Near infrared transillumination compared with radiography to detect andmonitor proximal caries: A clinical retrospective study
Marwa Abdelaziza,⁎, Ivo Krejcia, Thomas Pernegerb, Albert Feilzerc, Lydia Vazquezd
a Division of Cariology and Endodontology, University Clinics of Dental Medicine (CUMD), University of Geneva, rue Michel-Servet 1, 1211, Geneva 4, SwitzerlandbDivision of Clinical Epidemiology, Quality of Care Service, University Hospitals of Geneva, Switzerlandc Department of Dental Materials Science, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Gustav Mahlerlaan3004, 1081 LA, Amsterdam, Netherlandsd Division of Gerodontology and Removable Prosthodontics, Dentomaxillofacial Radiology, University Clinics of Dental Medicine (CUMD), University of Geneva, rueMichel-Servet 1, 1211, Geneva 4, Switzerland
Objective: To compare near infrared transillumination device, DIAGNOcam (DC) and bitewing radiography (BW)for the detection of proximal caries.Materials and methods: This retrospective analysis of DC and BW images of 18 students in dental medicine whohad consented to the anonymous use of their dental record. The data included BW and DC images performed fora check-up in 2013, and corresponding follow-up images performed in 2015. Two observers rated 376 proximalsurfaces on a 4-level dentin lesion scale and reached a unanimous rating for each surface. Calculated measures ofagreement for each assessment method over time provided the reproducibility of the information obtained byeach method.Results: Agreement between 2013 and 2015 within each method was excellent (intraclass correlation coefficient,BW: 0.86, DC: 0.90). Agreement between DC and BW was similar for dentin lesion detection, but was low forenamel caries detection; DC detected more enamel caries than BW. Agreement between DC and BW was modest(0.33 in 2013 and 0.36 in 2015), chiefly because DC identified more enamel caries.Conclusion: This study shows that DC is as reliable as BW to detect proximal dentin lesions. DC detects proximalenamel lesions at an earlier stage than BW. DC enables clinicians to differentiate lesions limited to the enamelfrom lesions that have reached the enamel dentin junction. Regular monitoring with DC should help provideindividualized preventive measures and early non-invasive caries management.Clinical significance: The early detection of enamel lesions with near infrared transillumination can help clin-icians undertake early non invasive treatments to prevent or slow down the progression of initial proximallesions.
1. Introduction
In recent decades, improvement in dental hygiene and regular pa-tient follow-up have led to important changes in caries presentation,with more concealed lesions and “hidden” caries, prompting the need todetect proximal carious lesions at earlier stages. Clinical examination,intraoral radiographs and temporary teeth separation can detect prox-imal dental caries [1–6]. X-ray examination, the most common methodfor caries detection [7], has advantages and limitations. Wenzel et al.[8] have suggested that 30–40% of enamel has to be demineralizedbefore an enamel lesion is visible by Rx examination and Yang andDutra [9] have stated that as much as 40–60% of tooth decalcification is
required for the lesion to be detected on a radiograph. Bitewing (BW) X-rays seem more efficient at detecting caries that have reached dentinthan at early diagnosis of initial enamel lesions [10]. Moreover, BWradiographs cannot determine whether a detected lesion is active and/or cavitated [8].
Increased emphasis on using less ionizing radiation [11–13] andminimally invasive treatment of early caries has prompted research intothe potential of light-based caries detection methods.[14–16]
Transillumination is one of the oldest alternative caries detectionmethods besides radiographs.[17,18] Enamel’s optical properties aremodified by very slight increases in enamel porosity, resulting in in-creased scattering when light passes through enamel.[7,14,17] Visible
https://doi.org/10.1016/j.jdent.2017.12.008Received 31 August 2017; Received in revised form 12 December 2017; Accepted 15 December 2017
⁎ Corresponding author at: Division of Cariology and Endodontology, University of Geneva, rue Michel-Servet 1, 1211 Geneva 4, Switzerland.E-mail addresses: [email protected] (M. Abdelaziz), [email protected] (I. Krejci), [email protected] (T. Perneger), [email protected] (A. Feilzer),
light, used for fiber optic transillumination (FOTI), has evolved to di-gital fiber optic transillumination (DIFOTI) to allow digital recordingand monitoring of early enamel lesions. Both techniques have beenextensively described and compared with radiography and clinical ex-amination. [11,19–22]
In the last decade, near infrared (NIR) light has been developed forocclusal and proximal caries.[14,23–25] Different NIR light wave-lengths have been tested. [26,27] The DIAGNOcam (DC) device (KaVo,Biberach Germany) using 780 nm NIR transillumination technologyrecently entered the marketplace. This intraoral camera has two flexibleextensions: one NIR light that transilluminates the tooth through theperiodontal tissues, and a camera that captures the images from theocclusal surface of the examined tooth. This device, by reducing theneed for BW radiography offers a safe alternative to ionizing radio-graphy to detect caries in young patients and pregnant women.[16,28–30] Furthermore, a recent clinical study found that, whencompared with BW radiographs, DC can detect more proximal enamellesions. [31] DC also provides information on the exact location of thelesion in the bucco-lingual dimension, showing the extent of the lesionin enamel until it reaches the enamel dentin junction, but DC cannotprecisely determine the depth of the lesion in dentin. DC is thus moresuited for enamel caries detection and monitoring, allowing earlyminimally invasive intervention if a lesion progresses towards the en-amel-dentin junction.
