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Meta-Analysis
. 2021 Jun 14;6(6):CD014546.
doi: 10.1002/14651858.CD014546.

Visual or visual-tactile examination to detect and inform the diagnosis of enamel caries

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

Visual or visual-tactile examination to detect and inform the diagnosis of enamel caries

Richard Macey et al. Cochrane Database Syst Rev. .

Abstract

Background: The detection and diagnosis of caries at the initial (non-cavitated) and moderate (enamel) levels of severity is fundamental to achieving and maintaining good oral health and prevention of oral diseases. An increasing array of methods of early caries detection have been proposed that could potentially support traditional methods of detection and diagnosis. Earlier identification of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol-generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.

Objectives: To determine the diagnostic accuracy of different visual classification systems for the detection and diagnosis of non-cavitated coronal dental caries for different purposes (detection and diagnosis) and in different populations (children or adults).

Search methods: Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 April 2020); Embase Ovid (1980 to 30 April 2020); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 April 2020); and the World Health Organization International Clinical Trials Registry Platform (to 30 April 2020). We studied reference lists as well as published systematic review articles.

Selection criteria: We included diagnostic accuracy study designs that compared a visual classification system (index test) with a reference standard (histology, excavation, radiographs). This included cross-sectional studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were considered. Studies that explicitly recruited participants with caries into dentine or frank cavitation were excluded. 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: We extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on QUADAS-2 specific to the review context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence intervals (CIs) and regions, and 95% prediction regions. The comparative accuracy of different classification systems was conducted based on indirect comparisons. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

Main results: We included 71 datasets from 67 studies (48 completed in vitro) reporting a total of 19,590 tooth sites/surfaces. The most frequently reported classification systems were the International Caries Detection and Assessment System (ICDAS) (36 studies) and Ekstrand-Ricketts-Kidd (ERK) (15 studies). In reporting the results, no distinction was made between detection and diagnosis. Only two studies were at low risk of bias across all four domains, and 15 studies were at low concern for applicability across all three domains. The patient selection domain had the highest proportion of high risk of bias studies (49 studies). Four studies were assessed at high risk of bias for the index test domain, nine for the reference standard domain, and seven for the flow and timing domain. Due to the high number of studies on extracted teeth concerns regarding applicability were high for the patient selection and index test domains (49 and 46 studies respectively). Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies: sensitivities ranged from 0.16 to 1.00 and specificities from 0 to 1.00. For all visual classification systems the estimated summary sensitivity and specificity point was 0.86 (95% CI 0.80 to 0.90) and 0.77 (95% CI 0.72 to 0.82) respectively, diagnostic odds ratio (DOR) 20.38 (95% CI 14.33 to 28.98). In a cohort of 1000 tooth surfaces with 28% prevalence of enamel caries, this would result in 40 being classified as disease free when enamel caries was truly present (false negatives), and 163 being classified as diseased in the absence of enamel caries (false positives). The addition of test type to the model did not result in any meaningful difference to the sensitivity or specificity estimates (Chi2(4) = 3.78, P = 0.44), nor did the addition of primary or permanent dentition (Chi2(2) = 0.90, P = 0.64). The variability of results could not be explained by tooth surface (occlusal or approximal), prevalence of dentinal caries in the sample, nor reference standard. Only one study intentionally included restored teeth in its sample and no studies reported the inclusion of sealants. We rated the certainty of the evidence as low, and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and inconsistency of results.

Authors' conclusions: Whilst the confidence intervals for the summary points of the different visual classification systems indicated reasonable performance, they do not reflect the confidence that one can have in the accuracy of assessment using these systems due to the considerable unexplained heterogeneity evident across the studies. The prediction regions in which the sensitivity and specificity of a future study should lie are very broad, an important consideration when interpreting the results of this review. Should treatment be provided as a consequence of a false-positive result then this would be non-invasive, typically the application of fluoride varnish where it was not required, with low potential for an adverse event but healthcare resource and finance costs. Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Wherever possible future studies should be carried out in a clinical setting, to provide a realistic assessment of performance within the oral cavity with the challenges of plaque, tooth staining, and restorations, and consider methods to minimise bias arising from the use of imperfect reference standards in clinical studies.

