Anna PYCHKINA-GRANDJEAN
5th, OF group 14
EARLY CARIES DETECTION: A SYSTEMATIC REVIEW Master’s Thesis
Supervisor
Sandra Žemgulyté
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC FOR PREVENTIVE AND PEDIATRIC DENTISTRY
EARLY CARIES DETECTION: A SYSTEMATIC REVIEW Master’s Thesis
Kaunas, 2018 Student.
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(day/month)EVALUATION TABLE OF THE MASTER’S THESIS
OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE.
Evaluation:... Reviewer:...
(scientific degree. name and surname) Reviewing date: ...
No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)
Is summary informative and in compliance with
the thesis content and requirements? 0.3 0.1 0 2 Are keywords in compliance with the thesis essence? 0.2 0.1 0
3
Introduc-tion, aim and tasks (1 point)
Are the novelty, relevance and significance of the work justified in the introduction of the
thesis? 0.4 0.2 0
4 Are the problem, hypothesis, aim and tasks formed clearly and properly? 0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0
7
Were the eligibility criteria of articles for the selected protocol determined (e.g., year,
language, publication condition, etc.) 0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11
Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
0.4 0.2 0
12
Are all the variables (for which data were sought and any assumptions and simplifications made)
listed and defined? 0.4 0.2 0
13
Are the methods, which were used to evaluate the risk of bias of individual studies and how this information is to be used in data synthesis, described?
0.2 0.1 0
14 Were the principal summary measures (risk ratio, difference in means) stated? 0.4 0.2 0
15 Systemiza-tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18
Are the extracted and systemized data from studies presented in the tables according to
individual tasks? 0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations of the performed systemic review discussed? 0.4 0.2 0
22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and
tasks of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly
and precisely? 0.2 0.1 0
27 Is the scientific level of references suitable for Master’s thesis? 0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older
than 5 years – at least 40%? 0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the analysed topic? +0.2 +0.1 0
30
Practical
recommen-dations
Are the practical recommendations suggested
and are they related to the received results? +0.4 +0.2 0
31
Were additional methods of data analysis and their results used and described (sensitivity
analyses, meta-regression)? +1 +0.5 0
32
Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of
each meta-analysis presented? +2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General
require-ments
Is the thesis volume sufficient (excluding annexes)? 15-20 pages (-2 points) <15 pages (-5 points)
34 Is the thesis volume increased artificially? -2 points -1 point
35 Does the thesis structure satisfy the
36 Is the thesis written in correct language, scientifically, logically and laconically?
-0.5 point -1 points
37 Are there any grammatical, style or computer literacy-related mistakes? -2 points -1 points
38
Is text consistent, integral, and are the volumes of its structural parts
balanced? -0.2 point -0.5 points
39 Amount of plagiarism in the thesis. (not evaluated) >20%
40
Is the content (names of sections and sub-sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point -0.5 points
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections
distinguished logically and correctly?
-0.2 point -0.5 points
42 Are there explanations of the key terms and abbreviations (if needed)? -0.2 point -0.5 points
43 Is the quality of the thesis typography (quality of printing, visual aids, binding) good?
-0.2 point -0.5 points
*Remark: the amount of collected points may exceed 10 points. Reviewer’s comments: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________________________________________
Reviewer’s name and surname Reviewer’s signature
TABLE OF CONTENTS
SUMMARY………...p.10.
INTRODUCTION………...………p.11.
MATERIAL AND METHODS ………..p.13.
SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY…..P.14.
SYSTEMIZATION AND ANALYSIS OF DATA……….…p.17.
DISCUSSION……….…….…p.25.
CONCLUSIONS……….p.26.
PRACTICAL RECOMMENDATIONS
REFERENCES………p.26.
ABBREVIATIONS
AC-accuracy
AF-autofluorescence (405-nm and 532-nm), bacterial fluorescence) AZ- areas under the ROC curve
BW - bitewing radiographs CF- conventional film
CBCT- cone beam computed tomography DF- digital film
DIFOTI- digital imaging fiber-optic transillumination LF- laser fluorescence device (DIAGNOdent)
MOI- multimodal optical clinical prototype (short-wavelength laser reflectance (405nm) images OSE- orthodontic separating elastics
Perm-permanent dentition Pr- primary dentition RA- radiographics
RPC- ratio percent change SE- sensitivity
SP- specificity
TE- teledentistry examination (intraoral camera) VI- visual inspection/examination
SUMMARY
Objective: to find out the different diagnostic methods of early caries detection, their advantages and limitations and to find the most accurate and conveniently applied in practice.
