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Meta-Analysis
. 2021 Jan 27;1(1):CD013855.
doi: 10.1002/14651858.CD013855.

Transillumination and optical coherence tomography for the detection and diagnosis of enamel caries

Richard Macey  1 , Tanya Walsh  1 , Philip Riley  2 , Richard Hogan  3 , Anne-Marie Glenny  1 , Helen V Worthington  2 , Janet E Clarkson  4 , David Ricketts  5
Affiliations
Meta-Analysis

Transillumination and optical coherence tomography for the detection and diagnosis of enamel caries

Richard Macey et al. Cochrane Database Syst Rev. .

Abstract

Background: Caries is one of the most prevalent and preventable conditions worldwide. If identified early enough then non-invasive techniques can be applied, and therefore this review focusses on early caries involving the enamel surface of the tooth. The cornerstone of caries detection and diagnosis is a visual and tactile dental examination, although alternative approaches are available. These include illumination-based devices that could potentially support the dental examination. There are three categories of illumination devices that exploit various methods of application and interpretation, each primarily defined by different wavelengths, optical coherence tomography (OCT), near-infrared (NIR), and fibre-optic technology, which incorporates more recently developed digital fibre optics (FOTI/DIFOTI).

Objectives: To estimate the diagnostic test accuracy of different illumination tests for the detection and diagnosis of enamel caries in children or adults. We also planned to explore the following potential sources of heterogeneity: in vitro or in vivo studies with different reference standards; tooth surface (occlusal, proximal, smooth surface, or adjacent to a restoration); single or multiple sites of assessment on a tooth surface; and the prevalence of caries into dentine.

Search methods: Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 15 February 2019); Embase Ovid (1980 to 15 February 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 15 February 2019); and the World Health Organization International Clinical Trials Registry Platform (to 15 February 2019). We studied reference lists as well as published systematic review articles.

Selection criteria: We included diagnostic accuracy study designs that compared the use of illumination-based devices with a reference standard (histology, enhanced visual examination with or without radiographs, or operative excavation). These included prospective studies that evaluated the diagnostic accuracy of a single index test and studies that directly compared two or more index tests. Both in vitro and in vivo studies of primary and permanent teeth were eligible for inclusion. We excluded studies that explicitly recruited participants with caries into dentine or frank cavitation. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.

Data collection and analysis: Two review authors extracted data independently and in duplicate using a standardised data extraction form and quality assessment based on QUADAS-2 specific to the clinical context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence regions. The comparative accuracy of different illumination devices was conducted based on indirect and direct comparisons between methods. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

Main results: We included 24 datasets from 23 studies that evaluated 16,702 tooth surfaces. NIR was evaluated in 6 datasets (673 tooth surfaces), OCT in 10 datasets (1171 tooth surfaces), and FOTI/DIFOTI in 8 datasets (14,858 tooth surfaces). The participant selection domain had the largest number of studies judged at high risk of bias (16 studies). Conversely, for the index test, reference standard, and flow and timing domains the majority of studies were judged to be at low risk of bias (16, 12, and 16 studies respectively). Concerns regarding the applicability of the evidence were judged as high or unclear for all domains. Notably, 14 studies were judged to be of high concern for participant selection, due to selective participant recruitment, a lack of independent examiners, and the use of an in vitro study design. The summary estimate across all the included illumination devices was sensitivity 0.75 (95% confidence interval (CI) 0.62 to 0.85) and specificity 0.87 (95% CI 0.82 to 0.92), with a diagnostic odds ratio of 21.52 (95% CI 10.89 to 42.48). In a cohort of 1000 tooth surfaces with a prevalence of enamel caries of 57%, this would result in 142 tooth surfaces being classified as disease free when enamel caries was truly present (false negatives), and 56 tooth surfaces being classified as diseased in the absence of enamel caries (false positives). A formal comparison of the accuracy according to device type indicated a difference in sensitivity and/or specificity (Chi2(4) = 34.17, P < 0.01). Further analysis indicated a difference in the sensitivity of the different devices (Chi2(2) = 31.24, P < 0.01) with a higher sensitivity of 0.94 (95% CI 0.88 to 0.97) for OCT compared to NIR 0.58 (95% CI 0.46 to 0.68) and FOTI/DIFOTI 0.47 (95% CI 0.35 to 0.59), but no meaningful difference in specificity (Chi2(2) = 3.47, P = 0.18). In light of these results, we planned to formally assess potential sources of heterogeneity according to device type, but due to the limited number of studies for each device type we were unable to do so. For interpretation, we presented the coupled forest plots for each device type according to the potential source of heterogeneity. We rated the certainty of the evidence as low and downgraded two levels in total due to avoidable and unavoidable study limitations in the design and conduct of studies, indirectness arising from the in vitro studies, and imprecision of the estimates.

