Oral Sciences n3


Original Article Braz J Oral Sci.
January  |  March 2015 - Volume 14, Number 1

Different methods of dental caries diagnosis in
an epidemiological setting

Renato Pereira da Silva1, Andréa Videira Assaf2, Gláucia Maria Bovi Ambrosano3, Fábio Luiz Mialhe4,
Marcelo de Castro Meneghim5, Antonio Carlos Pereira5

1 Universidade Federal de Viçosa – UFV, Department of Nutrition and Health, Area of Public Health, Viçosa, MG, Brazil.
2 Universidade Federal Fluminense – UFF, Dental School, Department of Specific Formation, Nova Friburgo, RJ, Brazil

3 Universidade Estadual de Campinas – UNICAMP, Piracicaba Dental School, Department of Community and Preventive Dentistry, Area of Biostatistics,
Piracicaba, SP, Brazil.

4 Universidade Estadual de Campinas – UNICAMP, Piracicaba Dental School, Department of Community and Preventive Dentistry, Area of Health Education,
Piracicaba, SP, Brazil.

5 Universidade Estadual de Campinas – UNICAMP, Piracicaba Dental School, Department of Community and Preventive Dentistry, Area of Preventive
Dentistry and Public Health, Piracicaba, SP, Brazil.

Correspondence to:
Renato Pereira da Silva

Universidade Federal de Viçosa Departamento
de Nutrição e Saúde

Av. Peter Henry Rolfs, s/n
36570-900, Viçosa, MG, Brazil

Phone: +55 31 3899 2545 Fax: +55 31 38992108
E-mail: renatop.silva@ufv.br

Abstract

Aim: To evaluate the performance of dental caries detection when adjunct methods are associated
and their applicability in epidemiological survey of dental caries, at D3 (cavitated carious lesions
at dentin layer) and D1+D3 (non cavitated and cavitated carious lesions at enamel/dentin layer)
diagnostic thresholds. Methods: A total of 2189 posterior teeth from 165 12-year-old schoolchildren
underwent visual examination without (CL1) and with artificial lighting (CL2), radiographic bitewing
(BW), fiber-optic transillumination/FOTI (FT), DIAGNOdentTM (DD) and associations of these methods.
Reproducibility was calculated by Kappa statistics and validity was calculated by sensitivity, specificity
and accuracy tests. ANOVA (Scott-Knott test) was performed in order to compare the average
values of DMF-S obtained by the diagnostic methods. Results: The CL2FTDDBW (D3) and
CL2BW (D1+D3) exams presented the highest values for accuracy at epidemiological setting.
The DMF-S index obtained for those exams was statistically different at D3 and D1+D3 thresholds.
Conclusions: The association of adjunct methods increased the validity of dental caries
examination in an epidemiological setting. However, the potential of CL2BW (traditional caries
detection methods) or visual exam performed under a more refined diagnostic criteria must be
considered in dental caries epidemiological surveys.

Keywords: dental caries; diagnosis, oral; epidemiology.

Introduction

With the purpose of improving the quality of dental caries diagnosis, the
association of adjunct diagnostic methods with the conventional visual examination
has been proposed, and it has been successful to some extent in studies conducted
under epidemiological conditions and adopting more sensitive diagnostic
thresholds of dental caries1.

There has been underestimation of caries prevalence in surveys verified in
groups of 12-year-old or in older children, when examined by the visual method2.
In addition, the visual method of examination and WHO criteria have not been
sufficient to properly identify the whole spectrum of the dental caries and

Received for publication: January 23, 2015
Accepted: March 23, 2015

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subsequent treatment needs in posterior teeth3.
According to the systematic review of Bader et al.4, the

strength of scientific evidence for adjunct methods of caries
detection is poor. However, some studies have presented
satisfactory results with the use of auxiliary resources (often
low-tech and low-cost actions that improve visual
examination as previous tooth brushing and drying or
artificial lighting, for example) and adjunct methods (often
high-tech devices as fiber-optic transillumination/FOTI,
Diagnodent™, Electronic Caries Monitor/ECM or digital
radiography, for example) for the detection of caries5-6.

