|Year : 2015 | Volume
| Issue : 1 | Page : 15-19
An In Vivo S tudy of Different Methods of Detection and Quantification of Occlusal Dental Caries in Permanent Molars
Purvi A Mehta, N Vimala, Lalitagauri Mandke
Department of Conservative Dentistry and Endodontics, D. Y. Patil University, School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India
|Date of Web Publication||17-Jun-2015|
57, Sabarigiri Anushakti Nagar, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The objective of this study was to evaluate a new laser fluorescence device, DIAGNOdent for occlusal caries detection and to compare the diagnostic accuracy of DIAGNOdent with conventional bitewing radiography. And to determine the sensitivity and specificity of DIAGNOdent. Methods: 60 teeth were selected having pit and fissure carious lesions by 2 examiners. After visual and tactile examination of each lesion, DIAGNOdent readings were recorded and bitewing radiographs were taken. Caries removal was done and volume of the cavity was calculated by packing the cavity with composite of specific density. Results: Correlation between DIAGNOdent and visual tactile is 0.398 (P < 0.05); correlation between DIAGNOdent and radiographic method is 0.578 (P < 0.001). Sensitivity is 0.68 % and specificity is 0.37 %. Conclusion: DIAGNOdent is more accurate than visual- tactile and radiographic methods of caries detection. It is a more sensitive system of occlusal caries detection.
Keywords: Caries detection, DIAGNOdent, specificity, sensitivity
|How to cite this article:|
Mehta PA, Vimala N, Mandke L. An In Vivo S tudy of Different Methods of Detection and Quantification of Occlusal Dental Caries in Permanent Molars. Indian J Oral Health Res 2015;1:15-9
|How to cite this URL:|
Mehta PA, Vimala N, Mandke L. An In Vivo S tudy of Different Methods of Detection and Quantification of Occlusal Dental Caries in Permanent Molars. Indian J Oral Health Res [serial online] 2015 [cited 2019 Mar 25];1:15-9. Available from: http://www.ijohr.org/text.asp?2015/1/1/15/158904
| Introduction|| |
Diagnosis and prevention are important factors to be considered to tackle dental caries, one of the major health problems of the human race. 
With the advent of minimal intervention dentistry, dental practitioners are searching for newer and more efficient techniques for caries detection. Several diagnostic techniques are available, such as, visual, visual-tactile, radiographic examination, a number of scoring systems has also been devised, using nominal or ordinal scales for recording and detecting its severity (Ekstrand et al., 2011).  Recent fluorescence-based methods, such as the laser fluorescence device, DIAGNOdent pen (KaVo, Biberach, Germany), and fluorescence camera (FC, Vista Proof, Durr Dental Germany) have been developed to detect and quantify carious lesions. The aim of introducing these devices was to harness the fluorescence of red light in detecting and quantifying the demineralized tissue. This aids in the detection of caries which may have been overlooked by the earlier conventional diagnostic methods. 
For a method to be considered innovative and reliable for caries diagnosis, its performance must be superior to other available methods. Thus, the comparison of the laser fluorescence device with conventional diagnostic methods, such as the radiographic method seems to be essential.  The clinical implication would be that the clinicians can rely on the laser fluorescence readings not only as a detection tool but also to track the growth of a carious lesion over time. 
Thus, the purpose of this study was to evaluate the efficiency of laser fluorescence DIAGNOdent measurements in comparison with conventional radiography for occlusal caries detection. It also assessed the correlation of depth and volume of decay removed by conventional methods of cavity preparation with DIAGNOdent readings.
| Subjects and Methods|| |
Sixty lesions were identified in recorded patients, to whom the aims and procedure of the study were explained, and informed consent was obtained. The procedure was conducted according to Helsinki Declaration 1975 and after the Institutional Review Board approved the protocol. The teeth selected were permanent maxillary or mandibular molars. Caries represented an active primary carious lesion involving occlusal surfaces (Class I). The teeth were free of any restoration, hypoplastic pits, and degree of fluorosis. Teeth with frank cavitation or symptoms of pulpitis were excluded.
Each tooth received a visual and tactile examination. Instruments used for visual examination were standard dental mouth mirror, probe, and the operatory chair side light. Exposure of a bitewing radiograph using intraoral films and DIAGNOdent (KaVo, Biberach, Germany) evaluation were done. All the examinations were done independently by two operators. One conducts the study and the other examiner have at least 10 years of experience.
After drying the tooth with compressed air, the area of the lesion was evaluated from the occlusal aspect using direct and reflected light.
Following the manufacturers' instruction, calibration of the DIAGNOdent was performed. Following the visual and tactile examination, initial DIAGNOdent reading (D1) was recorded. The peak value was referred to as the highest level scanned on the occlusal surface. The surface was then thoroughly washed and cleaned by ultrasonic scaling and air-dried. A second DIAGNOdent reading was taken (D2) [Figure 1]. If the peak values differed between the readings, the numbers were averaged to determine the surface DIAGNOdent reading.