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Conflict of interest statement

Richard Macey: none known. Tanya Walsh: none known. I am Senior Statistical Editor with Cochrane Oral Health. Philip Riley: none known. I am Deputy Co‐ordinating Editor of Cochrane Oral Health. Anne‐Marie Glenny: none known. I am Co‐ordinating Editor of Cochrane Oral Health. Helen V Worthington: none know. I am Statistical Editor with Cochrane Oral Health. Lucy O'Malley: none known. I am Editor with 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 available datasets, sorted according to sensitivity.
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Summary sensitivity and specificity points of all included datasets with 95% confidence and prediction regions.
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Forest plot grouped according to visual classification system (ICDAS, ERK, and other visual examinations) sorted according to sensitivity.
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Summary sensitivity and specificity points by ICDAS, ERK, and other visual classification system with 95% confidence and prediction regions.
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Forest plot grouped according to primary or permanent dentition, sorted according to sensitivity.
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Summary sensitivity and specificity points by primary and permanent dentition with 95% confidence and prediction regions.
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Forest plot grouped by reference standard, sorted according to sensitivity.
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Summary sensitivity and specificity points by reference standard with 95% confidence and prediction regions.
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Sensitivity analysis of studies using a reference standard only, with in vivo studies removed.
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Forest plot grouped by tooth surface, sorted according to sensitivity.
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Summary sensitivity and specificity points by tooth surface with 95% confidence and prediction regions.
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Forest plot grouped by prevalence of dentine caries (low: 0% to 14%, medium: 15% to 34%, and high: ≥ 35% prevalence) sorted according to sensitivity.
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Summary sensitivity and specificity points by prevalence of dentine caries (low: 0% to 14%, medium: 15% to 34%, and high: ≥ 35% prevalence) with 95% confidence and prediction regions.
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1. Test
All
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2. Test
ICDAS
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3. Test
ERK
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4. Test
Other visual
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References

References to studies included in this review

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References to studies excluded from this review

