Detection Of Approximal Caries Research Articles

Gold standard for the comparison of the diagnostic accuracy of panoramic images for approximal caries detection

Free AccessLetter to the editorGold standard for the comparison of the diagnostic accuracy of panoramic images for approximal caries detectionA WenzelA WenzelDepartment of Oral Radiology, School of Dentistry, Aarhus University, Denmark; E-mail: Search for more papers by this authorPublished Online:28 Jan 2014https://doi.org/10.1259/dmfr/18326926SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail AboutDentomaxillofacial Radiology (2009) 38, 245. doi: 10.1259/dmfr/18326926The authors of the research article titled “A comparison of the diagnostic accuracy of bitewing, periapical, unfiltered and filtered digital panoramic images for approximal caries detection in posterior teeth” published in Dentomaxillofacial Radiology 2007; 37: 441–4421 claim that a particular emboss filter for panoramic images has a higher diagnostic value than original images for detection of caries lesions. The authors of this study use a “consensus of the three observers” as an expression for the true state of the disease (a caries lesion). In fact, no data are available for the true state of the disease in this study. It is therefore unfortunate that the data are treated by receiver operating characteristics (ROC) analysis (which demands that a solid gold standard is available) and that the term “diagnostic accuracy” is used.Three criteria should be fulfilled for a method to provide a worthy gold standard:it should be established by a method that is itself precise, i.e. reproducibleit should reflect the pathoanatomical appearance of the diseaseit should be established independently of the diagnostic method under evaluation.2The three-observer-consensus-truth does not fulfill any of these criteria.It has moreover been shown that not only will ROC areas become extremely large (around 0.9) when an observer is also the gold standard (logically, since the same mind that produces the test results produces the reference results against which the test is held), but also the mutual accuracy among the modalities tested is different when a solid gold standard and an observer-consensus-standard is applied. The results from a study with the latter design can therefore not be trusted, neither regarding the diagnostic accuracy of the modalities, nor the mutual performance among the modalities.3, 4 It only muddles our findings. References 1 Akarslan ZZ, Akdevelioglu M, Güngör K, Erten H. A comparison of the diagnostic accuracy of bitewing, periapical, unfiltered and filtered digital panoramic images for approximal caries detection in posterior teeth. Dentomaxillofac Radiol 2008;37:458–463. Link ISI, Google Scholar2 Wenzel A, Hintze H. The choice of gold standard for evaluating tests for caries diagnosis. Dentomaxillofac Radiol 1999;28:132–136. Crossref Medline ISI, Google Scholar3 Wenzel A, Hintze H. Comparison of microscopy and radiography as gold standards in radiographic caries diagnosis. Dentomaxillofac Radiol 1999;28:182–185. Link ISI, Google Scholar4 Hintze H, Wenzel A. Influence of the validation method on diagnostic accuracy for caries. A comparison of six digital and two conventional radiographic systems. Dentomaxillofac Radiol 2002;31:44–49. Link ISI, Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byROLE OF ARTIFICIAL INTELLIGENCE APPLICATIONS IN DENTOMAXILLOFACIAL RADIOLOGY: PART 124 August 2022 | Selcuk Dental JournalRadiographic modalities for diagnosis of caries in a historical perspective: from film to machine-intelligence supported systemsAnn Wenzel4 March 2021 | Dentomaxillofacial Radiology, Vol. 50, No. 5Caries20 February 2013Reply to the above commentary on the Letter to the Editor entitled “Gold standard for the comparison of the diagnostic accuracy of panoramic images for approximal caries detection” published in Dentomaxillofacial Radiology (2009;38:245)A Wenzel29 May 2014 | Dentomaxillofacial Radiology, Vol. 38, No. 7 Volume 38, Issue 4May 2009Pages: 187-246 © The British Institute of Radiology History Published onlineJanuary 28,2014 Metrics Download PDF

