Decision making in restorative dentistry: intuition or knowledge based?
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Decision Making↗
Biomedical subjects
E H Verdonschot
Publications and source records attributed to E H Verdonschot.
Light propagation through teeth containing simulated caries lesions.
The methods currently utilized in dentistry to detect caries lesions have their limitations and alternatives are being investigated. A promising option is tooth transillumination which is based on an increase of light scattering or light absorption in the affected tissue region. In this study transillumination applied to detect approximal caries lesions was investigated using premolar teeth containing simulated caries lesions. Cavities were drilled at the approximal surface and filled with light absorbing and light scattering fluids in different dye and particle concentrations to model successive stages of lesion progress. For light absorbing cavities the extinction as function of the decadic absorption coefficient measured at the occlusal surface could be approximated by the Lambert-Beer law (r = 0.98 +/- 0.01). For light scattering cavities the extinction as a function of the decadic reduced scatter coefficient wad fitted to a straight line (r = 0.98 +/- 0.03) for mu's (lambda = 633 nm) < 1.25 mm-1. For higher reduced decadic scatter coefficients the curves levelled off due to multiple scattering. In addition, the contribution of the dentinal cavity part to the radiance change induced by the total cavity was estimated. For light absorbing cavities illuminated with red light the average contribution was 10.5 (SD 4.2)% and for those illuminated with green light it was 1.4 (SD 0.9)%, indicating that the radiance change caused by a caries lesion is mainly determined by the enamel lesion part.
Biophysical Phenomena↗
Propagation of light through human dental enamel and dentine.
Techniques based on transillumination of teeth with visible light will be a valuable aid in caries diagnosis, if a higher sensitivity than that of the present Foti method is achieved. Therefore, a better understanding of light propagation through teeth is required, and hence it is useful to investigate the propagation of light through sound dental material. In this study the intensities emanating from the surfaces of enamel and dentine bars were measured when these bars were illuminated using a fibre rod transporting the light from a HeNe laser (lambda = 633 nm) as a light source. From the measured intensities, the radiant fluxes emanating from the surfaces were calculated. To account for a directional dependence of these fluxes, optical anisotropy in dental material was investigated by comparing the transmitted light intensity in a direction perpendicular and parallel to the approximal surface of the tooth from which the sample was cut. The mean ratio of the transmitted intensities in perpendicular and parallel direction was 0.86 +/- 0.06 for enamel and 2.88 +/- 0.43 for dentine. In addition, for enamel the asymmetry parameter, g, was estimated. The averaged value was g = 0.68 +/- 0.09. It was concluded that for dentine the optical anisotropy as measured supports the idea that tubules are the predominant cause of scattering in dentine. For enamel the results indicate that the hydroxyapatite crystals contribute significantly to scattering and that the influence of the prism structure on the light propagation is small.
Anisotropy↗
Electrical conductance and electrode area on sound smooth enamel in extracted teeth.
Electrical conductance measurements are being used experimentally to diagnose caries. Current equipment, e.g. the electronic caries monitor (ECM), uses a probe to scan occlusal fissures. For full-mouth examination this method is rather time-consuming. A method with which only one measurement is needed for an entire (occlusal) surface would be preferable. However, the enlargement of the area being measured will influence the conductance. It was the purpose of this study to investigate the relationship between the electrical conductance of human teeth and the enamel electrode area, and to compare the range of results of surface measurements with those of the scanning method. Twenty-five sound extracted teeth were selected for the study. The reference electrode of the ECM was connected to the roots. The buccal surface was blotted dry, and a coloured dentifrice was syringed in increments onto the surface. After each increment the surface was photographed together with a metric reference, a conductance measurement was performed by holding the ECM probe tip in the dentifrice, and the ECM reading was recorded. For each tooth between 5 and 10 increments were applied and measured. The photographs were digitised and the electrode areas were calculated. A least squares curve fitting procedure yielded a linear relationship between conductance and electrode area (0.88 < or = R2 < or = 1.0, mean R2 = 0.97). For most teeth the threshold for dentinal caries as used for scanning ECM measurements (ECM reading = 6.00) was reached only when the electrode area exceeded 12 mm2. For 6 teeth this conductance was already reached between 5 and 12 mm2.(ABSTRACT TRUNCATED AT 250 WORDS)
Dental Caries↗
Electrical conductance of fissure enamel in recently erupted molar teeth as related to caries status.