Material and methods. According to the PRISMA guidelines, publications of this systematic review were selected through PUBMED, Science Direct and Google scholar. The comprehensive search was restricted to English language articles, published from 2007 to 2017. In the results it was shown 234 publications (abstracts). Later, 48 articles related to the topic were revised, of which 12 consistent with the subject of this review were qualified regarding to PICOS criteria.
Results. The 10 articles presented studies done in vivo and 2 publication in both types in vivo and in vitro. The sample of patients ranged from 5 to 363.The number of examined teeth (primary and permanent) widely ranged from 28 to 5609 in studies. Visual inspection/examination was used in 4 studies, while visual tactile examination was applied in 6 studies. Radiographic examinations were used in 10 publications. Laser fluorescence device (DIAGNOdent) was applied in 6 studies. Intraoral camera, digital imaging fiber-optic transillumination (DIFOTI) and orthodontic separating elastics were used for more accurate diagnostics of caries in 1 study.
Conclusion.The combination of different diagnostic methods increases the efficiency of early caries lesion detection. It has a beneficial not only for researchers, but also these innovative diagnostic methods can be applied in clinical practice due to lower percentages of underestimated caries lesions, more accurate diagnosis and implementing of treatment.
INTRODUCTION
Dental caries is still a major oral health problem in most industrialized countries, affecting 60-90% of schoolchildren and the vast majority of adults. [1]. It was observed that the more developed countries, especially in the Europe is presented DMFT index higher score than the least developed countries, especially the Africa region [1].
The latest scientific evidence supports the concept that a dental caries is a dynamic process, which is affected by numerous factors that can push the dynamic equilibrium to either remineralization or demineralization of tooth mineral [2]. Detection of dental caries in the early stage is very difficult when conventional diagnostic methods are used [3]. Moreover, early caries detection improves the prognosis of treatment due to implementation of preventive therapy and prevents minor changes and loss in the structure of the teeth [4].
Over the past 20 years, there has been a significant interest in the development of technologies to supplement the visual detection of early carious lesions [5].
A diagnostic method for dental caries should aim at detection of earlier pathological changes so as to ascertain the stage up to which the disease can be reversed [33]. The early diagnosis of caries lesions provides for more efficient arrest thus avoiding operative treatment [7,8,9]. A variety of innovative technologies have been developed and introduced in the last few years to aid clinicians not only in early caries detection but to make a firm diagnosis and treat cases conservatively [10]. It is essential that clinicians would not overlook diseases in need of treatment, and, at the same time, they must not make a diagnosis when it is not warranted [11]. Furthermore, the differences in caries location can show different sensitivity and specificity of detection for all sites[10]. It might happen that the conventional methods have a higher risk of failing to detect approximal lesions [12].
Usually the diagnostic tests are evaluated in terms of its validity and reliability [14]. While, validity can be assessed in different ways and this assessment requires the existence of external criteria, which is called ‘golden standards’ and focus on the degree of correctness of the diagnosis [14]. Caries diagnostic criteria are focused on depth of lesion penetration assessed clinically or radiographically [14] .
The visual tactile methods is performed under this condition: an air booster, dental explorer, fiber optics, and a mouth mirrow are used in the examination,which is performed in a dental chair with
an ordinary working light after the subject had brushed.[ 15] This method requires only ordinary devices and instruments. Visual examination has shown high specificity, and low sensitivity and reproducibility for occlusal caries detection.[16,17]
Ehanced visual method allows for the detection of a carious lesion by changes in the scattering and absorption of light photons resulting from a local decrease of transillumination owing to the characteristics of the carious lesion [19], [20]
Quantitative Light-induced Fluorescence (QLF) offers the opportunity to detect early caries and then longitudinally monitor its progression or regression [5].Fluorescence is a phenomenon by which an object is excited by a particular wavelength and then emits light at higher wavelength [5]. Studies have shown that when underlying dentin is removed from the enamel, fluorescence is lost, although only a small amount of dentin is required to produce the fluorescence seen [5], [10 ], [19]. DIAGNOdent-using infra red light to detect caries based on the difference in fluorescence between sound and demineralized enamel [20], [10 ], [19].
