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PubMed2026

Artificial intelligence for dental caries detection: An umbrella review.

Artificial intelligence (AI) has been proposed as a tool to improve dental caries detection across imaging modalities; however, its clinical value remains uncertain. This umbrella review aimed to synthesize and critically appraise systematic reviews evaluating AI for caries detection and diagnosis. An umbrella review was conducted following PRIOR guidance (PROSPERO CRD420261340728). Searches were performed in MEDLINE, Embase, Scopus, Web of Science, and Google Scholar up to 15 March 2026. Methodological quality was assessed using AMSTAR 2, and overlap of primary studies was quantified using the corrected covered area (CCA). Seventeen systematic reviews were included, of which five reported diagnostic test accuracy meta-analyses using bivariate or HSROC models. Across these meta-analyses, pooled sensitivity ranged from 0.76 to 0.94 and specificity from 0.85 to 0.91. Most systems were based on deep learning models applied to bitewing radiographs and intraoral photographs. However, substantial heterogeneity was observed in imaging modalities, lesion thresholds, analytical tasks, and evaluation metrics. In addition, a high degree of overlap across reviews and recurrent methodological limitations, including reliance on retrospective datasets, limited external validation, and inconsistent reporting, substantially weaken the reliability of the evidence. Although AI models demonstrate high diagnostic performance under experimental conditions, current evidence does not support their use as stand-alone diagnostic tools. Their clinical applicability remains limited, and implementation should be restricted to decision-support contexts until robust prospective validation demonstrates meaningful impact on clinical decision-making and patient outcomes.

Dental Caries↗

PubMed1991

ROC analysis of observer-response subjective rating data--application to periodontal radiograph assessment.

Many physical anthropological studies require that an observer or device discriminate between states that can be easily confused. Receiver operating characteristic (ROC) analysis currently offers the best method for determining the accuracy of such choices, particularly for small sample sizes. Although ROC analysis is widely accepted in psychophysical and biomedical testing, its use in anthropological studies has not been reported. ROC analysis is used here to determine the usefulness of enhanced dental radiographs to assess vertical alveolar bone defects for quantitative studies of human variation with regard to periodontal disease. The presence or absence of vertical-bony defects (truth) for 75 human skulls was established by the consensus of two trained observers. Dental bitewing-radiographs were taken of the alveolar processes, the radiographs digitized, and the brightness and contrast of the digital images enhanced. The two observers who established truth then rated 1) plain bitewing radiographs, 2) unenhanced digital images of bitewings, and 3) enhanced digital images of bitewings for vertical bony defects. The rating scale varied from 1 (vertical defect definitely or almost definitely present) to 5 (definitely or almost definitely absent). ROC analysis was used to compared the diagnostic value of the 3 imaging modalities. All modalities had nearly identical diagnostic performance, measured as Az values (areas beneath ROC curves) that were less than 0.80, which indicates only moderate usefulness. It is concluded that enhancement does not increase success in vertical-bony-defect diagnosis from digital dental radiographs processed in this manner. Moreover, it is suggested that conventional bitewing radiographs may be unsuitable for accurate quantification of such defects.

Alveolar Bone Loss↗

PubMed1997

Hidden caries: what is it? Does it exist? Does it matter?

Hidden caries is a term used to describe occlusal dentine caries that is missed on a visual examination, but is large enough and demineralised enough to be detected radiographically. The detection rate of such lesions will depend upon the prevalence of caries in the population and the frequency with which bitewing radiographic examinations are performed. Whether 'hidden caries' is a distinct clinical entity, reflecting a particular anatomical fissure topography or a different bacterial aetiology, is unknown. It is possible that an improved visual examination, with careful cleaning and drying of teeth, may improve occlusal caries detection to the point where 'hidden caries' no longer exists. However, this possibility has yet to be tested clinically and until it is, practising dentists would be wise to examine bitewing radiographs carefully for occlusal demineralisation. The authors would treat such hidden lesions by removing soft caries and placing sealant restorations.

