Year : 2009 | Volume
: 27 | Issue : 2 | Page : 90--93
An in-vitro comparison of visual inspection, bite-wing radiography, and laser fluorescence methods for the diagnosis of occlusal caries
SJ Pourhashemi1, A Jafari1, P Motahhari2, M Panjnoosh2, MJ Kharrazi Fard3, I Sanati1, M Sahadfar1, M Pariab1,
1 Department of Pediatric Dentistry, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Oral and Maxillofacial Pathology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
S J Pourhashemi
Department of Pediatric Dentistry, School of Dentistry, Tehran University of Medical Sciences, No 110 Ghods Avenue, Enghelab Street, Tehran
Purpose: The purpose of this study was to compare accuracy and reproducibility of visual inspection (VI), bitewing (BW) radiography, and laser fluorescence (LF, DIANOdent) methods in the diagnosis of occlusal caries. Materials and Methods: The study was done on 80 extracted permanent premolars that seem to be intact or with primary caries in fissures. Three trained dentist examined the teeth in four stages: VI, BW radiography, LF, and histologic examination. Sensitivity, specificity, positive and negative predictive values, and accuracy of all methods were calculated and compared. For the LF method, using ROC curve and counterpart points on it, we determined upper and lower limits and calculated the parameters. Results: The estimated accuracy was 58.9% for VI and 45.1% for BW radiography methods. Kappa coefficient for interexaminer reproducibility was 57% and 34.1% in VI and BW radiography, respectively. Inter- and intraexaminer reproducibility coefficients of LF methods were 78.4% and 83.6%, respectively. The mean intraexaminer reproducibility coefficient in the VI method was 61.2%. Conclusion: Although accuracy and reproducibility of the LF method were higher than those of the VI and BW radiography, it is better to use this method together with other methods to reduce diagnostic faults.
|How to cite this article:|
Pourhashemi S J, Jafari A, Motahhari P, Panjnoosh M, Kharrazi Fard M J, Sanati I, Sahadfar M, Pariab M. An in-vitro comparison of visual inspection, bite-wing radiography, and laser fluorescence methods for the diagnosis of occlusal caries.J Indian Soc Pedod Prev Dent 2009;27:90-93
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Pourhashemi S J, Jafari A, Motahhari P, Panjnoosh M, Kharrazi Fard M J, Sanati I, Sahadfar M, Pariab M. An in-vitro comparison of visual inspection, bite-wing radiography, and laser fluorescence methods for the diagnosis of occlusal caries. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2021 May 16 ];27:90-93
Available from: https://www.jisppd.com/text.asp?2009/27/2/90/55333
With the substantial decrease in dental caries prevalence in many countries, most of the new lesions currently occur in pit and fissures. , Estimations show that in children and adolescents, more than 75% of the caries lesions develop in occlusal pit and fissures.  While early detection of caries is very important for prevention, the diagnosis of these lesions is sometimes challenging for the dentists due to the morphology of occlusal pit and fissures. 
Usual diagnosis of pit and fissure caries is based on direct observation, examination by probe, and bitewing (BW) radiography. , Studies on accuracy of these methods have shown various results. While visual inspection (VI) after cleaning and thorough drying of fissures has been considered as a relatively accurate method, the accuracy of BW radiography to detect early occlusal caries has been questioned. , This, together with, the occurrence of hidden caries in deep pits and fissures, and application of sealants on suspected fissures has made usage of new diagnostic methods necessary. , Among the new methods such as fiber optic transillumination, electronic resistance measurement, and laser fluorescence (LF), the latter has led to more acceptable results, and many in-vivo and in-vitro studies have indicated high accuracy and reproducibility of the DIAGNOdent device which uses the LF method. ,, This method has been recommended to detect dentinal caries. ,, Coupled with clinical examination, it has also been considered as a valuable method in epidemiologic studies. ,, Reproducibility of DIAGNOdent has been shown to be very good. ,,
The objective of the present study was to compare accuracy and reproducibility of VI, BW radiography, and LF methods in the diagnosis of occlusal caries.
Materials and Methods
This in-vitro study was done on 80 extracted permanent premolars that seem to be intact or with primary caries in fissures. The teeth were stored in chloramine-containing thymol. The teeth were separately mounted on silicone. Professional prophilaxy with pumice was done for all teeth. The teeth then were rinsed with water spray and thoroughly dried.