The aim of this study was to assess the reproducibility of proximalcaries detection using NIR transillumination device and BW radio-graphy in a population at low risk for caries, and to assess the agree-ment between the two methods. We assumed that the progression rateof early lesions would be slow over a 2 year timeframe, thus providingreliable information on using NIR transillumination for caries detectionand monitoring over time.
2. Methodology
2.1. Materials
BW radiographs were taken by different practitioners in 2013 and2015, exposure parameters were set at 70 kV, 7mA, 0.16–0.20 s.Various digital imaging plates size 2 and CS 7600 scanning system(Carestream Health, Rochester, NY, USA) were used. For NIR tran-sillumination images, DIAGNOcam 2170U (Kavo, Biberach, Germany)was used with the KaVo integrated desktop (KID) software V 2.4.2 withthe replaceable tip for adults.
2.2. Data collection
After obtaining ethical approval, retrospective analyses of the di-gital dental records of final year undergraduate dental students(n=18) were carried-out. The students had previously consented tothe anonymous use of their dental record including BW and DC images.Images were recorded between 2013 and 2015 and collected in 2016.Eighteen digital records were screened for BW radiography (approxi-mately 24 months’ interval between first and second X-ray examina-tions), and 6 patients were excluded due to incomplete or missing in-formation. Data from 12 patients (ages 22 to 32) with BW and DCimages performed for a check-up in 2013, and corresponding BW andDC follow-up images performed in 2015, were analysed. For each pa-tient, a PowerPoint file with 4 slides was made (separating the 4quadrants). One slide, missing the DC images from 2015, was excluded.The images were a priori anonymized, the 47 slides were mixed, ran-domly reorganized, then numbered, conferring complete irreversibleanonymity. Each of the final 47 slides with the BW and DC for 2013 and2015 were then re-distributed on 5 slides for separate analysis of thefollowing data: BW 2013, BW 2015, DC 2013, DC 2015, and full data.The final data set included 188 teeth (376 proximal surfaces). Eachsurface was assessed by BW and DC in 2013 and again in 2015.
2.3. Data interpretation
Two trained dentists, with extensive experience in radiology andNIR transillumination images, were calibrated to rate the DC and BWimages. BW and DC images were analysed separately, and each inter-preted proximal surface was given a letter score. The two observersagreed on one score for each image, which was recorded in an Excel filefor the final statistical analysis. The two observers evaluated eachimage for each diagnostic method and year. Table 1 shows the scoringsystem and examples of BW and DC images for each score.
2.4. Statistical analysis
The descriptive data analysis was obtained. The correlation betweenboth diagnostic methods was tested using the Kappa statistic, for di-chotomous ratings, and intra-class correlation coefficient (ICC) (two-way, mixed as the methods were considered fixed factors but the toothsurfaces were random factors, and absolute level of agreement) for the4-level scale. This method accounts for the severity of disagreement,represented by the number of categories for each discrepancy. All thedata were analysed with SPSS software version 17 (Illinois, Chicago,USA).
3. Results
Data collected from retrospectively-analysed dental records of 12patients yielded 376 proximal surfaces acquired with 2 distinct caries
Table 1The scoring system used in the present study.