Dental Caries↗

PubMed1998

Health gain from restorative dental treatment evaluated by computer simulation.

OBJECTIVE: To simulate the influence over time of relevant factors on health gain from restorative dental treatment under varying assumptions and to compare outcomes with those resulting under a 'do nothing' scenario. DESIGN: A decision model was used in a computer simulation of the caries process in posterior approximal tooth surfaces. The effect of superimposing restorative treatment, based on bitewing radiology, was incorporated. Input data came from current observational studies and included caries progression rates, notional survival times of restorations, and sensitivity (Sn) and specificity (Sp) of treatment decision making by a high (A) and a low (B) performing dentist. Utility values, on a scale 0-1, for different tooth health states were obtained from questioning 92 adults of appropriate age. SETTING: By assumption, the primary dental care sector. PARTICIPANTS: A hypothetical population, initially 14-15 years old. INTERVENTIONS: Class II amalgam restorations. OUTCOME: Computed in utility based units (UBUs) as sums of the product of numbers of sound, carious and restored surfaces and their utility values. Health gain (in UBUs) was assessed relative to interim end point UBUs pertaining under 'do nothing'. RESULTS: One thousand approximal surfaces, designated initially as 920 sound, 51 carious and 29 filled were followed in the model over 10 years. The greatest health gain (33.16 UBUs) was from dentist A (Sn = 0.23, Sp = 0.99, 50 per cent restoration survival rate = 10 years, caries rate = 4.4% per annum). The least was from dentist B (Sn = 0.52, Sp = 0.88, 50% survival = 5 years, caries rate = 0.0% per annum) representing a loss of 17.07 UBUs compared with 'do nothing'. CONCLUSIONS: Results suggest that caution is advisable when making positive decisions to restore on the basis of bitewing radiographs.

Adolescent↗

PubMed1994

Validation of dental radiographs for human identification.

Visual comparison of dental bitewing radiographs in simulated forensic identification, using observers of varying degrees of experience and radiographs with a range of time intervals from one to fifteen years showed an accuracy of 93%.

Adolescent↗

PubMed1993

Digital radiographic image-based bone level measurements: effect of film density.

Previous studies have demonstrated that accurate alveolar bone-level measurements can be made using digitally enhanced bitewing radiographs. In this study, we determined the effect of exposure variations on bone-level measurement accuracy using digital radiographic images of dry skulls. 6 direct bone-level measurements on the mandibular 1st molars of dry skulls were established by consensus of 2 expert observers. 13 bitewing radiographs were taken on each side of 11 skulls, using a specially designed positioning device. Exposure settings of 70 kVp, 10 mA, and 24 impulses were empirically chosen as the baseline. Kilovoltage and impulses times were individually varied (50 to 100 kVp in 10 kV increments and 15 to 48 impulses in 6 steps) to ensure a wide range of clinically relevant optical densities on the test images. The radiographs were digitized and alveolar bone level measurements, corresponding to those for skulls, were made on the images by 2 observers. Pearson product-moment coefficients between radiographs and criteria measurements were calculated. It was found that dry skull and digital bitewing radiographic measurements were highly correlated, within the limits of exposure parameter variations tested. Accurate measurements of alveolar bone level are possible from bitewing radiographs taken within a wide range of exposures, when digital image processing techniques are employed.

Absorptiometry, Photon↗

PubMed1992

Approximal caries and frequency of bitewing examinations in Swedish children and adolescents.

The aim of this study was to assess the number of, and time intervals between, bitewing examinations performed on a group of Swedish patients between 3 up to and including 18 yr of age and to relate them to the accumulated posterior approximal caries experience of the patients as found in the last bitewing examination before age 19. The patients showed a marked variability in approximal caries experience. 25% accounted for about 1% of the total number of carious lesions and restorations accumulated up to age 19 while 25% accounted for 60%. From age 9 up to age 18 more than 75% of the patients were subjected to at least one bitewing examination annually. Between 10 and 15 yr of age more than 90% received annual radiographic examinations. Mean number of bitewing examinations was 10.4 and the average time interval between bitewing examinations was 11.5 months. 11% of the variation in the number of bitewing examinations and 8% of the variation in average time intervals between bitewing examinations could be explained by the number of lesions and restorations in the approximal surfaces of the patients accumulated up to age 19.

