Assessment of cavitated and active non-cavitated caries lesions in 3- to 4-year-old preschool children: a field study.

BACKGROUND: The prevalence of early childhood caries (ECC) is high in developing countries; thus, sensitive methods for the early diagnosis of ECC are of prime importance to implement the appropriate preventive measures. AIM: To investigate the effects of the addition of early caries lesions (ECL) into WHO threshold caries detection methods on the prevalence of caries in primary teeth and the epidemiological profile of the studied population. DESIGN: In total, 351 3- to 4-year-old preschoolers participated in this cross-sectional study. Clinical exams were conducted by one calibrated examiner using WHO and WHO + ECL criteria. During the exams, a mirror, a ball-ended probe, gauze, and an artificial light were used. The data were analysed by Wilcoxon and Mc-Nemar's tests (α=0.05). RESULTS: Good intra-examiner Kappa values at tooth/surface levels were obtained for WHO and WHO+ECL criteria (0.93/0.87 and 0.75/0.78, respectively). The dmfs scores were significantly higher (P<0.05) when WHO+ECL criteria were used. ECLs were the predominant caries lesions in the majority of teeth. CONCLUSIONS: The results strongly suggest that the WHO+ECL diagnosis method could be used to identify ECL in young children under field conditions, increasing the prevalence and classification of caries activity and providing valuable information for the early establishment of preventive measures.

Resin infiltration of proximal caries lesions differing in ICDAS codes.

Resin infiltration of non-cavitated proximal caries lesions has been shown to inhibit further demineralization. However, the effect of resin infiltration in cavitated lesions is unknown. Therefore, the aim of this in vitro study was to evaluate infiltration patterns of proximal caries lesions differing in International Caries Detection and Assessment System (ICDAS) codes. Extracted human molars and premolars showing proximal caries lesions with and without cavitations (ICDAS codes 2-5) were etched with 15% hydrochloric acid gel and resin infiltrated according to the manufacturer's instructions. Three sections from each lesion were prepared and analyzed using a dual-fluorescence staining technique and confocal microscopy. The dimensions of the demineralized and cavitated lesions areas, as well as the resin-infiltrated parts within these lesions, were measured. The demineralized parts were infiltrated from 73% to 100% (median values) but the cavities were filled only negligibly (0-5%). Teeth that had an ICDAS code of 5 showed a significantly lower percentage infiltration/filling of lesions compared to teeth with ICDAS codes of 2 and 3. It was concluded that under in vitro conditions the tested infiltrant penetrates most parts of the demineralized enamel but is not capable of filling up cavities and therefore the efficacy of caries infiltration, particularly in lesions with larger cavitations, might be impaired.

Dental caries and pulpal disease.

This article reviews the diagnostic process, from the first clinically evident stages of the caries process to development of pulpal pathosis. The caries diagnostic process includes 4 interconnected components-staging caries lesion severity, assessing caries lesion activity, and risk assessments at the patient and tooth surface level - which modify treatment decisions for the patient. Pulpal pathosis is diagnosed as reversible pulpitis, irreversible pulpitis (asymptomatic), irreversible pulpitis (symptomatic), and pulp necrosis. Periapical disease is diagnosed as symptomatic apical periodontitis, asymptomatic apical periodontitis, acute apical abscess, and chronic apical abscess. Ultimately, the goal of any diagnosis should be to achieve better treatment decisions and health outcomes for the patient.

Influence of the ICDAS e-learning program for occlusal caries detection on dental students.

The aim of this study was to evaluate the influence of ICDAS training in a group of dental students for occlusal caries detection in permanent teeth. Premolars and molars (N=104) with occlusal surfaces varying from ICDAS scores 0 to 6 were cleaned, one occlusal site per tooth was selected, and a photograph taken to identify the site. Eight senior dental students examined the teeth twice with a one-week interval between examinations during each of two phases: before and after the ICDAS e-learning program. Teeth were histologically assessed for caries extension. Intraclass correlation coefficients for intra- and interexaminer repeatability were high, both before (0.75 and 0.72, respectively) and after e-learning (0.82 and 0.78, respectively). The ICDAS scores decreased significantly from before to after e-learning (p=0.0001). Correlation between ICDAS scores and histology scores was moderate (0.57 before e-learning and 0.61 after). Although the ROC curve shows an improvement in the use of the ICDAS scoring after e-learning, the difference was not significant (p=0.10). Specificity of the ICDAS scores significantly improved after e-learning (77 percent vs. 36 percent), and sensitivity was reduced slightly after e-learning (87 percent vs. 92 percent). The ICDAS e-learning program improved the performance of the diagnostic skills of the investigated students for the detection of occlusal caries lesions.