Effect of monitors on approximal caries detection in digital radiographs—standard versus precalibrated DICOM part 14 displays: An in vitro study

The aim of this study was to evaluate if different ways of adjusting brightness and contrast of monitors with different technical standards influence the diagnosis of carious lesions in digital radiographs. One hundred extracted teeth (premolars and molars) were radiographed. Seven observers evaluated images for approximal carious lesions on 3 monitors: a standard color monitor with brightness and contrast manually adjusted for viewing radiographs, a Digital Imaging and Communication in Medicine (DICOM) part 14 precalibrated color monitor, and a DICOM part 14 precalibrated monochromatic monitor. All evaluations were made in ambient light <50 lux. Receiver operating characteristic curves were plotted to evaluate results. The standard criterion was a histologic examination of sliced teeth. Kappa statistic evaluated intraobserver agreement. No significant difference in accuracy of approximal carious lesion diagnosis was found between the monitors. Intraobserver agreement varied between fair and good. No differences that could affect clinicians' abilities to detect carious lesions in digital radiographs existed between the standard monitor and the color and monochrome DICOM part 14 precalibrated monitors.

Performance of a Pen-Type Laser Fluorescence Device and Conventional Methods in Detecting Approximal Caries Lesions in Primary Teeth – in vivo Study

This in vivo study aimed to compare the performance of different methods of approximal caries detection in primary molars. Fifty children (aged 5–12 years) were selected, and 2 examiners evaluated 621 approximal surfaces of primary molars using: (a) visual inspection, (b) the radiographic method and (c) a pen-type laser fluorescence device (LFpen). As reference standard method, the teeth were separated using orthodontic rubbers during 7 days, and the surfaces were evaluated by 2 examiners for the presence of white spots or cavitations. The area under the receiver-operating characteristics curve (A_z) as well as sensitivity, specificity and accuracy (percentage of correct diagnosis) were calculated and compared with the McNemar test at both thresholds. The interexaminer reproducibility was calculated using the intraclass correlation coefficient (ICC-absolute values) and the kappa test (dichotomizing for both thresholds). The ICC value of the reference standard procedure was 0.94. At white-spot threshold, no methods tested presented good performance (sensitivity: visual 0.20–0.21; radiographic 0.16–0.23; LFpen 0.16; specificity: visual 0.95; radiographic 0.99–1.00; LFpen 0.94–0.96). At cavitation threshold, both LFpen and radiographic methods demonstrated higher sensitivity (0.55–0.65 and 0.65–0.70, respectively) and A_z (0.92 and 0.88–0.89, respectively) than visual inspection sensitivity (0.30) and A_z (0.69–0.76). All methods presented high specificities (around 0.99) and similar ICCs, but the kappa value for LFpen at white-spot threshold was lower (0.44). In conclusion, both LFpen and radiographic methods present similar performance in detecting the presence of cavitations on approximal surfaces of primary molars.

The relative diagnostic yields of clinical, FOTI and radiographic examinations for the detection of approximal caries in youngsters

The detection of carious lesions in the initial stages of development is very important in order to prevent the occurrence of cavitation. The aim of the present study was to compare three methods-visual examination, FOTI, and bitewing radiographic examination-for the detection of noncavitated and cavitated approximal carious lesions. Seventy students (mean age 14 years) with low caries prevalence were examined by three examiners. The tooth surfaces judged as having caries by at least one examiner or one diagnostic method were scheduled for tooth separation. The results showed that the incorporation of FOTI and radiographic examination represented an additional diagnostic yield of 50% and about 110%, respectively, compared to clinical examination alone. We conclude that FOTI or radiographic examination, or both, used as adjuncts to clinical examination, could improve the detection of noncavitated and cavitated approximal carious lesions. Although FOTI should not replace bitewing radiographic examination, it does seem to have additional value for the detection of carious lesions on approximal surfaces of the posterior teeth in school children with low caries prevalence.