Authors' conclusions: Of the devices evaluated, OCT appears to show the most potential, with superior sensitivity to NIR and fibre-optic devices. Its benefit lies as an add-on tool to support the conventional oral examination to confirm borderline cases in cases of clinical uncertainty. OCT is not currently available to the general dental practitioner, and so further research and development are necessary. FOTI and NIR are more readily available and easy to use; however, they show limitations in their ability to detect enamel caries but may be considered successful in the identification of sound teeth. Future studies should strive to avoid research waste by ensuring that recruitment is conducted in such a way as to minimise selection bias and that studies are clearly and comprehensively reported. In terms of applicability, any future studies should be undertaken in a clinical setting that is reflective of the complexities encountered in caries assessment within the oral cavity.

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Conflict of interest statement

Richard Macey: none known. Tanya Walsh: none known. I am an Editor with Cochrane Oral Health. Philip Riley: none known. I am Deputy Co‐ordinating Editor of Cochrane Oral Health. Richard Hogan: I am employed by the Colgate‐Palmolive Company as a Clinical Study Manager. I also hold an Honorary Research Fellow position with The University of Manchester. Anne‐Marie Glenny: none known. I am Co‐ordinating Editor of Cochrane Oral Health. Helen V Worthington: none know. I am Emeritus Co‐ordinating Editor of Cochrane Oral Health. Janet E Clarkson: none known. I am Co‐ordinating Editor of Cochrane Oral Health. David Ricketts: none known.

Figures

1
1
Keystones of the International Caries Classification and Management System (ICCMS™).
Copyright© 2018 Ismail AI, Pitts NB, Tellez M. The International Caries Classification and Management System (ICCMS™) an example of a caries management pathway. BMC Oral Health 2015;15(Suppl 1):S9. Reproduced with permission.
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Study flow diagram.
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Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies.
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Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study.
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Forest plot of all included datasets.
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Summary receiver operating characteristic (SROC) plot of all included datasets.
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Forest plot of tests subgroups: near‐infrared (NIR), optical coherence tomography (OCT), and fibre‐optic transillumination (FOTI)/digital fibre‐optic transillumination (DIFOTI).
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Summary receiver operating characteristic (SROC) plot of tests highlighting the 3 different groups (near‐infrared (NIR), optical coherence tomography (OCT), and fibre‐optic transillumination (FOTI)/digital fibre‐optic transillumination (DIFOTI)).
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Illustration of the uncertainty in the optical coherence tomography (OCT) devices.
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Forest plot of optical coherence tomography (OCT) datasets investigating the effect of prevalence at the dentine level.
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Summary receiver operating characteristic (SROC) plot of optical coherence tomography (OCT) datasets, highlighted according to the prevalence of dentine level caries.
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Forest plot of 2 near‐infrared (NIR).
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Summary receiver operating characteristic (SROC) plot of the near‐infrared (NIR) group, individual datasets being highlighted according to the reference standard applied.
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Forest plot of optical coherence tomography (OCT) sorted according to the reference standard applied.
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Summary receiver operating characteristic (SROC) plot of the optical coherence tomography (OCT) group, individual datasets being highlighted according to the reference standard applied.
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Forest plot of the fibre‐optic transillumination (FOTI)/digital fibre‐optic transillumination (DIFOTI) group, sorted according to reference standard applied.
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Summary receiver operating characteristic (SROC) plot of the fibre‐optic transillumination (FOTI)/digital fibre‐optic transillumination (DIFOTI) group, individual datasets being highlighted according to the reference standard applied.
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Summary receiver operating characteristic (SROC) plot of optical coherence tomography (OCT) studies illustrating those that assessed a single site on the tooth's surface and those that assessed multiple sites on a tooth's surface.
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1. Test
ALL
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2. Test
NIR
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3. Test
OCT
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4. Test
FOTI/DIFOTI
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5. Test
DIFOTI
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