Pit-and-fissure caries lesions contribute greatly to the caries incidence in permanent molar teeth in children. To date, the diagnosis of occlusal caries is still performed mainly by visual inspection, periodically aided by bite-wing radiography. However, in detecting small occlusal carious lesions, these methods perform inadequately, especially in low caries prevalence populations or individuals. The use of electrical conductance measurements (ECMs) has been evaluated to improve the diagnosis of small occlusal carious lesions. The aim of this study was to monitor the electrical conductance of fissure enamel in recently erupted molar teeth and to relate these measurements to the caries status. 50 children aged 5-15 years, having first or second permanent molars that were not exposed to the oral environment for more than 6 months, participated in the study. The diagnostic systems evaluated were visual inspection and ECMs. Following baseline data recording, diagnostic measurements were repeated three times within 18 months. Data were collected at predefined sites in the fissures. 18 months after baseline recording, 179 sites at 60 molar teeth in 27 children were judged to require a sealant based on visual inspection. After removal of carious tissue, two examiners jointly decided on the status of decay as per the criteria: 0 = no caries or caries limited to enamel, and 1 = caries involving dentine. The sensitivity of ECM continued to increase with time after a slight initial dip, whereas the specificity continuously increased after baseline measurements as a result of the decreasing amount of false-positive diagnoses.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Validity of electrical conductance measurements in evaluating the marginal integrity of sealant restorations.
The use of sealants and sealant restorations has increased considerably over the past 10 years, and with it increased the problem of detecting secondary caries and marginal (micro)leakage. It was the purpose of this study to investigate the validity of electrical conductance measurements (ECMs) in diagnosing marginal leakage into dentine of sealants and sealant restorations. Ninety extracted premolar teeth were divided into three groups. Initial ECMs, denoted 'baseline ECMs', were conducted in all three groups by placing the probe tip of an Electronic Caries Monitor in the occlusal fissure which was filled with a dentifrice. The ECMs were divided by the area, yielding ECM/mm2 values. In group A 30 teeth were treated to receive 'nonleaking sealants'. In the 30 teeth of group B a narrow groove was cut at the occlusal surface reaching the dentine and restored by the application of a sealant without etching of the adjacent enamel to create a high probability of marginal leakage. The samples in group C received the same treatment as those in group B, but in this group the enamel was etched to reduce the probability of marginal leakage. The ECMs subsequently conducted were denoted 'sealed/restored ECMs'. Teeth in groups B and C were thermocycled 700 times (4-67 degrees C) to provoke leakage, after which ECMs were conducted (denoted 'ECMs after thermocycling'). The teeth were immersed in fuchsin for 24 h and cut along the fissure system to validate marginal leakage. The electrical conductance decreased significantly from baseline to the sealed/restored stage in all groups (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Bicuspid↗
Prediction of the need for bitewing radiography in detecting caries in the primary dentition.
In recent literature some controversy has been reported regarding the prescription of bitewing radiography for caries diagnosis, particularly in children. While the low prevalence of caries justified the decision not to take radiographs, it has also been reported that the benefits of detecting slowly progressing, clinically undetectable lesions could outweigh the "costs" of radiography. It was the aim of this study to investigate whether specific risk factors could predict the presence of additional dentinal lesions (ADL) in the primary dentition on radiographs which could not be detected by visual inspection. Bitewing radiographs were taken in 182 children aged 5 yr. Risk factors for ADL were identified and appropriate rating scales were designed. Sensitivities, specificities and relative risks expressing the relation between scale values and ADL were computed for each of the risk factors and direct and stepwise discriminant analyses were performed. The results indicate that particularly the presence of lactobacilli and mutans streptococci in saliva and the detection of three or more discolored enamel lesions or dentinal lesions were good predictors of ADL. It is suggested that these risk factors be used in the timing of bitewing radiography in children with a primary dentition.