Apart from adding new diagnostic adjuncts with the
aim of designing a more reliable nosological chart, more
sensitive diagnostic thresholds recording the presence of
initial carious lesions and/or activity have been proposed
with some success in the literature1,3,7.

Nowadays, epidemiological studies have shown that
initial caries lesions in posterior teeth are very common. The
detection of the whole spectrum of dental caries is an
important tool for oral health services planning and
evaluation. The aim of this study was to evaluate the
performance of dental caries detection when adjunct methods

are associated and their feasibility in epidemiological survey
of dental caries, at D3 (cavitated carious lesions at dentin
layer) and D1+D3 (non cavitated and cavitated carious
lesions at enamel/dentin layer) diagnostic thresholds.

Materials and methods

The study was conducted in accordance with resolutions
196/96 of National Health Council of Brazilian Ministry of
Health, and resolution CFO 179/93 of the Dental Professional
Code of Ethics, started after its approval by Research Ethics
Committee Protocol No. 082/2006.

Dental examinations
The epidemiological data were gathered by clinical

visual examination without (CL1) or with artificial lighting
(CL2), radiographic bitewing examination (BW), FOTI (FT),
laser fluorescence examination (DIAGNOdentTM/ DD) and their
respective associations: CL2FT, CL2DD, CL2BW, CL2FTDD,
CL2FTBW, CL2DDBW and CL2FTDDBW. The codes and
criteria1,7-10 are shown in Table 1.

* Adapted from Assaf et al.1, Fyffe et al.7 and WHO8
** Adapted from Hintze et al.9
***Criteria and codes from Zanin et al.10

Table 1.Table 1.Table 1.Table 1.Table 1. Diagnostic criteria and codes for dental examinations

Different methods of dental caries diagnosis in an epidemiological setting

Braz J Oral Sci. 14(1):78-83



8080808080

The CL1 and CL2 exams were carried out by using dental
mirror, WHO probe, previous tooth brushing and air-drying
for 5 s per each dental surface. The D3 diagnostic criterion,
which considers cavitated carious lesions in dentine, and the
D1+D3 diagnostic criterion, which considers cavitated and
non-cavitated carious lesions in enamel and/or dentine were
adopted. Bitewings were taken of the schoolchildren’s posterior
teeth in a separate session, by an examiner experienced in
this type of dental examination. The radiographical film Agfa
Dentus M2 Comfort - M2-58, E/F-speed, and a Spectro 70X
X-ray device (Dabi-Atlante, Ribeirão Preto, SP, Brazil) of 70
Kvp, 8 MA and 0.4 s exposure time were used. Radiograph
processing was standardized and performed in an automatic
processor. The radiographs were analyzed in a viewing box
(VH, Araraquara, SP, Brazil) without magnification by the
benchmark examiner and the participant examiner. For the
examination of proximal dental surfaces by FOTI, a Fiber-
Lite® PL-800 series device (Dolan-Jenner Elaborate, Lawrence,
MA, USA), with a 0.5 mm diameter tip (positioned below the
proximal point of contact) was used. The laser fluorescence
examination by a DIAGNOdent™ 2095 device (KaVo,
Biberach, Germany) was performed according to the
manufacturer’s recommendations for the occlusal dental
surfaces, but considering the classification scale and
interpretation of the reading values proposed by Zanin et al.10,
which was more adequate for the study proposals.

Sample
One hundred and sixty five 12-year-old schoolchildren

from public schools in Piracicaba, SP, Brazil, with low to
high prevalence of dental caries, were randomly selected.
The sample size was determined considering an agreement
proportion of 90%, disagreement proportion of 5%, test power
of 92% and an alpha of 5% under a bilateral test.
Schoolchildren who presented fixed orthodontic devices,
severe fluorosis and enamel hypoplasia or a serious systemic
disease were replaced by other children without these
conditions. Only the mesial, distal and occlusal dental surfaces
of permanent posterior teeth were considered in this study,
totaling 6565 surfaces of 2189 teeth. Two dental surfaces
were excluded because they could not be examined by all
the diagnostic methods.