Adolescent↗

PubMed1991

Periodontal disease progression in teenagers with no preventive dental care provisions.

Periodontal disease progression was studied on bitewing radiographs taken at baseline and after 1 year for a group of 422 teenagers who had no access to preventive or therapeutic dental services. Subjects exhibiting one or more proximal surfaces of 1st molars with longitudinal bone loss and/or with vertical bone defects at the 2nd examination were regarded as periodontal risk patients. This group then underwent a further examination in which periapical radiographs of the anterior teeth were taken and the clinical loss of attachment at the proximal surfaces of all teeth was assessed. Subsequently, the radiographic and clinical states of the risk group were compared. Most sites exhibiting bone loss during the study period displayed vertical bone defects and were largely confined to mesial surfaces of first molars. 24% of sites showing alveolar bone loss at baseline demonstrated further loss 1 year later. Girls exhibited significantly higher prevalence and incidence of sites showing bone loss than did boys. 24 children (5.7%) were regarded as periodontal risk patients. The radiographs significantly underestimated the prevalence of periodontal destruction in the risk group as compared to clinical measurements. It was concluded that using 2 bitewing radiographs is adequate for the identification of risk subjects, and that periodontal progression in adolescence occurs mainly in the first molar region and may affect girls more often than boys.

Adolescent↗

PubMed1996

Dentists' variability in restorative decisions, microscopic and radiographic caries depth.

Restorative and dental caries depth decisions were recorded for 5168 un restored approximal tooth surfaces by 17 dentists who worked in the school dental clinics of the North York (Ontario) Public Health Department. Each dentist examined 15 pairs of experimental bitewing radiographs for which true caries depth had previously been determined by microscopy of the sectioned teeth following production of the radiographs. The dentists independently recorded their restorative decisions and radiographic caries depth perceptions. The relationship between the variation in the dentists' restorative decisions and their perceptions of caries depth based on a re-reading of the bitewings on the one hand, and true caries depth on the other was also examined. The percentages of total variability in each dentist's restorative decisions attributable to radiographic and to microscopic caries depth were estimated using regression analyses. Large variations were found among the 17 dentists' distributions of overall restorative and depth decisions. The relationship between microscopic caries depth and the dentists' restorative decisions was, understandably, less strong than that of the dentists radiographic perceptions of caries depth and restorative decisions. Relative to true caries depth, high numbers of false positive and false negative restorative decisions were made. Overall, 50% of the variability in the dentists' restorative decisions was explained by the perceptions of radiographic caries depth; however, among individual dentists, the range was from 29% for one dentist to 69% for another. A much lower percentage of the overall restorative variation was explained by microscopic depth, 18%. Like the finding of the only two previous European studies that quantified the role of radiographs on clinical decisions, this study demonstrated that dentists' perceptions of dental caries depth using bitewing radiographs play a major but variable role in their restorative decisions for approximal tooth surfaces.

Clinical Competence↗

PubMed2003

[Decision making in cariology].

By conducting an oral examination, during radiographic examination and in treatment planning procedures dentists make numerous decisions. A dentist will be required to make his decisions explicit. Decision trees and decision analyses may play an important role. In a decision analysis, the probability of correct and incorrect decisions are multiplied by the utility of the decision outcomes. The treatment outcome with the highest expected utility should be selected. Complex decision tasks such as the estimation of an individual's caries risk or the diagnosis of bone disorders are currently available as computer applications. Also, a preliminary version of a computer programme which detects caries lesions from bitewing radiographs independent from the dentist has become available. It is expected that the applicability of decision analyses will increase when implemented in the dental practice software packages.

Decision Making↗

PubMed2000

Clinical and radiographic judgement of occlusal caries in adolescents.