The ability of intraoral camera to capture and share all relevant patient information and clinical data makes this method an easy choice for innovative dental care delivery [21 ]
A caries diagnostic performance is enhanced by combining radiographic information with clinical findings [22; 23; 24] in [19], is also least costly, but had limited effectiveness [25]. Conventional and digital bitewing, periapical X-ray, dental CBCT, provides a fast, non-invasive way of answering a number of clinical questions.[5]. The most used of radiographs methods in early detection of caries currently is digital bite-wing technique and it may help with the diagnosis, treatment planning and evaluation of certain conditions [5, 2 ]. Furthermore, bitewing x-ray imaging is the method of choice for determining the presence and extent of decay in the areas of the contacting surfaces of the posterior teeth.[5] Radiographs are generally recommended for detection of proximal carious lesions and are of limited use in the diagnosis of incipient occlusal caries [33]. Cone-beam computed tomography systems (CBCT) are a variation of traditional CT systems [10 ]. Although the radiation doses from dental CBCT exams are generally lower than other CT exams, dental CBCT exams typically deliver more radiation than conventional dental X-ray exams. Concerns about radiation exposure are greater for younger patients because they are more sensitive to radiation and they have a longer lifetime for ill effects to develop [10].
The purpose of a diagnostic test is to use its results to make a diagnosis, so we need to know the probability that the test result will give the correct diagnosis.
The results of studies which investigate various examination methods are expressed by sensitivity, specificity, accuracy and ROC curve.
An accuracy of method provides evidence on how well a test correctly identifies or rules out disease and informs subsequent decisions about treatment for clinicians, their patients, and health care providers [26]. Studies done in vivo may show poorer diagnostic performance than studies performed under laboratory conditions due to the difficulties such as saliva or the presence of plaque [11].
The sensitivity of a test is defined as the proportion of people with disease who will have a positive result and it can only be calculated from those people who have the disease [27].
The specificity of a test is the proportion of people without the disease who will have a negative result and is calculated from those people who do not have the disease.[27].
An ROC curve represents the relation between sensitivity and specificity (and hence is a test to determine these values) when clinicians are allowed a degree of uncertainty in their decision making not afforded in dichotomous decisions [28].
Aim:
To analyze the publications related to early caries detection and assess which methods are the most effective in order to promote the preventive intervention regarding to caries risk category.
Objectives:
1.To search and select the publications according to prepared inclusion and exclusion criteria for systematisation and analysis.
2.To compare the results of selected studies regarding the main used outcomes.
3.To assess which diagnostic method(s) are the most accurate and conveniently applied in practice.
1. MATERIAL AND METHODS
1.1 Literature search strategy.
According to the PRISMA guidelines, publications of this systematic review were selected through PUBMED, Science Direct and Google scholar. The following key words and their combinations early caries detection/ noncavitated lesions/ radiography were used to search.
The comprehensive search was restricted to English language articles, published from 2007 to 2017. One investigator carried out the selection and evaluation of articles. In the results it was shown 234 publications (abstracts). If full-content publications were not accessible without purchasing and duplicated articles were excluded. Later, 48 articles related to the topic were revised, of which 12 consistent with the subject of this review were qualified regarding to PICOS criteria.
After all information’s having collected and exclusions that have been made, the gathering information was sufficient and efficient for the research project.
1.2 Inclusion and exclusion criteria
1.2.1 Inclusion criteria for the selection were the following:
1.Publication written in English;
2. Studies performed on humans only ( in vitro and in vivo); 3. Participants who meet the selection criteria;
4 .Articles which were published over the last 10 years.
1.2.2 Exclusion criteria were the following: 1. Not full articles were available;
2.Conference proceeding;
3. Systemic review and review articles; 4. Commentaires;
5.Studies performed on animals; 6. Participants older than 18 years old;
PICOS (eligibility criteria)
Participants were included if age was under 18 years old and gender did not play a role. Teeth were examined regarding to the following criteria ICDAS, WHO, Nyvad, Ekstrand’s and Pitts and Fyffe. Teeth were included of both dentitions primary and permanent, and proximal and occlusal surfaces were investigated.