Calibration of examiner
The calibration between the benchmark examiner and

the participant examiner consisted of 9 sessions lasting 4 h,
contemplating lectures, clinical training and calibration
exercises for CL1, CL2, BW, FOTI and DIAGNOdent™. A
time interval of 10 days, needed to measure the intra-examiner
agreement (only for the participant examiner), was adopted.
Thirteen schoolchildren, with low to high caries prevalence,
exclusively examined for this purpose, were involved in the
final calibration exercise. The Cohen’s Kappa statistics was
used for both intra and inter-examiner agreement.

Statistical analysis
Sensitivity (Sn), specificity (Sp) and accuracy (A) tests

were used to evaluate the validity of the dental caries
examinations. The standard for the validation of exams was
the CL2BW exam performed by the benchmark examiner.
Each diagnostic method was compared with the CL2BW
(performed by the benchmark examiner) by the McNemar
test (á=0.05). ANOVA was performed in order to compare
the average values of DMF-S obtained by the diagnostic
methods. The Scott-Knott test, which is used when there are
too many treatment modalities, and there is interest to separate
their results without ambiguity, was used for this purpose.

Results

The reproducibility was calculated by Cohen’s Kappa
statistics. At the D3 diagnostic criterion, the Kappa values
for the inter-examiner agreement were 0.87 for CL1 and CL2,
0.94 for BW, 0.92 for FOTI, and 0.34 for DD exam, while the
intra-examiner agreement was 0.99 for CL1 and CL2, 1.00
for BW and FOTI, and 0.42 for DD exam. At the D1+D3
diagnostic criterion, the Kappa values for inter-examiner
agreement were 0.86 for CL1 and CL2, 0.88 for BW, 0.89 for
FOTI and 0.48 for DD exam, while for the intra-examiner
agreement the values were 0.98 for CL1, 0.97 for CL2, 1.00
for BW, 0.95 for FOTI and 0.42 for DD exam.

The validity of the dental caries examinations at the D3
and D1+D3 diagnostic thresholds are shown in the Table 2.

At both diagnostic thresholds the CL2FTDDBW exam
presented the best values of sensitivity (Sn). However, the CL2BW
exam produced a satisfactory clinical performance with good
values of sensitivity (Sn) and accuracy (A) (Table 2).

The mean DMF-S index values as well as their differences
among the dental caries examinations, measured by ANOVA
(Scott-Knott test), are presented in Table 3.

At both diagnostic thresholds, the association of BW with
the CL2 exam (CL2BW) was responsible for a considerable
improvement in determining the DMF-S index. However, the
simultaneous association of the BW and DD exams with the
CL2 exam was statistically similar to the performance of
CL2FTDDBW and differed statistically from the CL2BW
performance for all diagnostic thresholds (Table 3).

Discussion

Diagnosis of dental caries has been considered a complex
process, under both clinical and epidemiological conditions,
due to the current pattern of disease, characterized by a smaller
number and size of lesions and a concentration of them
mainly in the posterior teeth2,11. A great number of studies
deal with the development and the use of new technologies
to improve the diagnosis of dental caries, especially at the
early stages5,12-19. Generally, such studies are performed under
controlled conditions, in vitro (laboratory settings) or in vivo
(clinical settings) methodology. None was performed in
epidemiological settings.

The first limitation of the present study was its “gold
standard” to validate the diagnostic methods. Despite the

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                                                    Occlusal + approximal surfaces
         D3 criterion        D1+D3 criterion

Examinations S n S p A S n S p A
CL1 4.56 99.88 89.69* 56.61 98.61 91.21*
CL2 4.99 99.88 89.73* 57.99 98.43 91.30*
BW 77.08 99.26 96.85* 59.74 99.18 92.16*
CL2FT 5.13 99.86 89.74* 59.46 97.73 90.98*
CL2DD 33.48 97.99 91.09* 68.19 95.97 91.08*
CL2BW** 77.49 99.23 96.91* 86.78 97.69 95.76
CL2FTDD 33.62 97.97 91.08* 69.66 95.27 90.76*
CL2FTBW 77.49 99.22 96.90* 87.12 96.99 95.24
CL2DDBW 82.62 97.37 95.79 90.15 95.25 94.35*
CL2FTDDBW 82.62 97.36 97.78 90.49 94.55 93.83*

Table 2.Table 2.Table 2.Table 2.Table 2. Validity of the dental caries examinations

* Significant difference between diagnostic method and validation method (pd”0.05).
** Performed by participant examiner. All examinations were tested against the CL2BW
exam performed by the benchmark examiner.

