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Visual and Visuo-tactile Detection of Dental Caries

Department of Cariology, Restorative Sciences, and Endodontics, School of Dentistry, University of Michigan, Ann Arbor, MI 48109-1078, USA; ismailai{at}umich.edu

ABSTRACT

The objective of this review is to describe and discuss the content validity of a sample of caries detection criteria reported in the literature between January 1, 1966, and May 1, 2000. Using filters to locate randomized or controlled clinical trials on dental caries, fluorides, sealants, and "restorative" care, I identified a total of 171 documents from MEDLINE and the Cochrane Collaboration’s Oral Health Group (CC-OHG) special register. These articles met the following inclusion criteria: (1) Data had been collected from samples of patients or populations; and (2) dental caries was assessed clinically, and criteria were either published or described in the paper. From the selected articles, evidence tables were prepared describing each caries detection criterion. Analysis of the content validity of the criteria systems was based on evaluation of the disease process, exclusion of non-caries lesions, subjectivity, use of explorers, and drying of teeth prior to examination. This review included 29 unique criteria systems. Of those, 13 originated from the UK, 3 from the USA, 4 from Denmark, and others from the World Health Organization (WHO), Sweden, Switzerland, Norway, Netherlands, and Canada. Thirteen of the criteria systems either measured active and inactive early and cavitated lesions or defined separate criteria for smooth and occlusal tooth surfaces. Nine systems measured early as well as cavitated stages of the caries process, and 7 measured cavitation only. Eleven of the criteria systems provided explicit descriptions of the disease process measured or information on how to exclude non-caries from caries lesions. The use of explorers and drying and cleaning of teeth varied widely among the criteria. The majority of the newly developed criteria systems originated from Europe. In conclusion, this review of the content validity of the 29 criteria systems found substantial variability in disease processes measured, inclusion and exclusion criteria, and examination conditions.

Key Words: dental caries • diagnosis • detection • validity • criteria • measurement

INTRODUCTION

Since the late 19th century, it has been recognized that detection and classification of dental caries are not easy tasks. The problems of misdiagnosis of caries lesions and "hidden caries" are not new phenomena (Knapp, 1868; Anonymous, 1869). The following account, reported in 1869 by a dentist from Missouri, USA (Anonymous, 1869), clearly shows the dilemmas that faced and still face dentists. The author reported:

"A few months ago a young lady called on me for an examination of her teeth. I endeavored to make it thorough. Seventeen cavities were found and so reported to her. Her astonishment was very great for she had just come from one who had made an examination of her teeth, and reported four cavities. In a couple of weeks I had finished operations on her teeth and plugged eighteen cavities."

That dentist’s solution to the problem, however, has also been the subject of debate and study (and controversy) during at least the last 20 years. He reported:

"There are some cases of failure in diagnosis of dental decay, even when one intends to be very thorough. First and foremost is the large size of the excavator used for examination. The...excavator should be of the very smallest kind, and hatchet shaped..... This excavator should be made for diagnosis alone, and not for cutting enamel or dentine. The mouth mirror is another cause of defective diagnosis. One that magnifies two diameters should be used, and not the ordinary natural mirror. Saliva often obscures slight decay, especially in the fissures of the bicuspids."

Interestingly, the same dentist proclaimed that "once the teeth are separated, a good eye, experienced in this kind of diagnosis, and the mirror will usually be sufficient" (Anonymous, 1869). Visual detection of dental caries is not a new suggestion!

The concept that dental caries is a process rather than a categorical disease with "cavitated" and "not cavitated" states was also reported over 100 years ago. Magitot (1886) divided the diseases into three stages: caries of enamel, caries of dentin, and deep caries. Morsman, in 1888, stressed the importance of diagnosis as the "first step" in the management of dental caries—a goal that is yet to be universally achieved and supported.

In the early decades of the 20th century, the technical foundation of restorative dentistry was developed. In the USA, a pioneering and inquisitive dentist, dental teacher, and researcher, Dr. G.V. Black, developed a system for restoring decayed teeth. Dr. Black was surprisingly well aware of the limitation of the restorative approach to management of dental caries (Black, 1880, 1910, 1922, 1924). A recent discovery of a speech presented in 1910 confirmed that he did recognize the importance of caries in enamel. In a visionary lecture before the Philadelphia dental society, Dr. Black (1910) stated:

"Studies of [the] beginning caries should be continuously made, as it appears in the teeth of patients in the chair from day to day, with the view of becoming more familiar with its tendencies to spread on the surface of the enamel and the positions and directions of spreading.