A comparison of the diagnostic accuracy of bitewing, periapical, unfiltered and filtered digital panoramic images for approximal caries detection in posterior teeth

The aim of this study was to investigate the diagnostic accuracy of conventional bitewing, periapical radiographs, unfiltered and filtered digital panoramic images for the assessment of approximal carious lesions in posterior teeth. 20 patients who required bitewing, periapical and panoramic radiographs participated in the study. The digital panoramic images were treated with the "sharpen", "smooth" and "emboss" filters. Three experienced observers evaluated the bitewing and periapical radiographs, and the unfiltered and filtered digital panoramic images for the presence or absence of approximal carious lesions according to a 5-point confidence scale. Intra- and interobserver reliability was analysed with the Cronbach alpha test and diagnostic accuracy was evaluated using receiver operating characteristic (ROC) analysis. According to the results, the intra- and interobserver agreement levels were found to be almost perfect. The highest diagnostic accuracy was found for the bitewing, followed by the periapical and panoramic images. Compared with the unfiltered panoramic images, the filtered images had an almost equal or slightly higher diagnostic accuracy. The largest increase in diagnostic accuracy was observed for those images filtered with the emboss filter. The accuracy of unfiltered and filtered digital panoramic images is lower than conventional bitewing and periapical radiographs. The filtration of the digital panoramic images, especially the emboss filter, may have some value for the detection of approximal carious lesions.

Detection accuracy of approximal caries by black-and-white and color-coded digital radiographs

The objective of this study was to compare detection of approximal caries in vitro by black-and-white and color-coded digital radiographs. The material comprised 2 groups of tooth sample. One group consisted of 40 premolars mounted in groups of 3 or 4 and the other group included 90 premolars mounted in groups of 5. Radiographs, respectively exposed with the Dixi and the Digora Optime digital radiographic systems, were color-coded using specially designed software. Seven observers in each of 2 centers subjectively evaluated one series of black-and-white and color-coded radiographs. The teeth were subsequently sectioned for histological determination of the lesions. ROC analyses were performed. Differences between the area under the ROC curves for the digital black-and-white and the color-coded radiographs were analyzed by ANOVA. There were no significant differences between the black-and-white and the color-coded radiographs in detection of approximal caries. Color-coded digital radiographs may be used as an alternative to digital black-and-white radiographs.

Effect of ambient light and monitor brightness and contrast settings on the detection of approximal caries in digital radiographs: anin vitrostudy

The aim of this study was to investigate how brightness and contrast settings of the display monitor and ambient light level (illuminance) in the viewing room affect the clinician's ability to diagnose carious lesions in digital radiographs. Standardized radiographs were taken of 100 extracted teeth. Seven observers evaluated the images for approximal carious lesions twice, once under 50 lux and once under 1000 lux room illumination. Monitor brightness and contrast were varied +/-50% and +/-6%, respectively, to mimic the normal limits of monitor adjustment by an inexperienced user and one optimal setting. This was done by adjusting radiograph brightness and contrast by +/-25%. Thus, five radiographs of each tooth were evaluated. Receiver operating characteristic (ROC) analyses were performed. Histological examinations of the teeth served as the criterion standard. A paired t-test was used to evaluate whether differences in the areas under the ROC curves were significant and kappa was used to evaluate intraobserver agreement. When a monitor with optimal brightness and contrast settings was used to detect approximal carious lesions, ambient light levels less than 50 lux were significantly better than levels above 1000 lux (dentin and enamel lesions, P < 0.01; dentin lesions, P < 0.02). Increasing the contrast setting of the monitor by 6% did not change these results; 50 lux was still significantly better than 1000 lux (enamel lesions, P < 0.01; dentin and enamel lesions, P < 0.02) for evaluating radiographs. Intraobserver agreement differed from fair to good. Reducing ambient light to less than 50 lux significantly increased the accuracy of diagnosing approximal carious lesions on a monitor with an optimal brightness setting and an optimal or slightly higher than optimal contrast setting.