Examinations D3 criterion D1+D3 criterion
DMF-S S D DMF-S S D

CL1 1.32a 2.45 6.58a 4.97
CL2 1.37a 2.50 6.92a 5.14
BW 4.55c 2.17 6.88a 3.74
CL2FT 1.39a 2.51 7.67a 8.02
CL2DD 3.29b 2.96 8.38b 4.98
CL2BW** 5.32d 2.58 9.06b 4.95
CL2FTDD 3.32b 2.99 8.68b 5.11
CL2FTBW 5.59d 2.56 9.00b 4.75
CL2DDBW 5.97e 2.58 9.72c 4.84
CL2FTDDBW 6,23e 2.61 10.08c 4.78

Table 3.Table 3.Table 3.Table 3.Table 3. DMF-S index values obtained by the examinations
at the D3 and D1+D3 diagnostic thresholds.

Mean values followed by distinct letters on column-wise are statistically different
(p<0.05).
** Perfomed by participant examiner.

controversy around the association between visual (CL2) and
bitewing radiography (BW) exams performed by an
experienced examiner as “gold standard”, such association
was adopted. Ideally, the histological validation and the
opening lesions are the most indicated methods to such
purposes. However, those validation methods could not be
adopted because the design of the present study simulates a
real epidemiological survey of dental caries. Satisfactory
results from the CL2 or CL2BW exams have been related in
literature 13,20, especially when immediate operative
intervention is not implemented12,15. The exclusive use of
bitewing radiographs as baseline in permanent dentition may
be considered for populations with an overall low caries
prevalence. That recommendation, along with the correctness
of technique, the use of faster films, intraoral bitewing holders
and leaded protective aprons with a thyroid collar, minimize
the hazards of ionizing radiation21.

The purposes of an epidemiological survey of dental
caries include registering the trend of the disease and the
general treatment needs of a particular population8 aiming
to organize the demand and the oral health services. For this

reason, dental examinations at epidemiological survey are
not suitable for caries diagnosis and treatment. To detect
carious lesions is different from to diagnosing the dental
caries disease. For caries diagnosis and subsequent decision
treatment, a set of other factors must be considered. Such
factors include the initial caries signs, the rest of the dentition,
the patient’s case history and population factors, fluoride
availability and sugar intake. Diagnostic decision making is
a balancing act5.

Although there is low strength to the evidence as regards
the performance of diagnostic methods4, there are positive
results described in the literature2,6-7,22 about the association
of auxiliary resources and adjunct diagnostic methods for
identifying initial carious lesions. This trend was evident
and was in agreement with the results of this study. Although
the poor reproducibility of the DD exam in epidemiological
setting, it was maintained exclusively as an adjunct
technique22. Such reproducibility may be explained by the
tooth cleaning method used in the study. The DIAGNOdent®
manufacturer’s advice is to perform professional prophylaxis
previous to the examination. However, it is time-consuming
and not required for visual examination. A previous tooth
brushing (and drying procedure) is sufficient for that purpose.
Nevertheless, toothpaste and biofilm remaining over occlusal
dental surfaces may have influenced the DD readings23.

In the present study, the association of the clinical
method with different adjunct technologies improved the
sensitivity to detect caries, corroborating the results of Pereira
et al.5. It is especially important to use methods or their
association with others, which generate high sensitivity results
in detecting caries in populations that present moderate to
high prevalence of non-cavitated or hidden dentin lesions.
Therefore, the sensitivity values of CL2DDBW and
CL2FTDDBW at both diagnostic thresholds could be better
indicated for these populations. However, since the
CL2DDBW and CL2FTDDBW DMF-S means did not differ
statistically, the use of CL2DDBW could be suggested first,
assuming that such examination is simpler to perform than
the CL2FTDDBW.