"The whole subject of caries of the enamel is a most important one in its relation to everyday practice..."

The dilemma is that while several solutions have been proposed, we still do not have consistent and valid systems for clinical caries detection. Hence, this paper aims to evaluate the content validity of published visual and visuo-tactile caries detection systems. Content validation refers to the comprehensiveness of a system used to measure a phenomenon (Feinstein, 1987).

Content validity, in contrast to criterion validity (correlational or predictive validity), is not judged by statistical analyses (e.g., sensitivity and specificity or ROC analysis). While research of caries diagnostic methods has focused exclusively on criterion validity, the content validity of existing and proposed systems has not yet been thoroughly evaluated. The most recent comprehensive review of the sensitivity and specificity of clinical diagnostic systems (criterion validity), conducted by the Research Triangle Institute/University of North Carolina, investigated the evidence on the correlational validity of caries diagnostic systems (Bader, 2001). That review found that the visual and visuo-tactile methods have low sensitivity and moderate to high specificity in detecting cavitated lesions. The correlational validity in detecting enamel caries on occlusal surfaces was lower than the desired 80% (Bader, 2001). The gold standard in the studies included in that review was histological examination of extracted teeth.

The objective of this paper is to review the content validity of selected caries criteria system based on the perspective that dental caries is:

1. a disease process that is caused by an imbalance, in favor of demineralization, in the demineralization-remineralization cycle in the oral cavity;
   
2. a disease process that may manifest itself first by minor changes in the enamel structure that may lead, if it continues, to the destruction of tooth structure and cavitation; and
   
3. a disease process that may reverse or stop, resulting in complete healing of the demineralized dental tissue or in preservation of minutely damaged tissue.
   

MATERIALS & METHODS

This review is not a systematic search for all evidence ever published on visual and visuo-tactile methods of caries detection. Rather, the review focuses on the content validity of a sample of caries detection criteria reported in literature published in MEDLINE and the Cochrane Collaboration’s Oral Health Group (CC-OHG) special register of randomized or controlled clinical trials. Papers included in this review met the following inclusion criteria: (1) Data were collected from samples of patients or populations; and (2) dental caries assessed clinically in the study and criteria were either published or described in the paper. The review focused on papers published in English. Due to time constraints, only the author read, selected, and abstracted the relevant studies.

To sample relevant studies, in May, 2001, I conducted the following searches of the two databases. In the first search, the following filters were used to identify relevant documents published between January 1, 1966, and May 1, 2001, in MEDLINE:

exp Tooth demineralization/ or demineralization.mp. or caries.mp. or caires.mp. or craies.mp. or careis.mp. or "tooth cavit:".mp. or "teeth cavit:".mp.or "dental cavit:".mp. or "tooth decay:".mp. or "teeth decay:".mp. or "active decay".mp. or "white spots".mp. or "enamel decay".mp. or "rampant decay".mp. or carious.mp. or "non-cavitated lesion:".mp. or "noncavitated lesion:".mp. or "precavitat:".mp. or Tooth remineralization/ or "dental fissure:".mp. or "tooth fissure:".mp. or "teeth fissure:".mp. or "oral fissure:".mp. or "cariesfree".mp. or "caries-free".mp. or "cariogenic:".mp. or Cariogenic agents/ or "filled teeth".mp. or "filled tooth".mp. or dft.mp. or dfs.mp. or dmf:.mp.

This search found 37,397 citations.

The search also located citations classified under "sensitivity and specificity" (explode "sensitivity and specificity") or those classified under diagnostic errors (explode diagnostic errors) or predictive value in the title (predictive value$.tw.). This search resulted in 154,996 citations. Finally, the terms "diagnosis, differential" and "diagnostic criteria" ("diagnostic criteria".mp.) were searched. A total of 222,496 citations was classified as such or had these words. When these last two searches were combined (with "or"), 366,519 citations were identified. This group of citations was cross-matched with the "caries" filter (the first 37,397 citations), resulting in 1022 citations. Of those, 997 were classified as "human" studies. Based upon a review of the titles of the 977 citations, 136 articles were selected for photocopying because the titles or abstracts of these articles indicated that the studies may include criteria for the detection of dental caries.