Erratum to The influence of zero value subtraction on the performance of a new laser fluorescence device for approximal caries detection

Erratum to The influence of zero value subtraction on the performance of a new laser fluorescence device for approximal caries detection

The influence of zero value subtraction on the performance of a new laser fluorescence device for approximal caries detection

The aim of this study was to assess the influence of the zero value subtraction on the performance of laser fluorescence (LFpen) for approximal caries detection. Three areas (cuspal, middle and cervical) of both mesial and distal buccal surfaces of 78 permanent molars were assessed using both wedge-shaped (WDG) and tapered wedge-shaped (TWDG) tips. With the addition of the average, one cut-off value for each area was obtained and the performance was assessed. The areas under the receiver operating characteristics (ROC) curve, specificity, sensitivity and accuracy with and without the zero value subtraction were calculated. The McNemar test revealed a statistically significant difference for specificity at thresholds D(1), D(2) and D(3) (WDG) and D(1) and D(2) (TWDG) when the zero value subtraction was not performed. Influence of the zero value subtraction on the LFpen performance was observed for approximal caries detection. However, when modified cut-off values were used, the zero value subtraction could be eliminated.

Detection of Approximal Caries by Clinical and Radiographic Examination in 9-Year-Old Swedish Children

The aims were to determine caries prevalence in 9-year-olds belonging to a low-caries prevalence population and to assess how accurately some commonly used risk factors/risk markers (predictors) can identify additional approximal caries as judged from bitewing examination (BW). One calibrated dentist examined 117 consecutive 9-year-olds from the inner city of Stockholm. The predictors were the number of clinically detected dfs and DFS, visible plaque, salivary mutans streptococci, tooth brushing habits, consumption of sugary products, parents’ education, and (before BW) an overall clinical judgement by the examiner. Analyses of the data included sensitivity and specificity and a multiple logistic regression model. When BW was included, the mean DFS was 0.27 and the mean dfs 1.74. For approximal enamel and dentin lesions, the average gain from BW was 0.20 lesions for permanent first molars and 1.23 lesions for primary molars. Altogether, 48% of the children benefited from BW. The best predictors of additional approximal caries from BW were presence of caries (cavitation/dentin level) on occlusal surfaces of permanent first molars and the dentist’s judgement based on clinical findings, both with a combined sensitivity and specificity of 134%. The only statistically significant variables in a logistic regression model were the dentist’s judgement and the child’s statement about regular tooth brushing. It is concluded that a sizeable proportion of 9-year-olds, representing a low-caries prevalence population, benefited from BW. However, the ability to identify these children from the predictors was limited.

In vitrocomparison of conventional film and direct digital imaging in the detection of approximal caries

To compare the diagnostic accuracy of conventional film, unenhanced direct digital and inversion grayscale direct digital imaging in the detection of approximal caries. 150 approximal surfaces of extracted permanent molars and premolars were selected for the study on the basis of varying lesion depth. The teeth were radiographed using Ektaspeed Plus film; digital images were made with a Schick CMOS-APS sensor. 7 examiners evaluated 58 randomized images of each modality. Histological sectioning of the teeth was used to verify the presence and extent of decay. No significant difference was found between the diagnostic accuracies of the three imaging modalities (P=0.226). Analysis of the diagnostic accuracy of the three modalities on lesion depth showed no statistically significant interaction; however, the main effect of the lesion depth was significant (P<0.001, eta(2)=0.936). The overall diagnostic accuracy of the three modalities in the detection of approximal carious lesions was comparable. All three modalities performed poorly in the detection of enamel lesions.