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Ashley 2000 {published data only}
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Askaroglou 2011 {published data only}
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Attrill 2001 {published data only}
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Bengtson 2005 {published data only}
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Bizhang 2016 {published data only}
    1. Bizhang M, Wollenweber N, Singh-Husgen P, Danesh G, Zimmer S. Pen-type laser fluorescence device versus bitewing radiographs for caries detection on approximal surfaces. Head & Face Medicine 2016;12(1):30. - PMC - PubMed
Bozdemir 2013 {published data only}
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Braga 2009a {published data only}
    1. Braga MM, Mendes FM, Martignon S, Ricketts DN, Ekstrand KR. In vitro comparison of Nyvad's system and ICDAS-II with Lesion Activity Assessment for evaluation of severity and activity of occlusal caries lesions in primary teeth. Caries Research 2009;43(5):405-12. - PubMed
Chen 2012 {published data only}
    1. Chen J, Qin M, Ma W, Ge L. A clinical study of a laser fluorescence device for the detection of approximal caries in primary molars. International Journal of Paediatric Dentistry 2012;22(2):132-8. - PubMed
Chong 2003 {published data only}
    1. Chong MJ, Seow WK, Purdie DM, Cheng E, Wan V. Visual-tactile examination compared with conventional radiography, digital radiography, and Diagnodent in the diagnosis of occlusal occult caries in extracted premolars. Pediatric Dentistry 2003;25(4):341-9. - PubMed
Chu 2010 {published data only}
    1. Chu CH, Lo ECM, You DSH. Clinical diagnosis of fissure caries with conventional and laser-induced fluorescence techniques. Lasers in Medical Science 2010;25(3):355-62. - PMC - PubMed
Cortes 2003 {published data only}
    1. Cortes DF, Ellwood RP, Ekstrand KR. An in vitro comparison of a combined FOTI/visual examination of occlusal caries with other caries diagnostic methods and the effect of stain on their diagnostic performance. Caries Research 2003;37(1):8-16. - PubMed
Costa 2007 {published data only}
    1. Costa AM, Bezzerra AC, Fuks AB. Assessment of the accuracy of visual examination, bite-wing radiographs and DIAGNOdent on the diagnosis of occlusal caries. European Archives of Paediatric Dentistry 2007;8:118-22. - PubMed
Diniz 2011a {published data only}
    1. Diniz MB, Sciasci P, Rodrigues JA, Lussi A, Cordeiro RCL. Influence of different professional prophylactic methods on fluorescence measurements for detection of occlusal caries. Caries Research 2011;45(3):264-8. - PubMed
Dong 2007 {published data only}
    1. Dong C, Choo-Smith L, Werner J, Ko A, Hewko M, Cleghorn B, et al. Comparing clinical and spectroscopic methods for detecting early dental caries. Journal of Dental Research 2007;85(Spec Iss B):1241.
Duruturk 2011 {published data only}
    1. Duruturk L, Ciftci A, Baharoglu S, Oztuna D. Clinical evaluation of DIAGNOdent in detection of occlusal caries in newly erupted noncavitated first permanent molars in caries-active children. Operative Dentistry 2011;36:348-55. - PubMed
El‐Damanhoury 2014 {published data only}
    1. El-Damanhoury HM, Fakhruddin KS, Awad MA. Effectiveness of teaching International Caries Detection and Assessment System II and its e-learning program to freshman dental students on occlusal caries detection. European Journal of Dentistry 2014;8(4):493-7. - PMC - PubMed
Elhennawy 2018 {published data only}
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Erten 2006 {published data only}
    1. Erten H, Uctasli MB, Akarslan ZZ, Uzun O, Semiz M. Restorative treatment decision making with unaided visual examination, intraoral camera and operating microscope. Operative Dentistry 2006;31(1):55-9. - PubMed
Forgie 2002 {published data only}
    1. Forgie AH, Pine CM, Pitts NB. The use of magnification in a preventive approach to caries detection. Quintessence International 2002;33(1):13-6. - PubMed
Fyffe 2000 {published data only}
    1. Fyffe HE, Deery C, Nugent ZJ, Nuttall NM, Pitts NB. In vitro validity of the Dundee Selectable Threshold Method for caries diagnosis (DSTM). Community Dentistry and Oral Epidemiology 2000;28(1):52-8. - PubMed
Goel 2016 {published data only}