Child, Preschool↗
Performance of diagnostic systems in occlusal caries detection compared.
Many investigations have been conducted to evaluate existing and new diagnostic systems in the detection of occlusal carious lesions. The performances of these systems are difficult to compare with each other, because of the disadvantages associated with the widely used validity parameters sensitivity and specificity. In this study a meta-analysis was performed to facilitate a comparison between the performances of diagnostic systems which are currently in use in occlusal caries diagnosis. Nine in vitro studies and one in vivo study complied with the selected criteria for inclusion in the analysis. The sensitivity and specificity values obtained from these studies were converted into normal deviate values, and plotted on linearly scaled normal-deviate axes. DZ values, which quantify the performance above chance of a diagnostic test in one single value, were calculated. Averaged DZ values of the diagnostic systems were subsequently compared to each other. The results indicate that electrical resistance measurements and fiber-optic transillumination had a comparatively good, and visual inspection and xeroradiography a poor, performance in occlusal caries diagnosis. All the other radiographic image modalities had intermediate performances.
Contrast Media↗
Impact of the validator and the validation method on the outcome of occlusal caries diagnosis.
In studies evaluating the performance of caries-diagnostic methods, a validation of the true state of disease is needed. The aim of this study was to evaluate the impact of the validator and the validation system (stereomicroscopy or radiography of tooth sections) on the outcome of diagnostic tests for occlusal caries. The material consisted of 60 extracted third molars which were serially sectioned (500-600 microns thick). Four observers examined the sections by two caries validation methods: stereomicroscopy and film radiography. The presence of caries in the occlusal surfaces of these teeth had previously been recorded by visual inspection and conventional film radiography. The kappa values for interobserver agreement within one validation method ranged from 0.44 to 0.76 for radiography and from 0.47 to 0.60 for microscopy. The intraobserver agreement with the two methods was low (range 0.31-0.49), and by cross-tabulating the data, it was found that the disagreements originated in a consistently deeper lesion score with stereomicroscopy than with radiography by all observers except 1. By use of receiver operating characteristic curve areas, little impact of the validation method was seen when visual inspection was validated (against microscopy mean area = 0.75, against radiography mean area = 0.74). The mean receiver operating characteristic area was higher when diagnostic film radiographs were validated against radiography (0.68) than against microscopy (0.63). The differences between observers within a validation method were larger with microscopy than with radiography. In conclusion, caries validation methods are subject to variability. The outcome of caries--diagnostic tests may be influenced both by the validator and the validation method.
Dental Caries↗
Some considerations in the evaluation of diagnostic tests in dentistry.
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Dental Caries↗
Performance of electrical resistance measurements adjunct to visual inspection in the early diagnosis of occlusal caries.
The detection of small carious lesions at occlusal surfaces is a difficult task, particularly in low caries prevalence populations and individuals. The aim of this study was to evaluate the performance of electrical resistance measurements (ERM) in diagnosing small dentinal lesions at one site per occlusal surface in low caries prevalence populations when used adjunct to visual inspection, and to compare the performance of ERM to that of radiographic examination. The occlusal surfaces of 81 third permanent molar teeth extracted from young adolescents were diagnosed by four examiners, who measured the electrical resistance of enamel on a one measurement per surface basis, and furthermore assessed the occlusal surfaces visually and radiographically. The teeth were sectioned for validation by histological examination. The ERM had the highest sensitivity (0.67), and visual inspection had the highest specificity (0.89). ROC analysis showed no statistically significant differences between the performance of the observers when using visual inspection and ERM (z-score test; P > 0.05). One examiner performed statistically significantly better by measuring the electrical resistance of enamel than by radiographic examination (P < 0.05). The average sensitivity and specificity of the three diagnostic systems were used to express the positive and negative predictive values as a function of caries prevalence. At a caries prevalence of 0.2 the negative predictive values for visual inspection, ERM and radiographic examination were 0.88, 0.91 and 0.89, and the positive predictive values were 0.53, 0.48 and 0.42 respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Applicability of Receiver Operating Characteristic (ROC) analysis on discrete caries depth ratings.