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On the other hand, CL1, CL2 and CL2FT at the D3
diagnostic threshold, and CL1, CL2 and BW at the D1+D3
diagnostic threshold, would be better indicated in
populations with low caries prevalence due to the high
specificity of their results. Since the DMF-S means did not
differ statistically, CL1 and CL2 at both diagnostic thresholds
could be recommended in surveys, although the most accurate
methods were CL2FTDDBW at the D3 diagnostic threshold
and CL2BW at the D1+D3 diagnostic threshold.

Although the DMF-S obtained by CL2BW is statistically
different from the values from CL2DDBW and CL2FTDDBW
(Table 3), its results (Tables 2 and 3) cannot be neglected
due its availability and familiarity among dentists. The
purposes of a dental caries surveys support such differences.

Furthermore, CL1 and CL2 accuracy results at the
D1+D3 diagnostic threshold, indicated that a well-trained
and competent professional is able to detect caries lesions.
Therefore, training strategies should be focused not only on
private but also on public services, because professional
experience may influence the diagnosis of caries 5 and
treatment of the disease, which is often underestimated by
professionals24.

Low sensitivity values for CL1 and CL2 methods, at
the D3 threshold, could be explained by the fact that dentin
lesions under intact enamel are rarely detected without the
use of an adjunct method, mainly the bitewing radiographic
method. In addition, results are sometimes compromised by
the examiners’ subjectivity due to their previous clinical
experience, verified even among calibrated examiners, such
as those who conducted this survey. An improvement in the
sensitivity of CL1, CL2 and BW, with the association of
DIAGNOdent™ was found in this survey. That improvement
in sensitivity is followed by a decrease in specificity. This is
critical in populations whose caries prevalence is low,
increasing the probability of false positive diagnoses5,12,21.
In spite of its performance in non-cavitated caries lesions on
occlusal surfaces 13,19, use of DIAGNOdent™ in
epidemiological surveys might be not recommended mainly
due to its high cost. It is important to mention that
improvement in detecting caries with the DIAGNOdent™
could be also explained by its trend to produce false-positive
diagnoses4. According to Pereira et al.5, to have data available
from multiple methods may influence on the number of
surfaces indicated for operative treatment. So, the adoption
of diagnostic adjuncts in epidemiological surveys must be
only used to supplement the decision to plan preventive
strategies for initial dental caries16.

Nowadays, professionals should be more prepared to
diagnose properly a higher number of intact teeth or teeth
with initial caries, than to detect cavitated lesions in dentin,
due to the current less progressive pattern of disease. For
this reason, it is recommended to “wait and watch” and not
to immediately “drill and fill” teeth25. According to Novaes
et al.17, visual inspection alone seems to be sufficient to detect
dental caries satisfactorily. The results from CL1 and CL2
exams corroborate that statement in some degree. The
training for dental caries diagnosis under a more refined

threshold is also needed nowadays12. However, studying
alternatives to the traditional diagnostic methods and criteria
does not mean to substitute them in all circumstances. The
availability to acquire such diagnostic adjuncts and
subsequent opportunity to apply them must always be
considered. The WHO criteria8 still have their important role
in Dentistry.

It is also relevant to know the advantages and
disadvantages of diagnostic technologies and their
associations, because there is no modality of examination
that can be successfully used alone for diagnosing caries
and able to produce representative data of the disease in a
population5,14.

In conclusion, the association of adjunct diagnostic
methods with the clinical method generated higher validity
results than the clinical method alone, at both D3 and
D1+D3 diagnostic thresholds, under epidemiological
examination conditions. Diagnosing is a balancing act.
Therefore, considering the familiarity of the professionals
with clinical and radiological examinations, the present results
show the potential of the CL2BW in epidemiological surveys
of dental caries. The visual exam (CL1 and CL2), under more
refined diagnostic criteria, also showed its potential at
epidemiological surveys. However, studies with similar
methodologies are needed to endorse the association of
adjunct diagnostic methods in epidemiological settings.

Acknowledgement

The authors would like to thank the volunteers and those
responsible for the schoolchildren of the public schools in
Piracicaba, SP, Brazil. The first author received a scholarship
from PROEX/CAPES-UNICAMP during the Doctorate Course
in Dentistry. The authors acknowledge the financial support
of the FAPESP (grants #06/58881-9).

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