In the second search, the CC-OHG was searched for articles or abstracts with the following key words: "caries and prevent" or "fluoride*" or "sealant*" or "xylitol*" or "chlorhexidine" or "prevent". A total of 3486 citations was located. A review of the titles of these citations identified 123 relevant articles. After reading the abstracts of the 123 articles, I photocopied 35 full reports.

Additionally, other key reviews, documents describing diagnostic criteria used around the world, and papers published in the 19th century or early part of the 20th century were included in this review. The search methods used to locate these articles have been described in a previous paper (Ismail et al., 2001).

Hence, 171 articles were photocopied, and the articles or abstracts (for those documents presented only as abstracts) were read (a copy of the citations of the 171 documents can be obtained from the author). From these articles, 29 were selected for inclusion because they include detailed description of unique criteria for caries detection. From these included articles, one evidence table was prepared. The content validity of each criteria system described in Table 1 was evaluated according to the following characteristics and scoring system:

1. Disease process
   
   1. Measures only one stage of an active disease process
      
   2. Measures at least two stages of an active disease process
      
   3. Measures active and inactive stages of the disease process or defines separate criteria for measuring the stages of the active disease processes on different tooth surfaces
      
   
   
2. Exclusion of non-caries lesions
   
   1. Inclusion of signs not related to caries or no differentiation between dental caries and other changes caused by staining or developmental enamel defects
      
   2. Focuses only on signs related to the caries process and differentiates between caries and staining or developmental enamel defects
      
   
   
3. Subjectivity
   
   1. Criteria contain vague terms that may increase examiner subjectivity.
      
   2. Criteria clearly define the terms used to measure the caries process.
      
   
   

Additionally, given concern about the use of sharp explorers (Ismail et al., 2001), the criteria were scored for use of an explorer (0 = Yes, 1 = No exploring or gentle exploring only, or explorer was used to clean the teeth) and drying or cleaning of teeth (0 = No, 1 = Yes). Based on this evaluation system, the possible score ranged between a minimum of 3 and a maximum of 9.

RESULTS

The criteria systems included in this review are described in Table 1. Thirteen of the 29 criteria systems were published in the UK (England and Scotland), 3 were from the USA, 2 from the Netherlands, 2 from the World Health Organization, 4 from Denmark, 2 from Sweden, 1 from Norway, 1 from Switzerland, and 1 from Canada. The criteria varied in definitions of dental caries, content, details on use of explorers, drying of teeth, and other examination conditions.

The evaluation of the criteria systems, presented in Table 2, shows that 13 of the criteria systems measured both active and inactive stages of the disease process or defined separate criteria for measuring the stages of the active disease process on different tooth surfaces; 9 measured only the carious process at the cavitation stage, and 7 measured non-cavitated as well as cavitated active caries lesions. Only 7 of the 29 criteria systems differentiated between caries and non-caries lesions (e.g., fluorosis or developmental defects). Subjectivity rating found that 11 of the criteria systems defined the terms used to measure the caries process in ways that may reduce subjectivity of the examiners. Eleven of the 29 criteria systems relied on either visual inspection or the use of "gentle exploring" or dull-ended explorer or periodontal probes for detection of caries. Fourteen out of the 29 criteria systems required examination of dried teeth. Overall, the content validity scores of the criteria systems developed during the preceding 5 years were higher than those of the other criteria systems described in Table 1. It is also interesting to note that most of the criteria systems published during the 1990s were developed in Europe.

View this table: [in this window] [in a new window]   Table 2. Content Validity of the Criteria Systems Described in Table 1

During the last 100 years, the dental profession has made significant progress in reducing the burden of dental caries in economically developed countries. The scientific and technological advances during the 20th century have profoundly revolutionized how dentistry is practiced and how dental diseases are managed. However, while dental caries still represents the major chronic disease afflicting humans, the application of understanding of the dynamic process of caries development has not yet been widely incorporated into dental practice and research. Criteria systems used for the clinical detection of caries lesions have not yet been scrutinized according to standard protocols that are in use in social and clinical sciences. Content validity of caries detection criteria has not yet been investigated. The importance of the "first step" (i.e., detection and diagnosis) in caries management has not been widely recognized, and dentists are usually underpaid for this activity.

This review focused on the content validation of caries detection systems. As stated before in this paper, calls to study and detect early caries lesions were made in the 19th century and by G.V. Black in 1910. Over the last 20 years, there have been many attempts to expand the methods used to detect and diagnose the presence of caries lesions. However, the narrow focus on "drilling and filling" and the misconception that early caries lesions cannot be reliably measured may have led to the development of criteria systems that have skewed the understanding of dental caries epidemiology, prevention, and management.