Three trained dentists examined the teeth in four stages:
Visual inspection (VI) : The examiners visually examined the teeth under dental unit light to detect fissure caries. The results were recorded according to Extrand et al .'s scoring system  (0: without cavity or fissure discoloration; 1: presence of opaque line in fissure; 2: fissure discoloration; 3: fracture in enamel margin; and 4: cavitation). Radiographic examination : A radiology technician took BW radiographs (Kodak film, speed E2). The films were processed automatically. Using a negatoscope, the examiners observed the radiographs and recorded the results according to the following criteria:
0: no radiolucency were observed (intact); 1: diagnosis not possible; 2: radioloucency was observed in enamel; and 3: radioloucency was observed in dentin.Laser fluorescence (LF): The measurements with the diagnodent device (Kavo-Biberach, Germany) were made after calibration of the device with a ceramic standard. Each tooth was tested on its sound enamel to determine baseline. Then the fissures were traced with the instrument tip, and the results were recorded and ranked according to Lussi et al .'s method based on maximum reading  : 0-18: without caries; 19-30: enamel caries; and >30: dentinal caries.
According to manufacturer recommendation, the device was calibrated two times per day.Histologic examination : The teeth were dissected mesio-distaly from occlusal fissures and the two sections were examined by a stereomicroscope to detect caries and its penetration depth, and the results were recorded: D0: without caries; D1: enamel caries; and D2: dentinal caries.
To achieve maximum blinding, the codes of the teeth were changed after each stage.
Sensitivity, specificity, positive and negative predictive values, and accuracy of all methods were calculated. The mean of these parameters among the three examiners were calculated. For the LF method, using ROC curve and counterpart points on it, we determined upper and lower limits and calculated the parameters. To assess intraexaminer reproducibility of VI and LF methods, the teeth codes were changed and the examinations were repeated after 20 days by the same examiners. To assess reproducibility (inter- and intraexaminer), for the VI and BW radiography, the kappa statistics, and for LF method, intraclass correlation coefficients (ICC) were used. SPSS 11.5 software for windows XP (Chicago Inc., IL, USA) served for statistical analysis.
[Table 1] shows sensitivity, specificity, positive predictive value, and negative predictive value of visual inspection and BW radiography methods. As it can be seen, the estimated accuracy was 58.9% for VI, and 45.1% for BW radiography methods.
Regarding the LF method, the lower and upper cut-off points were estimated to be 12 and 20, respectively. Percentages of sound and decayed tooth, according to these cut-off points have been shown in [Table 2]. With the upper cut-off point, 79% of the decayed and 6% of the sound teeth were diagnosed as decayed, which resulted in 94% positive predictive value. On the other hand, 2% of the decayed and 52% of the sound teeth were diagnosed as sound. Thus, the negative predictive value was estimated to be 95.3%.
Kappa coefficient for interexaminer reproducibility was 57% and 34.1% in VI and BW radiography, respectively. Inter- and intraexaminer reproducibility coefficients of the LF method, calculated by means of ICC, were 78.4% and 83.6%, respectively. The mean intraexaminer reproducibility coefficient in the VI method was found to be 61.2%.
In the present study, the LF method (DIAGNOdent) was found to be the more accurate means to detect occlusal caries compared to VI and BW radiography.
To increase the validity of the results, three dentists, blinded by changing the teeth codes, after each stage, performed all examinations. Moreover, histologic inspection, which is the most accurate method for caries diagnosis, served as gold standard. Since this study was in-vitro , however, the generalization of the results to real clinical situation should be done cautiously.
In the present study, accuracy, sensitivity, and specificity of VI were 58.9%, 43.8%, and 78.3, respectively. This finding shows that VI is a useful method for caries diagnosis, but it should be accompanied by more accurate method due to its low sensitivity leading to possible missing of hidden caries. In previous studies, the accuracy of this method has been estimated to be 83.9%  and 98%,  which is more than our estimation. Accuracy of BW radiography in the present study was 45.1%. This finding, showing inaccuracy of this method for occlusal caries diagnosis, is in contrast to Akarsu et al .  reporting no significant difference between the three studied methods for caries diagnosis. Our estimated accuracy is also lower than that reported by Buczkowska-Radliñska and. Mayschak (75%),  but it is in line with finding by Burin et al .  considering BW radiography with accuracy of 56% as an incompetent method to be used alone for caries diagnosis.
Generally, previous studies have considered the LF method (DIAGNOdent) as valuable especially for incipient and hidden occlusal caries. ,,,,,,, Our estimated accuracy for this method (94.8%) is consistent with study by Lussi and Hellwig reporting 83% accuracy.  Buczkowska-Radliñska and Mayschak,  however, reported 58% accuracy for the method, which was lower than those of the VI and BW radiography. 
The highest interexaminer reproducibility among the three studied methods belonged to the LF method (83.6%). Kühnisch et al .  also reported 84% interexaminer reproducibility for the LF method. Intraexaminer reproducibility also was highest for the LF method compared to other methods in our study, while Angnes et al .  have reported high values for both VI and LF methods.
Although accuracy and reproducibility of the LF method were higher than those of the VI and BW radiography, it is better to use this method together with other methods to reduce diagnostic faults.
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