Accuracy of diagnostic tests for caries detection is frequently evaluated by sensitivity and specificity values obtained from data acquired on an ordinal rating scale which classifies lesions according to the depth in enamel and dentin. The interpretation of these parameters may, however, be difficult. Receiver Operating Characteristic (ROC) analysis, on the other hand, yields an expression for overall diagnostic accuracy in a single parameter, facilitating a comparison of performance of several diagnostic tests. The basis for applying ROC analysis has been that data were collected on a confidence (likelihood) scale. The aim of this preliminary study was to investigate whether the application of ROC analysis would yield as valid parameters for diagnostic accuracy in assessment of approximal caries on a depth rating scale as on a likelihood rating scale. The results demonstrated that the accuracy of observer performance was not influenced by the type of rating scale employed, justifying the application of ROC analysis on discrete caries depth ratings.
Chi-Square Distribution↗
Effects of digital grey-scale modification on the diagnosis of small approximal carious lesions.
The aim of this study was to evaluate the accuracy of approximal caries diagnosis from digitized radiographs and digitally modified radiographic images, compared with conventional radiography. Twenty bitewing radiographs were digitized and from the digitized radiographs mirror-images were produced, resulting in 40 digital images. The caries progress at three approximal surfaces was graded by 12 dentists from conventional radiographs, digital unmodified images and digitally modified images. The image modifications were derived from the cumulative probability of grey values in the original digital image using one of five probability distributions: uniform, exponential, Rayleigh, hyperbolic cube root and hyperbolic logarithmic. Interobserver agreement was substantial. The unmodified digital images produced sensitivities comparable to radiographs but their specificities were lower. When the diagnostic task was to discriminate between 'caries' and 'no caries', the exponential, hyperbolic cube root and hyperbolic logarithmic modifications and radiographs performed equally well. With the decision cut off between 'dentinal caries' and 'no dentinal caries', the sensitivity of the hyperbolic logarithmic type of modification was statistically significantly superior to that of radiographs, but this modification was also associated with a statistically significant reduction of specificity. It is concluded that in particular the hyperbolic logarithmic modification can be an alternative to conventional radiography in incipient approximal caries diagnosis and restorative decision making.
Color↗
Performance of some diagnostic systems in examinations for small occlusal carious lesions.
The objective of this study was to compare the performance in occlusal caries diagnosis of various available diagnostic systems when applied to the same teeth. The sample investigated consisted of 13 children for whom 4 premolar and 19 molar teeth were judged to require a sealant. The indication was based on the criteria 'fissure discoloration', 'enamel decalcification' and 'absence of dentinal decay'. For predefined locations within these occlusal fissures a diagnosis was obtained by the following diagnostic systems: clinical examination, examination on fiber-optic transillumination (FOTI), fissure discoloration, electrical resistance measurement, radiographic examination and ratings of fissure morphology. Tooth material was removed until no (more) carious enamel or dentin was left. Two dentists then jointly decided on the status of decay for each of the defined locations within the fissure. These ratings served as the 'gold standard' diagnoses. The electrical resistance measurement with a sensitivity of 0.96 and a specificity of 0.71 was the only diagnostic tool with acceptable performance. Radiographic diagnosis was characterized by a moderate sensitivity and specificity. All other diagnostic systems had either very low sensitivities or very low specificities, or both. The positive predictive value of FOTI examination and the negative predictive value of the electrical resistance measurements were very high, irrespective of the prevalence of occlusal dentinal decay.
Adolescent↗
Accuracy of visual inspection, fiber-optic transillumination, and various radiographic image modalities for the detection of occlusal caries in extracted non-cavitated teeth.