Code Description BW DC
S Sound surface
E Enamel lesion
J Lesion reached Enamel-dentinJunction
D Dentin lesion
F Filled surface
M Missing surface or image
N Non interpretable
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detection methods; BW and DC with an average 2-year interval.Each surface had 4 different readings (DC 2013, DC 2015, BW 2013,
BW 2015). At each reading the surface was scored with one of the codesdescribed in Table 1. Table 2 shows, for all proximal surfaces, thedistribution frequency for each year by each method. For each methodand each year, Missing, Filled and Non-interpretable surfaces wereexcluded for the statistical analysis. Consequently, 192 surfaces wereevaluable by both methods in 2013, 193 in 2015, and 207 surfaces wereevaluable by BW in both years, 208 were evaluable by DC in both years,and 139 were evaluable for all 4 assessments. After the exclusion ofMissing, Filled and Non-interpretable surfaces, a second frequency tablewas obtained for the 139 surfaces with all 4 ratings available (Table 3).
The distal surface of the second molars was the least visible in bothBW and DC images, followed by the mesial surface on the first pre-molars (Table 4).
Agreement between 2013 and 2015 within each method was
excellent (ICC, BW: 0.86, DC: 0.90) (Table 5). Agreement between DCand BW was similar for dentin lesion detection, but was low for enamelcaries detection; DC detected more enamel caries than BW. Agreementbetween DC and BW was modest (0.33 in 2013 and 0.36 in 2015),chiefly because DC identified more enamel caries (Table 5). Similarresults were observed when Kappa statistics tested the correlation be-tween the methods after the scores were dichotomized (Table 5).
4. Discussion
On BWs, the percentage of healthy surfaces was 45.5% in 2013 and49% in 2015. On DC, by comparison, the percentage of healthy surfaceswas lower (16.2% in 2013 and 17.8% in 2015). The increased per-centage of healthy surfaces may be due to examiner error, but in othercases, the surfaces were not visible in 2013 due to overlap or film po-sition for example and the BW incidence in 2015 enabled its inter-pretation.
Enamel carious lesions were detected in 18.4% and 16.8% of BWradiographs in 2013 and 2015, compared with 32% and 26% on DC in2013 and 2015 respectively. This finding suggests that BW radiographsunder-estimate enamel lesions, which correlates with observations thatat least 30% of enamel demineralization is necessary for detection byRx examination [8].
The percentage of lesions reaching the enamel dentin junction was3.7% and 3.5% on BWs, and 16.8%, 17.8% on DC, in 2013 and 2015respectively. Unlike DC images, BW X-rays appear to underestimatethat the carious lesion has reached the enamel dentin junction. Theseresults suggest that DC is a reliable tool for the early detection of en-amel caries and enamel dentin junction carious lesions. This also con-firms the findings of the recent study demonstrating that diagnosticperformance of NIR imaging is better than radiography using histologyand PLM/TMR as the gold standard [32].
The detection frequency of dentin lesions was negligible on DCimages. Lesion depth is less likely to be visualized in dentin possiblybecause of insufficient contrast between carious and sound dentinewhen using transillumination with NIR light [16]. This observation iscorroborated by the percentage of lesions reaching enamel dentinjunctions with both methods. Compared with BW radiography, DC re-vealed approximately 4 times more lesions reaching the enamel dentinjunction which explains the low Kappa between the two methods(K= 0.21 in 2013, K= 0.20 in 2015). The ICC was modest in 2013(ICC= 0.33) and again in 2015 (ICC= 0.36) when DC was comparedwith BW. ICC, calculated for each method over time, showed highagreement (ICC=0,86) for BW and even higher for DC (ICC=0,90),indicating an excellent agreement for each method within itself overthe period of 2 years.
Similar findings were reported in a study [31] evaluating theagreement between DC and clinical and radiographic examinations todetect caries lesions. These authors reported that DC identified a highernumber of proximal lesions than did BW and, when looking at lesionsreaching dentine, the two methods identified the same number of carieslesions (Kappa=1), but DC recorded more proximal lesions in theenamel (Kappa=0.24).
The prevalence of caries in the analysed images was approximately
Table 2Frequency (%) distributions for all proximal surfaces (376 in total) including missing, noninterpretable and filled surfaces.
Table 5within-method and between-method reliability of BW and DC in assessments of dental surfaces.
