was used in the analysis of the assessment parameters at the chosen corresponding cutoffs. For the presence of caries, anything above D1 (all caries) was used as the histological threshold, and for dentinal caries, all readings above the D3 (dentine caries) threshold were used. It should be noted that the supplied cut-off values in the manufacturer operating instructions for each system were for permanent, not primary teeth.

For ICDAS II, the D1 threshold was calculated at code 1 as this represented the initial onset of caries into the outer half of the enamel layer. Because ICDAS II code 2 signifies the presence of either deep enamel or superficial dentine caries extension, the D3 threshold was calculated at both the code 2 and code 3 cutoffs, where code 3 represented an established dentinal lesion.

Because the ACIS device was designed to assess caries extension through the enamel layer, two cutoffs for D1 were taken based on manufacturer's instructions: Code 21 and code 51, corresponding to caries extension into the outer third and inner third of the enamel, respectively. The D3 threshold was calculated at cut-off 91, which represented lesion extension to the enamel-dentine junction.

The RVG cutoff for the D1 threshold and the first D3 threshold were taken at 1 and 2, respectively, based on operator instructions and previous work.


   Results Top


In vivo intra-rater reliability

In vivo intra-rater reliability showed a good agreement in all the three systems of scoring being high value of ICCs. The intra-rater reliability was very high with highest being of ACIS device (ICC = 0.93) followed by ICDAS II (ICC = 0.92) and RVG (ICC = 0.86) [Table 1].
Table 1: In vivo intra-rater reliability


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In vivo diagnostic accuracy of International Caries Detection and Assessment System II, radiovisiography, and alternating current impedance spectroscopy device

The in vivo diagnostic accuracy of ICDAS II, RVG, and ACIS device for both D1 and D3 cutoff is summarized in [Table 2].
Table 2: In vivo sensitivity and specificity of International Caries Detection and Assessment System, radiovisiography, and CarieScan PRO for the detection of occlusal caries in primary molars


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International Caries Detection and Assessment System II

For cut-off grade D1 (i.e., at enamel level), the diagnostic accuracy of ICDAS II was significant (area under the curve [AUC] = 0.764, Z = 2.24; P = 0.025) with 77.78% high sensitivity (95% confidence interval [CI] = 40.1-96.5) and 75.00% high specificity (95% CI = 35.0-96.1) [Table 2].

Similarly, for grade D3 (i.e., at dentine level), the diagnostic accuracy of ICDAS II was also found significant (AUC = 0.826, Z = 3.20; P = 0.001) with 81.82% high sensitivity (95% CI = 48.2-97.2) and 83.33% high specificity (95% CI = 36.1-97.2) [Table 2].

Radiovisiography

In contrast, for grade D1, the diagnostic accuracy of RVG was insignificant (AUC = 0.708, Z = 1.63; P = 0.104) and with 66.67% low sensitivity (95% CI = 30.1-92.1), but with 75.00% high specificity (95% CI = 35.0-96.1) [Table 2].

However, for grade D3, the diagnostic accuracy of RVG was found significant (AUC = 0.780, Z = 2.46; P = 0.014) with 72.73% high sensitivity (95% CI = 39.1-93.7) and 83.33% high specificity (95% CI = 36.1-97.2) [Table 2].

Alternating current impedance spectroscopy device

Conversely, for grade D1, the diagnostic accuracy of ACIS device was found insignificant (AUC = 0.632, Z = 0.96; P = 0.338) with 88.89% high sensitivity (95% CI = 51.7-98.2), but 37.50% low specificity (95% CI = 9.0-75.3) [Table 2].

Similarly, for grade D3, the diagnostic accuracy of ACIS device was also found insignificant (AUC = 0.705, Z = 1.58; P = 0.115) with 90.91% high sensitivity (95% CI = 58.7-98.5), but 50.00% low specificity (95% CI = 12.4-87.6) [Table 2].

Moreover, in comparison to RVG and ACIS device, ICDAS II showed both higher sensitivity and specificity at D3 as compared to D1.

In vitro intra-rater reliability

In vitro intra-rater reliability showed a good agreement in all the three systems of scoring being high value of ICCs. The intra-rater reliability was very high in all systems with highest being of ICDAS II (ICC = 0.93) followed by ACIS device (ICC = 0.91) and RVG (ICC = 0.89) the least [Table 3].
Table 3: In vitro intra-rater reliability


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In vitro diagnostic accuracy of International Caries Detection and Assessment System II, radiovisiography and alternating current impedance spectroscopy device

The in vitro diagnostic accuracy of ICDAS II, RVG and ACIS device for both D1 and D3 cut-off are summarized in [Table 4].
Table 4: In vitro sensitivity and specificity of International Caries Detection and Assessment System, radiovisiography and CarieScan PRO for the detection of occlusal caries in primary molars


Click here to view


International Caries Detection and Assessment System II

For grade D1, the diagnostic accuracy of ICDAS II was significant (AUC = 0.819, Z = 3.04; P = 0.002) with 88.89% high sensitivity (95% CI = 51.7-98.2) and 75.00% high specificity (95% CI = 35.0-96.1) [Table 4].