In this study, the clinical and radiographic material of two groups of 17- and 20-yr-old adolescents, born either in 1970 or in 1976, was compared to study changes in the prevalence of occlusal dentine caries and to determine the additional value of the bitewing radiographs. The first and second molars of 478 participants were included. Clinical data were derived from an epidemiological project. Two examiners judged the bitewing radiographs, of which about 10% was examined by both. The overall Cohen's kappa for interexaminer agreement was 0.87. The prevalence of occlusal caries had not changed for the two age groups; after clinical and radiographic examination, around 33% of the occlusal surfaces of the 17 yr olds and around 25% of the 20 yr olds exhibited dentine caries. The clinical prevalence of occlusal caries in first and second molars was highly underestimated when compared with the radiographs. In the 1976 group, more sealants were recorded during the clinical examination. On the bitewing radiographs, radiolucencies were found underneath one-half of the sealants of the 17 yr olds and underneath one quarter of the sealants present in the 20 yr olds.

Adolescent↗

PubMed1990

The prevalence of clinically undetected occlusal dentine caries in Scottish adolescents.

During the third examination of a 3-year anti-caries dentifrice study, bitewing radiographs were read to detect occlusal, as well as approximal caries lesions in 2623 subjects aged 14-15 years. These analyses showed that 1.4% of 2107 upper molars and 7.2% of 2288 lower molars (P less than 0.001), previously scored as clinically 'sound', were carious at a radiographic Grade '3' score (dentinal involvement), and 0.2% had radiographic pulpal lesions. However, for teeth which had been deemed as having a 'suspicion' of caries clinically, but which a 0.6 mm blunted probe would not enter, 29.1% of lower molars had definite radiographic evidence of dentinal caries as compared to only 7.6% of upper molars (P less than 0.001), and a further 0.5% exhibited pulpal extension. In addition, 23.9% of lower premolars also showed dentinal involvement in this group. Overall, 12.1% of lower molars and 3.1% of upper molars showed definite radiographic evidence of occlusal caries in the absence of a firm clinical indication. Thus, the use of bitewing radiographs would appear to be a most helpful adjunct to clinical caries diagnosis, not only of approximal lesions, but also for the detection of early occlusal caries, in these days of generally available topical fluoride.

Adolescent↗

PubMed2005

Clinical performance of DIAGnodent in the detection of secondary carious lesions.

The diagnostic value of DIAGNOdent in detecting primary occlusal caries has been investigated in many studies, although its use in in vivo detection of secondary caries remains unclear. The aim of this study was to investigate the ability of DIAGNOdent in in vivo detection of secondary caries on teeth with amalgam restorations. The material comprised 51 posterior teeth restored with amalgam material. Bitewing radiographs were taken of all teeth, in accordance with the standard clinical protocol, and analysed by five observers with respect to secondary caries. The restoration margins of each tooth were carefully scanned with DIAGNOdent and the site of the highest reading and its value were registered in a digital picture. The color (stained/unstained) of the restoration margins was also documented. The restoration material was removed and all cavities were examined carefully by two observers together, both visually and by probe. The results showed that the sensitivity and specificity of DIAGNOdent and conventional radiography in detecting secondary caries were 0.60/0.81 and 0.56/0.92, respectively. For DIAGNOdent, 100% of the teeth in the false-positive fraction had stains. Regarding receiver operating characteristic analyses, the Az values were 0.78 and 0.69 for DIAGNOdent and radiography, respectively. We conclude that DIAGNOdent may be used only as an adjunct to conventional methods in detecting secondary caries on teeth with amalgam restorations.

Adult↗

PubMed1996

Testing the consistency of measurements of the distance between the cemento-enamel junction and the alveolar bone crest on bitewing radiographs.