    1. Goel D, Sandhu M, Jhingan P, Sachdev V. Effectiveness of air drying and magnification methods for detecting initial caries on occlusal surfaces using three different diagnostic aids. Journal of Clinical Pediatric Dentistry 2016;40(3):221-6. - PubMed
Gomez 2013 {published data only}
    1. Gomez J, Zakian C, Salsone S, Pinto SCS, Taylor A, Pretty IA, et al. In vitro performance of different methods in detecting occlusal caries lesions. Journal of Dentistry 2013;41(2):180-6. - PubMed
Graye 2012 {published data only}
    1. Graye M, Markowitz K, Strickland M, Guzy G, Burke M, Houpt M. In vitro evaluation of the Spectra™ early caries detection system. Journal of Clinical Dentistry 2012;23(1):1. - PubMed
Heinrich‐Weltzien 2003 {published data only}
    1. Heinrich-Weltzien R, Kuhnisch J, Oehme T, Ziehe A, Stosser L, Garcia-Godoy F. Comparison of different DIAGNOdent cut-off limits for in vivo detection of occlusal caries. Operative Dentistry 2003;28(6):672-80. - PubMed
Huysmans 1998 {published data only}
    1. Huysmans MC, Longbottom C, Pitts N. Electrical methods in occlusal caries diagnosis: an in vitro comparison with visual inspection and bite–wing radiography. Caries Research 1998;32(5):324-9. - PubMed
Iranzo‐Cortés 2018 {published data only}
    1. Iranzo-Cortés JE, Almarche-Tarazona M, Montiel-Company JM, Almerich-Silla JM. Diagnostic validity of ICDAS II, VistaProof and a combination of these two methods. An in vitro study in pre‐cavitated lesions. Lasers in Surgery and Medicine 2018;50(2):166-73. - PubMed
Jablonski‐Momeni 2009 {published data only}
    1. Jablonski-Momeni A, Ricketts DN, Heinzel-Gutenbrunner M, Stoll R, Stachniss V, Pieper K. Impact of scoring single or multiple occlusal lesions on estimates of diagnostic accuracy of the visual ICDAS-II system. International Journal of Dentistry 2009;2009:798283. - PMC - PubMed
Jablonski‐Momeni 2013 {published data only}
    1. Jablonski-Momeni A, Liebegall F, Stoll R, Heinzel-Gutenbrunner M, Pieper K. Performance of a new fluorescence camera for detection of occlusal caries in vitro. Lasers in Medical Science 2013;28(1):101-9. - PubMed
Jablonski‐Momeni 2018 {published data only}
    1. Jablonski-Momeni A, Moos J, Manesh VS, Stoll R. Diagnostic accuracy of a bioluminescence system for the assessment of caries activity on occlusal surfaces. Caries Research 2018;52(4):279-87. - PubMed
Kavvadia 2008 {published data only}
    1. Kavvadia K, Lagouvardos P. Clinical performance of a diode laser fluorescence device for the detection of occlusal caries in primary teeth. International Journal of Paediatric Dentistry 2008;18(3):197-204. - PubMed
Kavvadia 2012 {published data only}
    1. Kavvadia K, Lagouvardos P, Apostolopoulou D. Combined validity of DIAGNOdent™ and visual examination for in vitro detection of occlusal caries in primary molars. Lasers in Medical Science 2012;27(2):313-9. - PubMed
Khalaf 2018 {published data only}
    1. Khalaf ME, Qudeimat M, Alomari QD, Al-Tarakmeh Y, Honkala E. Impact of magnifying loupes on interexaminer agreement in the detection of noncavitated occlusal carious lesions. Oral Health & Preventive Dentistry 2018;16(4):375-80. - PubMed
Kidd 2003 {published data only}
    1. Kidd EAM, Banerjee A, Ferrier S, Longbottom C, Nugent Z. Relationships between a clinical-visual scoring system and two histological techniques: a laboratory study on occlusal and approximal carious lesions. Caries Research 2003;37(2):125-9. - PubMed
Kordic 2003 {published data only}
    1. Kordic A, Lussi A, Luder HU. Performance of visual inspection, electrical conductance and laser fluorescence in detecting occlusal caries in vitro. Schweizer Monatsschrift für Zahnmedizin SMfZ 2003;113(8):852-9. - PubMed
Kuhnisch 2011 {published data only}
    1. Kuhnisch J, Bucher K, Henschel V, Albrecht A, Garcia-Godoy F, Mansmann U, et al. Diagnostic performance of the universal visual scoring system (UniViSS) on occlusal surfaces. Clinical Oral Investigations 2011;15(2):215-23. - PubMed
Lussi 1991 {published data only}
    1. Lussi A. Validity of diagnostic and treatment decisions of fissure caries. Caries Research 1991;25(4):296-303. - PubMed
Lussi 2003 {published data only}
    1. Lussi A, Francescut P. Performance of conventional and new methods for the detection of occlusal caries in deciduous teeth. Caries Research 2003;37(1):2-7. - PubMed
Melo 2017 {published data only}