Influence of the condition of the adjacent tooth surface on fluorescence measurements for the detection of approximal caries

The aim of this study was to test whether the status of the adjacent tooth surface has an influence on the signal of a new laser fluorescence (LF) device for the detection of approximal caries. Seventy-eight teeth were selected from a pool of extracted permanent human molars, frozen at -20 degrees C until use. Before being measured the teeth were defrosted, cleaned, and any calculus removed. As a control, a defined approximal surface of each tooth was measured with the LF device holding the tip with the detecting- and the reverse-side on it, but without a neighboring tooth contacting the surface. The proximal site under examination was then placed adjacent to a tooth, which had deep dentinal caries, a composite restoration, a provisional ZnO-Eugenol restoration, or a ceramic restoration. The adjacent tooth with the ZnO-Eugenol restoration, the composite restoration, and the dentinal caries all demonstrated a statistically significant increase of LF readings on sound tooth surfaces. Teeth with enamel or dentinal caries were only slightly (and not statistically significantly) influenced by the different types of neighboring surfaces compared with the control LF readings. It can be concluded that caries detection of approximal tooth surfaces with the new LF system might be influenced by the condition of the adjacent tooth surface.

Detection of Approximal Caries with a New Laser Fluorescence Device

The laser device DIAGNOdent developed for the detection of occlusal caries has limited value on approximal surfaces. The aim of this study was to develop and to test a new laser fluorescence (LF) device for the detection of approximal caries. Light with a wavelength of 655 nm was transported to the approximal surface using two different sapphire fibre tips. Seventy-five teeth were selected from a pool of extracted permanent human molars, frozen at –20°C until use. Before being measured, they were defrosted, cleaned and calculus was removed with a scaler. The molars were set in blocks simulating the contact area of adults. Bitewing radiographs were obtained using Kodak Insight films. After two independent assessments with the new LF device, the teeth were histologically prepared, and assessed for caries extension. Using the laser, specificity values for D₁threshold (outer half of enamel), D₂threshold (inner half of enamel), D₃threshold (dentine) ranged between 0.81 and 0.93, sensitivity between 0.84 and 0.92 with no difference between the two tips. Bitewing radiography showed an inferior performance compared to LF (p < 0.05). Intraex aminer reproducibility was high (kappa >0.74). The new LF system might be a useful additional tool in detecting approximal caries. Because of its good reproducibility, it could be used to monitor caries regression or progression on approximal surfaces.

Detection of Approximal Caries in 5-Year-Old Swedish Children

The aim was to assess how accurately some commonly used risk factors/risk markers (predictors) for caries development could identify children with and without approximal caries as judged from bitewing radiography. Two hundred and sixty-seven consecutive 5-year-old children from two Swedish cities participated. Three experienced dentists examined the children. The predictors were the overall dmfs (decayed, missing and filled surfaces) value (canines and molars), the number of occlusal dmfs, the frequency of intake of between-meal sugary products, visible plaque on free smooth surfaces of second primary molars, toothbrushing habits and (before bitewing examination) an overall judgement by the examining dentist. The mean dmfs value without bitewing examination was 0.40 (SD = 1.22). Twelve percent of the children had at least one dentin lesion and 33% at least one enamel lesion that were detected from bitewing examination only. The gain from adding bitewing examination to clinical examination amounted to a mean of 1.2 approximal enamel and/or dentin lesions. The ability to correctly identify children with approximal caries from the predictors was limited; sensitivity ranged from 0.27 to 0.75 and specificity ranged from 0.41 to 0.93. The single best predictor was the dentist’s overall judgement with an average precision of 73%; average sensitivity for the presence of enamel and dentin lesions was 0.48 and for the presence of dentin lesions 0.66. The rest of the predictors added little to the predictive power. It is concluded that 33% of the 5-year-olds, representing a low caries prevalence population, benefited from bitewing examination. The ability to identify these children from the predictors was, however, limited.