The other operative and restorative procedures were performed by one investigator. A dual impression tray was used and with the help of putty impression material (Aquasil, Dentsply Caulk International), the bite of the patient was recorded. A conservative dissection of the carious lesion was done with a straight fissure diamond (SF41) point and a small round (BR45) bur (Mani Co.). The active carious lesion was removed using rotary instruments. Following the tooth preparation, the amount of tooth structure removed was quantified using composite resin. Composite resin (Amelogen Plus, Ultradent, South Jordan, UT, USA) was used to fill the prepared cavity and the patient was asked to bite again on the previously taken putty impression and excess flash was discarded. The composite was removed from the cavity and weighed on a sensitive digital weighing machine (Kerro BL 3003, Columbus, USA) [Figure 2]. The volume was calculated multiplying the measured density of composite (2.1317 g/mm 3 ) and weight of the recovered sample. The depth of the cavity was measured using a measuring periodontal probe (UNC15 measuring probe, Trudent Co., India). The cavity was restored with Amelogin Plus. Results and analysis are provided in [Table 1],[Table 2],[Table 3] and [Table 4] and ]Graph 1 [Additional file 1]],[Graph 2 [Additional file 2]],[Graph 3 [Additional file 3]].
|Figure 2: Composite scooped out of prepared cavity for measurement of the cavity volume|
Click here to view
| Discussion|| |
The pits and fissures on the occlusal surfaces of the teeth are most susceptible to caries. , The new laser-based device DIAGNOdent would allow early and more conservative treatment, hence ensuring maximum preservation of tooth structure. ,
DIAGNOdent (KaVo Dental Corporation, Lake Zurich, IL, USA), a 655nm diode laser, is one such device. It is a small, lightweight, battery-powered, chair side, handheld instrument that is intended to detect cavitated and non-cavitated occlusal and smooth surface caries. As the incident laser light is propagated into the site, two-way handpiece optics allows the unit to simultaneously quantify the reflected laser light energy. The carious lesion when exposed to this specific wavelength, it emits more intense fluorescence as compared to the sound tooth structure. This is mostly due to organic components and protein chromophores found in the affected tooth structure.
The readings correlate not only with the presence or absence of caries, it also correlates with the extent of caries within the tooth structure. The clinical implication would be that laser fluorescence readings were not only a detection tool but also tracked growth of a carious lesion over time. 
It is important to stress that dental plaque and remnants of material such as pastes, powders or gels may emit some fluorescence and lead to false positive results. Thus, professional cleaning and drying are advised to ensure the correct detection of caries lesions through fluorescence measurements. There is an increase in the LF readings if the prophylactic material is not removed completely (Diniz et al.). , In the current study, only ultrasonic scaling with water was opted. This was done to determine the influence of plaque on DIAGNOdent readings. Means of D1 and D2 of both examiners were taken, and D1 was found to be 33.49 and D2 was found to be 32.69. At a value of P = 0.05, there was no significant difference between the two. Different prophylactic methods (e.g. sodium bicarbonate jet and fluoridated, non-fluoridated prophylactic pastes) influenced the performance of DIAGNOdent as per their efficiency.  In the current study, prophylaxis using ultrasonics was employed, and no significant difference was observed in the two DIAGNOdent readings.
It was necessary to set a cut-off limit for identifying the occurrence of dentinal caries, based on DIAGNOdent readings. In vitro analyses suggest lower cut-off limits as compared to in vivo studies. Krause et al. suggested cut-off point of 36 but have insisted that clinical use of these cut-off values should not be done, these merely provide adjunctive information. ,[9 ] The cut-off point of 20 for in vitro analyses and cut-off points around 25 for in vivo analyses were recorded, and accordingly preventive or conservative treatment was indicated (Lussi et al.). , Khalife et al. set a cut-off point between 35 and 40 in his in vivo study. , The readings were distinguished according to their location within the tooth structure and cut-off limit for dentinal caries was placed to be above 30.
Once the DIAGNOdent readings were sorted, its performance was compared with conventional diagnostic methods (visual-tactile and bitewing radiography). Such a comparison helped to determine if the newer system was innovative and reliable. Spearman's rho test was performed to determine the correlation between DIAGNOdent and radiographic values was not significant (r = 0.200, P > 0.05). The second correlation was done between DIAGNOdent and visual-tactile values using Pearson's test. There was significant correlation between DIAGNOdent values and visual-tactile (r = 0.398, P > 0.05). Thus, we can conclude DIAGNOdent is most sensitive in caries detection followed by visual tactile and then bitewing radiography. In an in vitro study, diagnostic accuracy of DIAGNOdent was better than that of conventional radiograph. , While comparing the sensitivity of bitewing radiograph, visual-tactile and DIAGNOdent, Lussi et al. suggested that DIAGNOdent was more sensitive than visual-tactile and radiographs and a combination of visual examination and DIAGNOdent was recommended. ,
In the current study, the lesion depth was measured at the deepest portion of the cavity with the calibrated periodontal probe similar to the method opted by Khalife , and Krause. , The volume of the lesion depends on the mass and density of available tooth structure. Composite was used to fill the prepared cavity. Hence, the volume of the lesion was calculated using the weight of the composite used to restore the prepared cavity and the density of composite resin (2.1317 g/cm 3 ). 