In a previous review, I discussed the reasons why early non-cavitated lesions should be included in new diagnostic systems of dental caries (Ismail, 1997). First, there is evidence—even from studies published in the 1940s, 1970s, 1980s, and 1990s—that non-cavitated caries lesions are more prevalent than cavitated lesions in economically developed countries (Ismail, 1997; Amarante et al., 1998). Second, non-cavitated caries lesions are more likely to be restored compared with sound tooth surfaces (Ismail and Gagnon, 1995; Ismail et al., 1997). Third, non-cavitated lesions, especially on smooth tooth surfaces in young children, may serve as indicators of caries activity (Domoto et al., 1994; Grindefjord et al., 1995; Imfeld et al., 1995). Fourth, inclusion of non-cavitated lesions may provide a better understanding of the mechanism of action of fluoride, sealants, and other preventive agents (Ismail, 1997). Fifth, inclusion of early signs of the caries process improves the precision of clinical trials of preventive agents (Howat et al., 1981).

Analysis of the data presented in Tables 1 and 2 shows that there is a gulf between researchers in Europe and those in the USA. European researchers, as early as the 1960s, have included early signs of dental caries in their criteria systems. By contrast, criteria developed in the USA have focused on measuring the cavitated stage of caries or the stage when an explorer sticks in teeth with visual signs of caries demineralization. The sensibility of the European criteria systems favors the disease process, while the sensibility of the USA systems favors reliability and comparability. The guiding principle for any new caries diagnostic system in the 21st century should be its contemporary content validity, provided that it is accompanied by a detailed protocol for calibration of examiners. Research studies should be conducted to identify scientifically based protocols that can lead to achieving a high degree of reliability among examiners. Any newly proposed protocol should define the tools, methods of use, and length and frequency of training of examiners in studies of dental caries.

This review shows the lack of consistency regarding the use of explorers. The first account for the need of a sharp instrument to detect caries lesions was reported by a dentist in the USA who attributed wide variation in diagnosis to the "...large size of the excavator used for examination. The...excavator should be of the very smallest kind, and hatchet shaped..... This excavator should be made for diagnosis alone and not for cutting enamel or dentine" (Anonymous, 1869). During the 20th century, the use of the term "explorer catch" became part of the tradition of caries diagnosis (Sognnaes, 1940). The 2001 NIH Consensus Development Conference on Dental Caries Diagnosis and Management Throughout Life concluded that "...the use of sharp explorers in the detection of primary occlusal caries appears to add little diagnostic information to other modalities and may be detrimental" (http://odp.od.nih.gov/consensus/cons/115/115_statement.htm#1).

Similarly, there seems to be a variation among the criteria systems described in Table 1 regarding whether teeth should be cleaned or dried before an examination. Some criteria stipulated that teeth should be cleaned with a toothbrush or professionally, while others recommended cleaning by means of an explorer. The majority of the criteria listed in Table 1 did not report on whether the teeth were cleaned or dried before examination. While no data are available to compare the accuracy and reliability of examiners of clean vs. unclean or dry vs. wet teeth, the detection of early signs of caries cannot be achieved unless the teeth are clean and dry.

In conclusion, analysis of the data summarized in this review paper underscores the need to define one criteria system for visual and visuo-tactile detection of dental caries that has content validity based upon current scientific evidence and the consensus of experts in the fields of cariology and restorative sciences. There is also a need to initiate a research program to test key constructs in caries detection and develop examination protocols that enable researchers to achieve a high degree of reliability. In achieving these goals, the workshop should address the following questions:

1. What stage of the caries process should be measured in clinical trials?
   
2. What are the definitions for each stage of the caries process?
   
3. What is the best approach, in terms of objectivity and consistency, which should be used to detect each stage of the caries process for different tooth surfaces?
   
4. What is the consensus on examiners’ training protocols that can provide the highest degree of examiner reliability?
   

All answers to these questions should be based on scientific evidence. If evidence does not exist, the participants in this conference should define the research questions that must be answered to advance the field of caries detection, diagnosis, and management.

FOOTNOTES

Presented at the International Consensus Workshop on Caries Clinical Trials, Glasgow, Scotland, January 7–10, 2002

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Journal of Dental Research, Vol. 83, No. suppl 1, C56-C66 (2004)
DOI: 10.1177/154405910408301S12


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