Discriminant validity of the International Caries Detection and Assessment System (ICDAS) and comparability with World Health Organization criteria in a cross-sectional study.

OBJECTIVES: The aim of this cross-sectional study in preschool children was to assess the ability of International Caries Detection and Assessment System (ICDAS) in discriminating socioeconomic factors associated with the presence of caries lesions at both noncavitated and cavitated thresholds and to compare with the standard World Health Organization (WHO) criteria. METHODS: The study was carried out in Amparo, Brazil, during the National Day of Children's Vaccination including 252 children aged 36-59 months. The same child was independently examined by two calibrated examiners, one using the ICDAS and the other using WHO criteria. Socioeconomic information was also recorded. Associations between socioeconomic factors and presence of caries assessed as binary (caries prevalence) and count outcome (actual dmfs values) obtained by WHO criteria and by ICDAS at noncavitated and cavitated thresholds were evaluated by Poisson regression analysis with robust variance. RESULTS: Some covariates were significantly associated with the presence of caries evaluated by the WHO criteria and by ICDAS (using score 3 as cut-off point). When noncavitated scores of ICDAS were used to calculate the presence of caries, the discriminant power decreased. When dmfs values were used as outcome, no differences in the associations were observed between two systems or using noncavitated caries lesions. CONCLUSION: Cavitated scores of ICDAS present similar discriminant validity compared with WHO criteria when presence of caries is used as outcome; however, when actual dmfs values are used, no differences are observed in using noncavitated or cavitated caries lesions.

Effect of different time intervals between examinations on the reproducibility of ICDAS-II for occlusal caries.

AIM: To evaluate intra- and interexaminer reproducibility of ICDAS-II on occlusal caries diagnosis when different time intervals were allowed to elapse between examinations. A subsidiary aim was to determine whether collapsing the codes would influence this reproducibility. METHODS: The occlusal surfaces of 50 permanent posterior teeth were investigated by 3 trained examiners using ICDAS-II at baseline, 1 day, 1 week and 4 weeks after baseline. RESULTS: Weighted kappa values for intra- and interexaminer reproducibility were 0.76-0.93. CONCLUSION: The time span did not have a major impact on assessing intra- and interexaminer reproducibility. Collapsing ICDAS-II codes had no impact on examiner reproducibility.

Reproducibility and accuracy of the ICDAS-II for occlusal caries detection.

OBJECTIVES: The aim of this in vitro study was to assess the inter- and intra-examiner reproducibility and the accuracy of the International Caries Detection and Assessment System-II (ICDAS-II) in detecting occlusal caries. METHODS: One hundred and sixty-three molars were independently assessed twice by two experienced dentists using the 0- to 6-graded ICDAS-II. The teeth were histologically prepared and classified using two different histological systems [Ekstrand et al. (1997) Caries Research vol. 31, pp. 224-231; Lussi et al. (1999) Caries Research vol. 33, pp. 261-266] and assessed for caries extension. Sensitivity, specificity, accuracy and area under the ROC curve (A(z)) were obtained at D(2) and D(3) thresholds. Unweighted kappa coefficient was used to assess inter- and intra-examiner reproducibility. RESULTS: For the Ekstrand et al. histological classification the sensitivity was 0.99 and 1.00, specificity 1.00 and 0.69 and accuracy 0.99 and 0.76 at D(2) and D(3), respectively. For the Lussi et al. histological classification the sensitivity was 0.91 and 0.75, specificity 0.47 and 0.62 and accuracy 0.86 and 0.68 at D(2) and D(3), respectively. The A(z) varied from 0.54 to 0.73. The inter- and intra-examiner kappa values were 0.51 and 0.58, respectively. CONCLUSIONS: ICDAS-II presented good reproducibility and accuracy in detecting occlusal caries, especially caries lesions in the outer half of the enamel.

Strategies for caries risk assessment in children and adolescents at public dental clinics in a Swedish county.