Similarly, for grade D3, the diagnostic accuracy of ICDAS II was also significant (AUC = 0.788, Z = 2.57; P = 0.010) with also 90.91% high sensitivity (95% CI = 58.7-98.5) but 66.67% low specificity (95% CI = 22.7-94.7) [Table 4].

Radiovisiography

In contrast, for grade D1, the diagnostic accuracy of RVG was insignificant (AUC = 0.708, Z = 1.63; P = 0.104) and with 66.67% low sensitivity (95% CI = 30.1-92.1) but with 75.00% high specificity (95% CI = 35.0-96.1) [Table 4].

However, for grade D3, the diagnostic accuracy of RVG was found significant (AUC = 0.780, Z = 2.46; P = 0.014) with 72.73% high sensitivity (95% CI = 39.1-93.7) and 83.33% high specificity (95% CI = 36.1-97.2) [Table 4].

Alternating current impedance spectroscopy device

In contrast, for grade D1, the diagnostic accuracy of ACIS device was found insignificant (AUC = 0.694, Z = 1.50; P = 0.135) with 88.89% high sensitivity (95% CI = 51.7-98.2) but 50.0% low specificity (95% CI = 16.0-84.0) [Table 4].

Similarly, for grade D3, the diagnostic accuracy of ACIS device was also found insignificant (AUC = 0.705, Z = 1.58; P = 0.115) with 90.91% high sensitivity (95% CI = 58.7-98.5), but with 50.00% low specificity (95% CI = 12.4-87.6) [Table 4].

When the comparison was made in all three systems in relation to sensitivity, though ACIS device had shown high sensitivity, it also had low specificity both at D1 and D3. ICDAS II was found to be the most sensitive system with high sensitivity at D3 as compared to D1.


   Discussion Top


The present study design utilized both an in vivo and in vitro component by using three different systems along with their gold standard histological validation, allowing for a direct comparison and analysis of their caries assessment capabilities.

Conventionally, serial sections are used, but in this study, hemi-section was preferred, since this was simpler. It could be argued that serial sectioning might have uncovered more caries; however, the available data [5] suggest that hemi-sections will detect as many lesions as serial sections when assessing occlusal surfaces.

The majority of the earlier studies [6] conducted were based on visual assessment following operative access to the tooth. Compared to above, the present study has utilized the histological method as gold standard in teeth immediately after extraction.

The results of the level of agreement between both groups (in vivo and in vitro) obtained by examiner were calculated using ICC [Table 1] and [Table 3]. Although the experimental conditions had changed, repeatability was analyzed in this way because such information is rarely reported and yet valuable as it directly relates laboratory results to clinical relevance.

In this study design and setting, the issue of teeth selection bias may be a concern as teeth tested would always be those that are indicated for extraction. Fortunately, primary molars are often indicated for extraction due to orthodontic purposes or at the verge of exfoliation. The inclusion of such primary molars ensured only those teeth throughout the sample that were sound or exhibited only initial lesions for a uniform distribution of histological depths. This is important to prevent over- or under-estimation of sensitivity and specificity values, especially when ROC analysis was performed with each system during histological validations.

Both in vivo and in vitro data [Table 1] and [Table 3] showed that ICDAS II had the highest validity and repeatability for caries assessment among three systems, which was in general agreement with other studies conducted on primary teeth. [6],[7],[8],[9] This indicates that any result obtained from in vitro findings can be reasonably extrapolated in vivo. A point to note is that while the higher sensitivities than specificities obtained at the D1 threshold in the present study [Table 4], these findings were similar to the results from a recent in vitro study by Neuhaus et al., whereas the inverse was true for an earlier study conducted by Shoaib et al., while specificity was higher than sensitivity.

In the present study, ICDAS II with sensitivity of 77.78% and specificity of 75% was more accurate than the radiographic methods with sensitivity of 66.67% and specificity of 75% for enamel occlusal carious lesions in primary molars. For dentine caries lesions, digital radiography specificity (83.33%) had a similar performance to ICDAS II specificity (83.33%) [Table 2] and [Table 4].

The results of this study for CarieScan PRO were not so encouraging. For a device designed to assess initial lesions, the lack of specificity at both D1 cutoffs was of concern, even when the second cutoff chosen at 51 represented deeper lesion extension into the inner third of the enamel layer. The high sensitivity obtained suggests that while the device correctly detected all carious lesions, this was due to no differentiation between the detection of caries and of sound tooth structure.

When ACIS device was used, intra-examiner reliability scores were 0.93 and 0.91 [Table 1] and [Table 3]. This score was similar to a previous study where substantial agreement was demonstrated by Hall et al. for both intra-and interexaminer repeatability of ACIS device. [10]

In the present study, ACIS device demonstrated high value of sensitivity at D1 (88.89) and D3 (90.91) and lower value of specificity at D1 (37.50) and D3 (50.00) [Table 2] and [Table 4]. In a previous study by Pitts et al., permanent teeth and a micro computerized tomography technique for histology were used, and better sensitivity (0.92) and specificity (0.92) values were recorded. [11] This difference can be explained with the anatomical variations on the occlusal surfaces of permanent and primary teeth and perhaps the difference for the histology technique.