A resource guide for practice development through technology

A resource guide for practice development through technology

Grey-scale reversed radiographic display in the detection of approximal caries

Purpose of this study was to determine the influence of grey-scale reversal of digital radiographic images on the detection of proximal caries. Five observers assessed digital bitewing radiographs (Sidexis((R)), Sirona) of 320 unrestored surfaces of extracted posterior teeth embedded in 20 models, simulating pairing of maxillary and mandibular arches, using a six-category caries rating scale. Images were displayed in normal [N] and inverse [IN] mode at different image sizes (display ratio: 1:1, 1:2, 1:7) on a cathode-ray tube monitor (Nokia 446 XS) and a TFT display (Panasonic LC 50 S). Validation standard was defined as histological lesion depth. Validity was expressed as areas under receiver operating characteristic curves (AUC) calculated for two levels of histological caries penetration: presence of caries and presence of a dentine lesion. The factors 'inverse display', 'image size on-screen' 'display type' and 'disease cut-off' were analysed by repeated measures ANOVA. Inverse image display significantly influenced the diagnostic validity (P=0.014), but a reduced accuracy was only seen at the lowest image size (AUC (SE): [N] 0.64 (0.02); [IN] 0.62 (0.02)). At the validation threshold 'dentine caries' approximal caries detection deteriorated when using grey-scale reversal (AUC (SE): [N] 0.71 (0.02); [IN] 0.69 (0.02)). In conclusion, grey-scale reversal of digital radiographs did not optimise approximal caries detection and aggravated the detectability of dentinal lesions.

Detection of approximal caries in digital radiographs before and after correction for attenuation and visual response. An in vitro study

To evaluate if digital compensation for exponential attenuation and the characteristics of the human visual system improves the diagnosis of approximal caries from digital radiographs.Forty premolar teeth were mounted in plaster blocks. Radiographs of the teeth were exposed with the Dixi digital intraoral system employing a Prostyle Intra dental X-ray unit (Planmeca Oy, Helsinki, Finland). Thirteen radiographs were then processed to compensate for the exponential attenuation and for the characteristic of the human visual system using equations presented in the paper. Ten observers were asked to diagnose approximal caries in all radiographs. ROC analyses were performed. The teeth were subsequently sectioned for histological validation of the lesions. The areas under ROC curves of original and processed radiographs were compared and analysed using Wilcoxon's signed-ranks test.There were significant diagnostic differences between the two types of radiographs (all lesions P=0.005. enamel P=0.028, and dentine P=0.050).Digital radiographs processed to compensate for exponential attenuation and the characteristics of the human visual system significantly improves the diagnosis of approximal caries in vitro.

The effect of the number of iterative restorations on tuned aperture computed tomography for approximal caries detection.

To determine whether the number of iterative restorations performed on TACT images affects observers' ability to detect dental caries. Eight TACT basis images of 40 extracted human posterior teeth were acquired using a CCD sensor. TACT slices of each tooth were generated and subsequently submitted to 1, 2 or 3 iterative restorations. Stacks of images from the three experimental conditions were presented to six observers in a balanced order, on a high-resolution 21' color monitor. Observers scored the presence or absence of approximal caries using a 5-point confidence scale. Observers' assessments were compared with the results of histological examination. Receiver operating characteristic (ROC) curves were generated and possible significant differences between observers and between modalities tested by ANOVA. The level of significance was set at alpha=0.05. Interobserver reliability was calculated as intraclass correlation. Mean areas under the ROC curves (A(z)) for the three experimental conditions were 0.791 (one iterative restoration), 0.81 (two iterative restorations), and 0.778 (three iterative restorations). ANOVA did not demonstrate any significant difference between modalities (P=0.25) but did so between observers (P=0.031). Interobserver reliability was similar for all experimental conditions tested. Varying the number of iterative restorations from one to three does not affect observers' ability to detect approximal caries with TACT slices.

The effect of the number of iterative restorations on tuned aperture computed tomography for approximal caries detection

The effect of the number of iterative restorations on tuned aperture computed tomography for approximal caries detection

Scanning resolution and the detection of approximal caries

Scanning resolution and the detection of approximal caries