BACKGROUND: Since caries prevalence has decreased and become polarized, high-risk preventive strategies have been widely adopted. The underlying factors leading to assessment and management of caries risk are poorly understood. AIM: The aim of this study was to identify the factors forming the basis for dentist's caries risk assessment in dental care for children and adolescents. DESIGN: From all 3372 children in a Swedish county identified as at high risk for developing caries, a sample of dental records from 432 children, aged 3-19 years, were randomly selected to be analysed in the study. Information about medical and social history, dental status, dietary habits, oral hygiene, and salivary data was obtained from the records. RESULTS: The results show that the only data registered in the majority of the dental records were dental status from the clinical examination and bitewing radiographs. In approximately half of the dental records, medical history and data concerning oral hygiene were registered. Dental history and dietary habits were noted in approximately 25% of the dental records, whereas other risk factors/indicators were occasionally registered. CONCLUSIONS: Dentists mainly base their caries risk assessments on past caries experience, a reliable risk indicator for assessing the risk of being affected by caries again. In children with no experience of caries, knowledge of other risk factors/indicators needs to be available to perform a caries risk assessment. In this study, documentation of such knowledge was strongly limited.

Occlusal caries diagnosis in permanent teeth: an in vitro study

A redução da prevalência de cáries não ocorreu uniformemente para todas as superfícies dentárias. Como as superfícies oclusais ainda são as mais susceptíveis ao desenvolvimento de lesões, novos métodos de diagnóstico ainda estão sendo avaliados. Este estudo comparou um sistema de fluorescência a laser (DIAGNOdent – DD) com o método visual de Ekstrand na detecção de cárie oclusal. Um total de 57 terceiros molares com superfícies oclusais macroscopicamente intactas foram selecionados. Dois examinadores examinaram 110 sítios por inspecção visual (IV) e DD. Após dez dias da primeira mensuração, todos os dentes foram novamente avaliados pelos mesmos métodos. A extensão de cárie foi validada por exame histológico (40 X). Os dados foram analisados quanto a sensibilidade, especificidade, reprodutibilidade intra e interexaminador e área sob a curva ROC. O teste kappa demonstrou boa reprodutibilidade intra e interexaminadores para ambos os métodos. A IV e o DD apresentaram sensibilidade semelhante para ambos os examinadores, entretanto, a IV apresentou maior especificidade que o DD. A análise geral, através da área sob a curva ROC, mostrou que a IV teve um melhor desempenho que o DD. Concluiu-se que o critério visual proposto por Ekstrand é mais confiável para o diagnóstico de cáries oclusais. O DD deve ser considerado apenas como um coadjuvante no exame de cárie em superfícies oclusais.

Occlusal caries diagnosis in permanent teeth: an in vitro study.

The reduction in caries prevalence has not occurred uniformly for all dental surfaces. As the occlusal surfaces are still the most likely sites for the development of lesions, new methods of diagnosis are still being evaluated. This study compared a laser fluorescence (LF) system (DIAGNOdent) with the Ekstrands visual system for in vitro detection of occlusal caries. A total of 57 extracted molars with macroscopically intact occlusal surfaces were selected. Two-examiners assessed 110 sites by visual inspection (VI) and LF. After ten days from the first measurement, all teeth were re-evaluated through the same methods by each examiner. Caries extension was histologically assessed (X 40). The methods were compared by means of sensitivity, specificity, intra- and inter-examiner reproducibility and area under the ROC curve. The kappas test showed good intra- and inter-examiner reproducibility for both methods. VI and LF showed similar sensitivities for both examiners, however, VI showed higher specificities than LF. The overall analysis, as demonstrated by the area under the ROC curve, showed that VI had a better performance than the LF device. It was concluded that the Ekstrands visual system is more reliable than the LF device. LF should be considered only as an adjuvant for occlusal caries diagnosis.

The challenges of validating diagnostic methods and selecting appropriate gold standards.

Caries diagnostic methods are usually methods for caries lesion detection and measurement. Caries lesions occur on a continuous scale of tissue damage, from subclinical surface changes to macroscopic cavities reaching the pulp. Any change of a lesion on this continuous scale offers the opportunity for the diagnosis of disease activity or remission. Research aimed at remineralizing agents may focus on lesions that are amenable to remineralization, and select a method that will measure small changes in early lesions. General caries management strategies depend on detecting all stages of lesion development, and methods covering early to late stages are preferred. This paper addresses some methodological issues in validating caries diagnostic methods. The available gold standards for caries lesions are discussed, with their suitability in different applications, and their "validity" as far as it is known or can be inferred. The gold standards are compared as far as their measurement of lesion parameters and reproducibility is concerned. Tentative conclusions are formulated, and recommendations for future research are given.