The following examination methods were included such as visual inspection, visual-tactile examination, several types of radiography (CF, DF, BW, CBCT), laser fluorescence(LF), laser diagnostic (DIAGNOdent), optic-transillumination (FOTI ;DIFOTI), teledentistry (intraoral camera).
Follow up period was not a mandatory aspect. The risk of bias has not been fairly paid attention to in some selected studies for this paper, which in its turn could have caused a fair level of bias across studies. This may be taken in consideration while reading this systematic review.
Figure 1 illustrates by a flow chart the process of filtering (PRISMA flow diagram)
Records identified through database
Searching( n=234)
Records after duplicates removed (n=0)
Records screened (n = 48)
Full-‐text articles assessed for eligibility (n = 21)
Records excluded (n =27)
Studies included in qualitative synthesis
(n = 12)
Full-‐text articles excluded, with reasons(n=9)
Studies included in qualitative synthesis (meta-‐analysis)
(n = 0)
Additional records identified through other sources
2. SYSTEMISATION AND ANALYSIS OF DATA
The main findings of this systematic review are presented in Table 1. A total 12 articles were analysed, while 5 clinical studies, 1study was a cross-sectional study, 6 were observational studies. The 10 articles presented studies done in vivo and 2 publication in both types in vivo and in vitro. The sample of subjects (patients) ranged from 5 to 363. Age of patient was mentioned not in all selected studies.
The number of examined teeth widely ranged (from 28 to 5609) and a total number of assessed teeth was 6444. Subsequently, teeth of both dentition primary and permanent were evaluated. 6 studies included only primary dentition, 4 studies- permanent dentition and 2 studies- both primary and permanent dentition.
The most prevalent examined and investigated surfaces were proximal and occlusal of premolars and molars of both dentitions.
The applied caries examination criteria were presented in 7 studies such as ICDAS, Nyvad, WHO, Ekstrand, Pitts and Fyffe. Depth of examined caries lesions varied from sound enamel to dentin lesions,cavity to the pulp.
In this systematic review only 3 studies had a follow-up period which ranged from 6 to 24 months. Considering the examination methods, almost all publications present more than one used caries assessment methods.
Thus, visual inspection/examination (VI) was used in 4 studies, while visual tactile examination (VT) was applied in 6 studies. Visual inspection (VI) showed various results, thus sensitivity ranged from 37% [29]. to 100% [30] , specificity was from 40% [30] to 95.13% [31]. and accuracy was lower when lesion was in dentin (52.3%) [30] and higher in enamel-dentin area (94%) [32] (Table 1). The main disadvantage of a visual inspection is probable underestimation of occlusal dentin caries in teeth without cavitation (Table 2).
Visual tactile examination showed very high specificity from 91.4% [33] to100% [34,29], whereas sensitivity varied from 35% in enamel[25] to 100% [34]
Radiographic examinations were used in 10 publications. Subsequently, bitewing radiographs (BW) method was used in 6 studies, conventional X-ray (film) in 2 studies, digital film in 2 studies. Cone beam computed tomography (CBCT) was applied as a caries examination method in 1 study.
Bitewing radiography (BW) as a radiography method showed the best results. Specificity score ranged from 96.96-100% [31,29] , whereas, sensitivity was lower 89.06% [31]. Accuracy ranged from 82% to 92.57% [31,29]. The main drawback of bitewing radiography can be that this method is an inappropriate for occlusal enamel caries detection according to studies’ findings. Furthermore, a well-focused radiographs in children requires considerable skills, time and ionising radiation must be taken into consideration as well. (Table 2).
The conventional film showed poorer results than both digital films and bitewing radiography. Subsequently, sensitivity ranged from 13% to 60% (conventional film) and from 22% to 64% (digital film), respectively. Meanwhile, specifivity was higher and ranged from 56% to 100% (conventional film) and from 74% to 100% (digital film) (Table 1).