Occlusal caries lesions may progress into the dentin without this resulting in a macroscopic breakdown of the enamel surface. Imaging methods may therefore be needed to aid in the visual detection of occlusal caries. It was the aim of this study to evaluate diagnostic accuracy in a laboratory set-up of visual inspection (VI), fiber-optic-transillumination (FOTI), conventional radiography (CR), and two digital radiographic image modalities (DRm and DRr) for detection of occlusal caries in clinically non-cavitated teeth. Eighty-one extracted third molars from 18-20-year-old males were assessed by four observers on a five-rank confidence scale by the five methods. Ground sections (500-600 microns) served as validation for true state of disease: 1 = no caries in dentin, 2 = caries just beyond dentino-enamel junction, or 3 = deep dentinal caries, halfway or more to the pulp. ROC analysis was performed on the basis of the confidence rank scale data on two diagnostic thresholds, T1 = caries in dentin (disease state 2+3) and T2 = caries deep in dentin (state 3). On the T1 level, use of the FOTI method gave on average the most accurate diagnosis, closely followed by VI, both performing better than use of radiography. On the T2 level, all five diagnostic methods performed equally well.
Adolescent↗
Aesthetic properties of three type II glass polyalkenoate (ionomer) cements.
The aesthetic properties of three recently marketed Type II glass polyalkenoate (ionomer) cements were evaluated in a combined laboratory and clinical study. The materials investigated were Fuji Cap II, ChemFil II in capsules and Ketac-fil Aplicap. The aesthetic properties of a glass ionomer restoration were represented by its translucency, the colour match with surrounding enamel and marginal adaptation. The translucency of all shades of the selected glass ionomer cements was measured under laboratory conditions and expressed as the optical density on transillumination. Colour match and marginal adaptation were evaluated in a clinical study. Twenty Class V restorations of each of the three products were placed. After finishing, the marginal adaptation was rated by two clinicians and colour slides of the restoration were made. Five clinicians assessed the colour match of the restorations from colour slides. ChemFil II and Ketac-fil Aplicap shades were considerably more translucent than the Fuji Cap II shades. The colour match of the ChemFil II restorations was significantly better than the Fuji Cap II and Ketac-fil Aplicap restorations. Marginal adaptation was judged excellent for all three products.
Aluminum Silicates↗
Applicability of an image analysis system in alveolar bone loss measurement.
Clinical and epidemiological studies in the field of periodontics and endodontics often utilize radiographs to monitor or measure the changes in bone structure and density. Periodontal bone loss or gain can be quantified on a radiograph by measurement of the distance between the bottom of the bony pocket and the apical contour of the involved tooth. The objective of this investigation was to study the accuracy of an image analysis system (IAS) to measure changes in height of the interproximal crest on radiographs. Artificial bone lesions were introduced in a dissectioned part of a human mandible. The distances between crest and apices were measured with a micrometer (MM). Radiographs were produced with horizontal and vertical deviations of 10 degrees. The radiographs were digitized and processed by computer. The landmarks in the digital image were enhanced mathematically and by histogram-based thresholding. The depth of the introduced defect was increased 6 times, followed by the measurement procedure. The IAS produced measurements of crown-apex distances with an accuracy of 0.066 to 0.358 mm. Repeated crest height measurements were recorded with an accuracy of 0.112 to 0.184 mm. Both the histogram-based binarization and the ellipse-fitting type of contour detection could be applied precisely. Misangulation errors during radiographic exposure of 10 horizontal or vertical did not statistically significant influence the IAS-measurements. The IAS can be applied in clinical trials and follow-up studies.
Alveolar Bone Loss↗
Approximal caries diagnosis using fiber-optic transillumination: a mathematical adjustment to improve validity.
Several studies were conducted recently to evaluate the use of Fiber-Optic Trans-Illumination (FOTI) in the diagnosis of approximal carious lesions. All these studies utilized radiographic readings to validate the FOTI diagnoses. Other investigations studied the value of radiographic readings using more solid validating techniques, which made it possible to judge the true state of decay, such as histology, cavity preparation and microradiography. In this study, data from both types of studies were used to estimate the validity of FOTI diagnosis of approximal caries relative to the true status of decay through correction for radiographic misclassification. The results indicate that particularly the sensitivity of FOTI diagnosis has yet to be determined.
Dental Caries↗