There was a lack of agreement between in vivo and in vitro results of ACIS device. Even at the in vitro D1 level, where the device similarly obtained high sensitivity and low specificity, the agreement with in vivo findings were poor which indicate that a high proportion of teeth being falsely identified as having caries differed under both conditions. Furthermore, the improvement in repeatability and dentinal caries assessment results in vitro as opposed to in vivo suggest that the device might behave differently under differing conditions. It was unlikely that the electrical conductance of teeth was affected when removed from the oral cavity. It provided good in vitro results with the ECM (Extracellular matrix, also an alternating current device) as reported by Ashley. [3]

Despite its potential, the AUC performance for ACIS device on primary teeth was low. Since the previous study conducted by Hall et al. showed promising results for ACIS device, a possible reason for this low performance would be the variation in the conductance of electrical impulses due to enamel thickness of primary teeth. Thus, at this juncture, any in vitro research conducted with the ACIS device in primary teeth should not be extrapolated to the clinical situation. Because primary and permanent teeth are still physiologically similar, care should also be taken when interpreting in vitro results obtained on permanent teeth, as they also may not necessarily correlate to in vivo findings with a degree of predictability. [12]


   Conclusion Top


On the basis of observations made during the course of study and their analysis, the following conclusions were drawn:

  • ICDAS II system demonstrated the highest validity and repeatability for assessing occlusal caries in the primary molars.
  • The digital radiographic method (RVG) was less accurate than the ICDAS II for detecting caries lesions confined to enamel. However, when dentine was involved, RVG was found to be effective for assessing occlusal caries in primary molars.
  • The ACIS device was less accurate among the three systems for caries assessment due to the variation in the conductance of electrical impulses.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Nielsen LL, Hoernoe M, Wenzel A. Radiographic detection of cavitation in approximal surfaces of primary teeth using a digital storage phosphor system and conventional film, and the relationship between cavitation and radiographic lesion depth: An in vitro study. Int J Paediatr Dent 1996;6:167-72.  Back to cited text no. 1
    
2.
Mariath AA, Casagrande L, de Araujo FB. Grey levels and radiolucent lesion depth as cavity predictors for approximal dentin caries lesions in primary teeth. Dentomaxillofac Radiol 2007;36:377-81.  Back to cited text no. 2
    
3.
Ashley P. Diagnosis of occlusal caries in primary teeth. Int J Paediatr Dent 2000;10:166-71.  Back to cited text no. 3
    
4.
Downer MC. Concurrent validity of an epidemiological diagnostic system for caries with the histological appearance of extracted teeth as validating criterion. Caries Res 1975;9:231-46.  Back to cited text no. 4
[PUBMED]    
5.
Hintze H, Frydenberg M, Wenzel A. Influence of number of surfaces and observers on statistical power in a multiobserver ROC radiographic caries detection study. Caries Res 2003;37:200-5.  Back to cited text no. 5
    
6.
Matos R, Novaes TF, Braga MM, Siqueira WL, Duarte DA, Mendes FM. Clinical performance of two fluorescence-based methods in detecting occlusal caries lesions in primary teeth. Caries Res 2011;45:294-302.  Back to cited text no. 6
    
7.
Shoaib L, Deery C, Ricketts DN, Nugent ZJ. Validity and reproducibility of ICDAS II in primary teeth. Caries Res 2009;43:442-8.  Back to cited text no. 7
    
8.
Neuhaus KW, Rodrigues JA, Hug I, Stich H, Lussi A. Performance of laser fluorescence devices, visual and radiographic examination for the detection of occlusal caries in primary molars. Clin Oral Investig 2011; 15:635-41.  Back to cited text no. 8
    
9.
Mendes FM, Novaes TF, Matos R, Bittar DG, Piovesan C, Gimenez T, et al. Radiographic and laser fluorescence methods have no benefits for detecting caries in primary teeth. Caries Res 2012;46:536-43.  Back to cited text no. 9
    
10.
Hall AF, Kaczmarek U, Pitts NB. Intra-and inter examiner repeatability of ac-impedance spectroscopy to detect sound and caries sites in vivo. Caries Res 2007;41:296-300.  Back to cited text no. 10
    
11.
Pitts NB, Longbottom C, Hall AF. Diagnostic accuracy of an optimised ac impedance device to aid caries detection and monitoring. Caries Res 2008;42:211-5.  Back to cited text no. 11
    
12.
Hall AF, Kaczmarek U, Pitts NB. Intra and inter examiner repeatability of ac impedance spectroscopy to detect sound and caries sites in vivo. Caries Res 2007;41:296-9.  Back to cited text no. 12
    


    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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