Laser fluorescence device (DIAGNOdent) was applied in 6 studies. Sensitivity of this method varied from 47% [29] to 100% (cinar). Specificity showed a bit higher percentages from 57% [30] to 96.87% [31]. Accuracy ranged from 66% [30] to 93.2% [30] (Table 1). Considering the results, an application of DIAGNOdent device can cut down radiography use (Table 2).
Some examination methods such as intraoral camera (TE) and digital imaging fiber-optic transillumination (DIFOTI) were used rare in selected articles of this systematic review. Results revealed that specificity of intraoral camera was 81% [34] Subsequently, sensitivity of DIFOTI varied from 46% to 89% [35] and specificity was 65-100% [35] (Table 1). Diagnostic accuracy of DIFOTI in detecting early proximal enamel lesions was greater than radiography method (Table 2). Orthodontic separating elastics were used for more accurate diagnostics of caries in 1 study. The main advantage of this method is formed absence of contacting point between teeth for better examination, while it can be used only as auxiliary tool [29] .
Table.1 The main characteristics of studies. Study design In vitro/ in vivo Methods Caries criteria Number of teeth (number of surfaces), surface Numbe r of patient s (years) Dentitio n Follow -up period Outcome 1.Hietala-Lenkkeri et al.,2014 Cross-sectional study in vivo VT BW WHO- examinat ion ICDAS 0-6 converte d 5 609 (11522) 363 Perm - 53% of subjects benefited from BW 2.Kopycka-Kedzierawski et al., 2013 Observat ional study in vivo Gr.1-VT Gr.2- TE - - 291 (1-5) Pr 6;12 months SE-100% (Gr1) SP 81% (Gr2) SP 100% (Gr1) 3. Zhang, et al.,2013 Observat ional study
Both MOI - in vitro-28 posterior teeth; in vivo- 5 molars, proximal 5 (4-11)
Both In vitro- a statistical significance between sound enamel and demineralized enamel. In vivo- RPC value lower in white spot lesion than in brown spot lesion (41% vs.70%) 4. Krzyżostaniak et al., 2014 Observat ional study in vitro CBCT CF DF - 135 (occlusal and proximal of posterior teeth) CBCT: Az 0.635(occlusal); 0.629 (proximal); DF: Az 0.581 (occlusal); 0.665 (proximal) ; CF : Az 0.613 (occlusal) ; 0.667 (proximal) ;
5. A Astvaldsdo ́ ttir, 2012 Observat ional study In vitro DIFOTI CF DF Pitt classifica tion: D1*,D3* 56 (112) proximal surfaces of premolars
- Perm - DIFOTI (in enamel
and dentin):
SE 46%- 89% ; SP 65%-100%;
CF (in enamel and dentin):
SE 13%-60%; SP 56%-100%;
DF (in enamel and dentin): SE 22%-64%; SP 74%-100%; 6. Ribeiro et al.,2015 Clinical study Both VT LF BW OSE(7 days) Nyvad 137 (209), proximal surfaces 33(8-12 ) Perm In vivo: VT (before OSE): SE 37%: SP 100%;AC 71%; VT (after OSE): SE 60%; SP 92%; AC 75%; LF (before OSE): SE 47%; SP 85%; AC 69%; LF(after OSE): SE 63%; SP 92%; AC 80%; BW: SE 47%; SP 85%; AC 69%; 7.Chen et al., 2012 Clinical study in vivo LF BW VI Ekstrand criteria 216 (256), proximal surfaces 96 (5-9) Pr VI: SE 50%, SP 95.31%; AC 72.65%; BW: SE 89.06%, SP 96.96%, AC 92.57%; LF: SE 81.25%, SP 96.87%, AC 89.06%
8. Schwendicke et al.,2015 Clinical trial in vivo VT VT+ RA E2**, D1**, D2** Proximal surfaces of posterior teeth (12 ) Perm 2 years (RA) VT: SE:35%(E2); 52.5%(D1); 60.2%(D2) SP: 100%(E2, D1), 92.2%(D2). RA: SE: 35.0% (E2); 52.5%(D1), 60.2%(D2). SP: 80.0%(E2); 95.7%(D1), 94.7%(D2). 9. Cinar et al., 2013 Observat ional study in vivo VI BW LF Pitt classifica tion: D0*-D4* (44), occlusal surfaces 20 (9-11) Pr - VI: SE(D3) 100%; 85.7% (D2); SP 40% (D3); 87% (D2); AC 52.3% (D3); 86.4% (D2); BW: SE 88.9% (D3); 67.2% (D2); SP 51.4% (D3); 60.9% (D2); AC 59.1%(D3); 68.2%(D2); LF: SE 100% (D3, D2); SP 57.1% (D3); 87% (D2); AC 66% (D3); 93.2%(D2); 10.Goel et al., 2017 Observat ional study in vivo LF VI VT BW Ekstrand ’s criteria 84 52 Pr - VI: SE: 52.78%, SP: 89.36%, AC: 73.49%; VT: SE: 50.0%, SP: 91.49%, AC: 73.49%, BW: SE: 30.56%, SP: 82.98%, AC: 60.24%,