Comparison of microscopy and radiography as gold standards in radiographic caries diagnosis.

OBJECTIVES: To compare the effect of the choice of gold standard on the diagnostic outcome of approximal caries detection in original and compressed digital radiographs. METHODS: 116 extracted teeth radiographed with a storage phosphor system constituted the original images. These images were compressed at 1:20 and 1:33 with the JPEG irreversible compression standard. Five radiologists scored the three sets of images for the presence of approximal caries on a five-rank confidence scale. The radiographic scores were validated by stereomicroscopy (the true gold standard). The individual ROC areas for the five observers were used to select the worst (obsworst) and the best (obsbest) performer: Their scores in the original images were used as the second and third 'gold standards' for the remaining observers. Mean ROC areas for the three observers with the three types of images were calculated using these two new 'gold standards'. Differences between the ROC areas when using microscopy, obsworst, and obsbest as the 'gold standard' were compared. RESULTS: The mean ROC areas in the original images were 0.66, 0.74 and 0.91 using the true gold standard and obsbest and obsworst as the 'gold standards' respectively. The difference between the true gold standard and obsworst was statistically significant (P < 0.001). The mean ROC areas using the true gold standard decreased with increasing compression whereas they were constant or increased using obsworst and obsbest as 'gold standards', respectively. CONCLUSIONS: Accuracy in approximal caries diagnosis was significantly higher when an observer was the 'gold standard' than when the true gold standard was obtained by microscopy. Paradoxically, the compressed, degraded images were more accurate than the originals when an observer was the 'gold standard' while they were less accurate with the true gold standard. Thus, results obtained using observers' scores from the radiographs which are being evaluated, as validation for the presence of caries may mislead the clinician.

British Association for the Study of Community Dentistry (BASCD) diagnostic criteria for caries prevalence surveys-1996/97.

This paper outlines the current (1996/97) version of the diagnostic criteria relating to dental caries employed in the BASCD coordinated NHS Dental Epidemiology Programme. Some of the details as to how these criteria have evolved over the past 13 years. since the original guidelines publication (Palmer et al., 1984), can be found in a previous publication (Pitts, 1993) and in an earlier paper in this supplement (Pitts and Evans, 1997).

Differences in the detection and enumeration of mutans streptococci due to differences in methods.

Different methods reported for assessing mutans streptococci (MS) make the direct comparisons of results across studies difficult. To quantitate the variations of MS estimates attributable to differences in method, stimulated and unstimulated saliva samples and oral swab samples were compared with pooled dental-plaque samples. Detection of MS in stimulated saliva samples was in excellent agreement with the presence of MS in pooled plaque samples. MS detection in unstimulated saliva samples, however, was significantly discordant with that in either pooled plaque or oral swab samples. When caries status was used as the criterion of validity of MS estimates, stimulated saliva samples demonstrated a sensitivity (94%) similar to that of pooled plaque samples, but exhibited a lower specificity (11%) than that of pooled plaque samples (17%). As a result, the measure of association between MS and caries was biased (towards null) when MS status was based on stimulated saliva samples. Interestingly though, in enumerating MS, stimulated saliva samples yielded significantly higher levels of MS (about 1.5 log10 increase) with a lower variability compared to unstimulated saliva samples. The use of different culture media for detection of MS gave different results as well. MS detection was poor (kappa = 0.31) and MS levels were lower (p = 0.0001) when samples were grown on glucose-sucrose-potassium tellurite-bacitracin agar compared to mitis-salivarius-bacitracin agar. Together with the relative ease of sampling and processing, these findings collectively justify the use of plaque samples for the qualitative assessment of MS and stimulated saliva samples for the quantitative assessment of MS, while providing a basis for adjustment of estimates when comparing results across studies.

[The diagnosis of initial carious changes]. / Zur Erkennbarkeit initialer kariöser Veränderungen.

On the basis of radiological studies on extracted teeth and of microscopic examinations of longitudinal ground sections it is stated that the early stages of dental caries are very difficult to diagnosticate clinically. Under the microscope, "healthy" teeth may also show initial carious lesions in the fissure region. The greater frequency of these changes (which might be considered to be premorbid conditions) in teeth with narrow fissures was not significant. For various reasons discussed in the present paper, it can be assumed that teeth with large fissures are earlier and more frequently prone to carious lesions.