Pearson correlation coefficients were calculated for DIAGNOdent measurements and lesion depth and volume. The DIAGNOdent readings correlated with clinical depth (r = 0.179). DIAGNOdent readings also correlated with volume (r = 0.139) and depth of the lesion. Thus, the correlation between volume and depth r = 0.587, (P < 0.001) was weakly significant. The reason for determining the correlation between DIAGNOdent readings, volume and depth was that depth and volume represented lesion extension in a multidimensional perspective. And this weak correlation showed that the intensity of fluorescence was not proportional to the size of caries lesion.
Sensitivity is the ability to recognize dentinal caries in teeth with/without cavitation and specificity is the correct recognition of sound tooth structure.  The sensitivity and the specificity in the current study were 0.68% and 0.35%, respectively. Thus, the sensitivity was higher, whereas specificity was low. Higher sensitivity determines the ability of DIAGNOdent to identify caries which may have been ignored in the visual examination. Low specificity results in the likelihood of false positive diagnosis and leads the clinician to intervene in a surface that may actually not be carious. According to Lussi et al., sensitivity was greater than 92% in comparison to the 31% of visual-tactile method. , Similarly, Anttonen et al. in his study derived a sensitivity 93% and specificity of 63%. , DIAGNOdent was a highly sensitive diagnostic system, as observed by the above-mentioned studies.
| Conclusion|| |
The accuracy and precision of the methods used in the current study have their own limitations but, with the help of two examiners for each reading, attempts have been made to minimize the errors. From the above analyses, it was suggested that DIAGNOdent was a sensitive diagnostic system in case of enamel caries, but accurate determination of deep dentinal caries was not possible.
| References|| |
Shafer, Hine, Levy. Shafer′s Textbook of Oral Pathology. Dental Caries. 5 th
ed., Ch. 9. Elsevier 2006. p. 567-628.
Ekstrand KR, Luna LE, Promisiero L, Cortes A, Cuevas S, Reyes JF, et al.
The reliability and accuracy of two methods for proximal caries detection and depth on directly visible proximal surfaces: An in vitro
study. Caries Res 2011;45:93-9.
Toraman Alkurt M, Peker I, Deniz Arisu H, Bala O, Altunkaynak B. In vivo
comparison of laser fluorescence measurements with conventional methods for occlusal caries detection. Lasers Med Sci 2008;23:307-12.
Ghaname ES, Ritter AV, Heymann HO, Vann WF Jr, Shugars DA, Bader JD. Correlation between laser fluorescence readings and volume of tooth preparation in incipient occlusal caries in vitro
. J Esthet Restor Dent 2010;22:31-9.
Roberson TM, Heymann H. Sturdevant′s Art and Science of Operative Dentistry. 5 th
ed., Ch. 3. Elsevier 2006. p. 68-109.
Lussi A. Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 1993;27:409-16.
Pinheiro IV, Medeiros MC, Ferreira MÂ, Lima KC. Use of laser fluorescence (DIAGNOdentTM) for in vivo
diagnosis of occlusal caries: A systematic review. J Appl Oral Sci 2004;12:177-81.
Diniz MB, Sciasci P, Rodrigues JA, Lussi A, Cordeiro RC. Influence of different professional prophylactic methods on fluorescence measurements for detection of occlusal caries. Caries Res 2011;45:264-8.
Krause F, Jepsen S, Braun A. Comparison of two laser fluorescence devices for the detection of occlusal caries in vivo
. Eur J Oral Sci 2007;115:252-6.
Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro
. Caries Res 1999;33:261-6.
Khalife MA, Boynton JR, Dennison JB, Yaman P, Hamilton JC. In vivo
evaluation of DIAGNOdent for the quantification of occlusal dental caries. Oper Dent 2009;34:136-41.
Shi XQ, Welander U, Angmar-Månsson B. Occlusal caries detection with KaVo DIAGNOdent and radiography: An in vitro
comparison. Caries Res 2000;34:151-8.
Anttonen V, Seppä L, Hausen H. Clinical study of the use of the laser fluorescence device DIAGNOdent for detection of occlusal caries in children. Caries Res 2003;37:17-23.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]