SP: 74.47%, AC: 75.90% 11. Bussaneli et al., 2015 Clinical study in vivo VI BW LF -NYVAD 2,3,5,6 59, proximal surfaces 45 (5-9)
Pr - VI (in enamel and dentin):
SE 95.7%; SP 84.6%; AC 94%;
BW (in enamel and dentin):
SE 76.1%; SP 61.5%; AC 72.9%
LF (in enamel and dentin): SE 97.8%; SP 62.6%; AC 89.9%; 12. Huth et al.,2008 Clinical study. in vivo VI BW LF - 120, occlusal surfaces 120 Both 12 months LF: SE 88%; SP 85%;
D0*- sound enamel ; D1*- enamel lesion, no cavity ; D2*- enamel lesion, cavity ; D3*- dentin lesion, cavity, D4- dentin lesion, cavity to the pulp.
E2**- lesion into inner third of enamel ; D1**- lesion into outer third of dentine ; D2 **- lesion into middle third of dentine.
Table. 2 The main advantages and limitations of examination methods analyzed in systematic review.
Examination method The main advantages Liminations
1.Visual inspection Visual inspection performed on clean and dried teeth shows high sensitivity [30]
Visual inspection may
underestimate occlusal enamel, dentin caries in teeth without cavitation. [33]
2.Visual/tactile examination
Visual-tactile examination presents better results than the other analysed examination methods [29]
Cost is low[25]
Visual tactile examination may underestimate occlusal enamel lesion in teeth [33]
3.DIFOTI This instrument is able to identify great change in lesion depth although small changes in the mineral content of the enamel lesion are not detectable [35] .
This method is restricted in more advanced lesions of dentin[35] .
4.Laser fluorescence device (DIAGNOdent) (LF)
LF pens can cut down radiography use [31]
LF pens are currently expensive [31]
5.Cone beam
computed tomography (CBCT)
The accuracy of detection noncavitated occlusal carious lesions is slightly better than other radiographic systems [36]
The detection accurac of noncavitated proximal caries is significantly worse than the other intraoral radiographic systems (CF, DF) [36] Ionising radiation must be considered[31]
6.Teledentistry (intraoral camera)
This method can be used for improving access to specialty dental care where it is not easily available [34]
-
7.Orthodontic separative elastics (OSE)
The effectiveness of approximal caries lesion detection is increased by the absence of contact
points [29].
It is used only as an auxilliary tool for non-cavitated caries diagnosis.
It may create discomfort feeling for patients.
It requires additional visit for examination [29].
8.Bitewing
radiography (BW)
Radiographics (RA)
Bitewing radiography shows good performance for lesions in dentin [32]
Cost is low [25]
Bitewing radiography is
inappropriate for occlusal enamel caries detection. [38], [15].
Producing of well-focused bitewing radiographs in children requires considerable skills and time. Ionising radiation must be considered [21]
9.Multimodal optical clinical prototype images (MOI)
In vitro, it successfully
quantitavely discriminates between sound and deminaralized enamel [37]
A strong portion of teeth autofluorescence is emmited from DEJ thickness of enamel, therefore distance to the junction may affect the spectroscopic measurements [37]
DISCUSSION
Despite the fact that many studies are carried out in vitro and in vivo, various caries lesions examination methods are applied for different teeth surfaces, results show that one proper diagnostic method having adequate sensitivity, specificity and accuracy of early caries detection does not exist.