Surfaces with all 4 assessments (N=139)
N Four-level grading ICC Dichotomous assessment, sound vs rest, kappastatistic
Dichotomous assessment, sound or enamel lesion vs rest, kappastatistic
BW versus DC in 2013 192 0.33 0.21 0.33BW versus DC in 2015 193 0.36 0.2 0.3BW, 2013 vs 2015 207 0.86 0.91 0.78DC, 2013 vs 2015 208 0.9 0.9 0.89
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43% on BW and 78% on DC. More data were lacking on DC (15.2 and21.8%) compared with BW (8.2 and 7.7%) in 2013 and 2015 respec-tively. The percentage of non-interpretable surfaces was similar for bothdiagnostic methods, namely 19.9%–17.6% on BW and 17.6%–13.3% onDC. Non-interpretable surfaces (mostly overlapping surfaces on BWradiographs) have been reported in the literature to range from 11 to65% varying with radiographic technique.[33–35] Non-interpretableDC images were caused by excess light or the lack of it depending on thehandling of the device or the position of the tooth itself. Filled surfacesincreased from 2013 to 2015, under both methods, because dentine
lesions detected in 2013 were treated resulting with fewer dentine le-sions observed on X-rays in 2015.
On DC images, distal surfaces on second molars and mesial surfaceson first premolars were the least well visualized surfaces and were morelikely to be coded either missing or non-interpretable. Two factors mayexplain the missing data. The second upper molar, often tilted in abucco-distal direction can be difficult to reach with the tip of thecamera. For the first premolar, the tip of the adjacent canine impededproper positioning of the camera. At other times, even under sufficientlight distribution, the quality of the enamel did not allow interpretable
Fig. 1. Examples of images scored non-interpretabledue to opaque enamel quality.
Fig. 2. DC images (a, c) of a lesion on the distalsurface of the lower right first premolar progressedfrom enamel to enamel dentin junction; the re-spective BW images (b, d) showed no changes after 2years.
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images; teeth with opaque enamel, hypomineralised or highly fluori-dated enamel surfaces made detection of proximal lesions impossible(Fig. 1).
We assumed that the progression rate of enamel carious lesions wasslow in the studied population. Although a histological validation wasnot carried out, we considered that the detection of the same enamellesion on DC images in 2013 and 2015 confirmed the presence of alesion, or in some cases its progression (Fig. 2). Nevertheless, non-carious enamel defects such as hypo-mineralisations or fluorosis of theenamel might have been mistakenly scored as carious lesion in 2013and 2015 on DC images (false positive). As any other caries detectiontool, the use of DIAGNOcam should be combined with a meticulousclinical examination to avoid that kind of error.
We only reported ICC and kappa because accurate sensitivity/spe-cificity values cannot be obtained by comparing new methods, such asDC, with older imperfect gold standards such as intraoral radiographyand clinical examination [36], which explains why some authors havereported low sensitivity of caries detection by transillumination whencompared with radiographs [16,28,30,37], whereas others have foundtransillumination to be highly sensitive [32,38].
Because transillumination may be sensitive for early caries detec-tion [20,39], the technology poses a danger of overtreatment if treat-ment decisions are based on old managmentt concepts. If dentistsfollow treatment strategies they applied under radiography, i.e. op-erative treatment when the lesion reaches the enamel dentin junction[40,41], overtreatment will result.
Dentists should seek the opportunities for continuing education onminimally invasive caries detection and management for a better un-derstanding of the paradigm shift.
DC is a new tool that may require a longer learning curve. In thepresent study, different operators might have influenced the quality ofthe acquired images. One limitation of this study may be the number ofimages missing on DC, which a prospective study with careful datacollection can resolve. DC software can video record the examination ofthe dental arch to help avoid missing data in future studies. A strongfeature in this study is the monitoring of the same enamel carious le-sions over time, with the second reading (2015) validating the (2013)readings.
5. Conclusions
NIR transillumination holds promise in daily clinical practice as aprimary screening for the early detection of proximal caries. If dentinlesions are detected on DC images, BW radiographs would then beobtained to determine the depth of the carious lesion. DC may reduce oreven eliminate the need for X-ray monitoring. Young patients with fewor no restorations are likely beneficiaries of regular DC monitoring,which drastically reduces their exposure to non-justified ionizing ra-diation. Regular monitoring with DC should help provide in-dividualized preventive measures and early non-invasive caries man-agement.
Conflicts of interest
None
Acknowledgments
Our gratitude to the students who participated in the study, espe-cially Sharmila Ibrahim and Ilies Attia who helped organize and collectthe data.
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