    1. Melo M, Pascual A, Camps I, Campo A Del, Ata-Ali J. Caries diagnosis using light fluorescence devices in comparison with traditional visual and tactile evaluation: a prospective study in 152 patients. Odontology 2017;105(3):283-90. - PubMed
Mialhe 2011 {published data only}
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Mitropoulos 2012 {published data only}
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Neuhaus 2015a {published data only}
    1. Neuhaus KW, Ciucchi P, Rodrigues JA, Hug I, Emerich M, Lussi A. Diagnostic performance of a new red light LED device for approximal caries detection. Lasers in Medical Science 2015;30(5):1443-7. - PubMed
Novaes 2012a {published data only}
    1. Novaes TF, Matos R, Celiberti P, Braga MM, Mendes FM. The influence of interdental spacing on the detection of proximal caries lesions in primary teeth. Brazilian Oral Research 2012;26(4):293-9. - PubMed
Pereira 2009 {published data only}
    1. Pereira AC, Eggertsson H, Martinez-Mier EA, Mialhe FL, Eckert GJ, Zero DT. Validity of caries detection on occlusal surfaces and treatment decisions based on results from multiple caries detection methods. European Journal of Oral Sciences 2009;117(1):51-7. - PubMed
Piovesan 2013 {published data only}
    1. Piovesan C, Moro BL, Lara JS, Ardenghi TM, Guedes RS, Haddad AE, et al. Laboratorial training of examiners for using a visual caries detection system in epidemiological surveys. BMC Oral Health 2013;13(1):49. - PMC - PubMed
Qudeimat 2016 {published data only}
    1. Qudeimat MA, Alomari QD, Altarakemah Y, Alshawaf N, Honkala EJ. Variables affecting the inter- and intra-examiner reliability of ICDAS for occlusal caries diagnosis in permanent molars. Journal of Public Health Dentistry 2016;76(1):9-16. - PubMed
Reis 2006 {published data only}
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Ricketts 1995 {published data only}
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Rodrigues 2008a {published data only}
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Senel 2010 {published data only}
    1. Senel B, Kamburoglu K, Ucok O, Yuksel SP, Ozen T, Avsever H. Diagnostic accuracy of different imaging modalities in detection of proximal caries. DentoMaxilloFacial Radiology 2010;39(8):501-11. - PMC - PubMed
Shoaib 2009 {published data only}
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Silva 2008 {published data only}
    1. da Silva Neto JM, dos Santos RL, Sampaio MC, Sampaio FC, Passos IA. Radiographic diagnosis of incipient proximal caries: an ex-vivo study. Brazilian Dental Journal 2008;19(2):97-102. - PubMed
Subka 2019 {published data only}
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Umemori 2010 {published data only}
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Ünal 2019 {published data only}
    1. Ünal M, Koçkanat A, Güler S, Gültürk E. Diagnostic performance of different methods in detecting incipient non-cavitated occlusal caries lesions in permanent teeth. Journal of Clinical Pediatric Dentistry 2019;43(3):173-9. - PubMed
Virajsilp 2005 {published data only}
    1. Virajsilp V, Thearmontree A, Aryatawong S, Paiboonwarachat D. Comparison of proximal caries detection in primary teeth between laser fluorescence and bitewing radiography. Pediatric Dentistry 2005;27(6):493-9. - PubMed
Wenzel 1990 {published data only}
    1. Wenzel A, Fejerskov O, Kidd E, Joyston-Bechal S, Groeneveld A. Depth of occlusal caries assessed clinically, by conventional film radiographs, and by digitized, processed radiographs. Caries Research 1990;24(5):327-33. - PubMed
White 1978 {published data only}
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Zandona 2009 {published data only}
    1. Zandona AGF, Al-Shiha S, Eggertsson H, Eckert G. Student versus faculty performance using a new visual criteria for the detection of caries on occlusal surfaces: an in vitro examination with histological validation. Operative Dentistry 2009;34(5):598-604. - PubMed

References to studies awaiting assessment

Luczaj‐Cepowicz 2019 {published data only}
    1. Luczaj-Cepowicz E, Marczuk-Kolada G, Obidzinska M, Sidun J. Diagnostic validity of the use of ICDAS II and DIAGNOdent pen verified by micro-computed tomography for the detection of occlusal caries lesions - an in vitro evaluation. Lasers in Medical Science 2019;34(8):1655-63. - PubMed

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