Due to difficulties to conduct some types of clinical studies, researches are carried out in vitro, thus even applied diagnostic devices reveal great results under laboratory condition, it is complicated to used them in clinical practice [39].
Some examination methods like tele-dentistry can substitute the traditional visual examination, although the evaluation quality of this technology is still unclear [40]. This systematic review included only one article meeting PICOS criteria, where tele-dentistry as examination method was used ; and it might happen due to demand of further investigations to determine the capability of this technology [40]. Furthermore, later smartphone technology can be adjusted in dental screening and mobile medicine will be more prevalent due to recently proven benefit [41].
Radiographic examination of teeth has a high importance in addition to clinical examination, especially for detection of proximal caries lesion in early stage [42]. Moreover, this method is commonly used for caries detection worldwide. This systematic review reveal the same tendency due to prevailing among examination methods. Bitewing radiographs are accepted as the gold standard for detection of these lesions, the issue of ionising radiation should be considered for every
Consequently, in this systematic review various methods such as digital imaging fiber-optic transillumination,DIAGNOdent can be compared with different kinds of radiography in order to ascertain innovative examination methods without a negative outcomes for example, ionising radiation. Furthermore, results showed almost similar sensitivity, specify and accuracy values or better results of other additional examination methods than radiographic examination.
Findings of carried out studies revealed that caries lesion does not always demonstrate radio lucidity in the radiographic examination [43]. Therefore, dental examination performed with instruments or devices which acts via interaction of light has advantages comparing with visual examination and radiographic examinations. Analysis of publications showed that various researches used different methods of devices applications for caries lesions detection. For instance, some authors compared different generations of the same devices and they used the same technique, while the others compared the different standard of caries detection, like standardised or modified in order to achieve the better sensitivity, specificity and accuracy values.
In literature, controversial opinions about achievement in early caries detection can be observed. The some authors believe that innovational technologies have a lot advantages to aid clinicians not only in early caries detection but to make a firm diagnosis and treat cases conservatively [10]. Although, an opposite opinion is confirmed that the advanced development in technology does not show definitive improvement in caries detection for decades [13]
CONCLUSION
The combination of different diagnostic methods increases the efficiency of early caries lesion detection. In addition, this systematic review revealed that one effective diagnostic method does not exist due to several reasons such as location and extent of caries lesion. It has a beneficial not only for researchers, but also these innovative diagnostic methods can be applied in clinical practice due to lower percentages of underestimated caries lesions, more accurate diagnosis and implementing of treatment. Moreover, more advantages can be mentioned as a time saving of clinicians, lower treatment's cost and more efficient preventive dentistry.
REFERENCES
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Annex 6 Protocol for systematic review according to PRISMA-P
Aim To analyze the publications related to early caries detection and assess which methods are the most effective in order to promote the preventive intervention regarding to caries risk category.
Tasks 1.To search and select the publications for analysis according to the inclusion and exclusion criteria. 2.To analyse and compare the results of selected studies.
3.To assess which diagnostic method(s) are the most accurate and conveniently applied in practice.
METHODS
Eligibility
criteria PICOS: P- Participants: children till 18 age years old
I-Intervention:
-radiography( different types)(OCT, BW,CBCT) -laser fluoresce (DIAGNOdent)
-optic-transillumination(FOTI ;DIFOTI)
-telecommunication technology( teledentistry, intraoral camera) -visual inspection
-visual/tactile examination -ortodontic separative elastics
- Multimodal optical clinical prototype images
C- Group of examined subjects: -primary and permanent teeth (proximal and
occlusal)
O- Sensivity, Specifity, Accuracy
S- Study design selection: clinical study, cross-sectional study, observational study.
Inclusion criteria:
1.Publication written in English
2.Studies performed on humans only ( in vitro and in vivo) 3. Particpants who meet the selection criteria.
4. Articles which were published over the last 10 years Exclusion criteria:
1. Not full available articles 2.Conference proceeding
3. Systemic review and review articles 4. Commentaires
5.Studies performed in animals 6. Participants older than 18 years old 7. Articles published more than 10 years ago
Information sources
. Electronic databases: PUBMED, Science Direct and Google scholar