UNLABELLED: The purpose of the research described in this paper is to test the consistency of measurements of the distance between the cemento-enamel junction and the alveolar bone crest (CJ-AC) on bitewing radiographs. The present paper shows how the consistency tests were organized and which statistical analyses were used. Since the actual characteristic (CJ-AC) could not alter, the variations of the results had to be due to one more of the 5 m-factors (man, material, machine, method and manipulation). To test the consistency of the measurements of CJ-AC, a pretest and an en route test were performed. Both the bitewing radiographs for the pretest and the en route test were sampled at random from the principal material. The principal material consisted of 856 sets of bitewing radiographs from persons born 1930-1949. The pretest of 40 sets of bitewing radiographs were read twice by 2 independent readers. The en route test consisted of 85 sets of bitewing radiographs which were read twice by 1 reader. Neither the results of the pretest nor the results of the en route test showed statistical or clinical differences of significance. IN CONCLUSION: the consistency of this method of measuring is satisfactory for the 2 readers.

Aged↗

PubMed2002

Radiographic prevalence of approximal enamel lesions and relationship with dentine lesions and restorations in Dutch adolescents.

AIM: The aim of this study was to assess the prevalence of approximal enamel lesions from radiographs in groups of 14, 17, 20 and 23 years old, and to determine the relation with dentine lesions and restorations present. METHOD: Per age group, the bitewings of 120 persons were randomly selected and assessed for enamel lesions from the distal surface of the first premolar to the mesial surface of the second molar. A second examiner assessed 20% of the material for enamel lesions to determine the interexaminer agreement (Cohen's kappa = 0.63). RESULTS: An enamel lesion was found in 12-15% of the unfilled surfaces. The mean number of surfaces with enamel lesions was almost three per person. For all age groups it was found that about 20% of the persons had at least four enamel lesions and the number of enamel lesions was significantly correlated with the number of dentine lesions. Of all enamel lesions 20% were found in persons without any dentinal lesions or restorations. CONCLUSION: The bitewing radiographs showed a considerable number of enamel lesions for these age groups. This seems to justify its use on a routine base as a diagnostic tool at the age of 14-16 years.

Adolescent↗

PubMed2005

A clinical and radiographic comparison of caries diagnosed in approximal surfaces of posterior teeth in a low-risk population of 14-year-old children.

INTRODUCTION: The prevalence of caries, and its preferential location, has changed in recent years. The percentage reduction in caries has been lower in pits and fissures than in other locations, making it necessary to use more sensitive diagnostic procedures than visual inspection for approximal lesions. OBJECTIVES: The objective of this study was to compare the amount of overlooked proximal caries by bitewing X-rays versus clinical in patients who were completing a public oral health program at the age of 14 years. METHODS: 162 children aged 14 years were clinically examined by a dentist as part of the systematic six-monthly dental check-ups of the children. The survey was carried out on dried teeth using a light, plane mouth mirror and blunt probe. All molar and premolar surfaces were examined in order to determine the presence of caries or restorations. In addition, two bitewing radiographs of each patient were obtained using a Klauser plastic parallelizer. RESULTS: Caries lesions were diagnosed better by the X-rays than clinically (delta X-ray = 0.61), whereas clinical examination was better at diagnosing the presence of fillings (delta X-ray = -0.03). Clinical examination diagnosed all occlusal caries but underestimated the interproximal lesions by 86.84%. CONCLUSIONS: In the context of public oral health programs, the authors consider it necessary to obtain two bitewing X-rays of the children's teeth before discharging them, as otherwise they could be told that they are healthy whereas, in fact, they present interproximal caries that could be treated by remineralization or restorative methods.

Adolescent↗

PubMed1996

Naught for your comfort.

A review of 51 children enrolled consecutively under the Dental Benefit Scheme in a private practice has shown that some children would have benefited from having bitewing radiographs at a much earlier age. Differences in dental development between girls and boys, and between children of European and Polynesian background mean that children vary greatly in the dental age when the first bitewing radiograph is taken, generally at enrollment in the General Dental Benefit Scheme. The decline in dental caries has made diagnosis and treatment planning more demanding, and this has exposed the deficiencies of the public programmes.

Child↗

PubMed2004

The bitewing radiograph as an assessment tool in fixed prosthodontics.

Molar crown preparations, as described in the literature, have standard forms dictated by the demands of retention, resistance and the physical properties of materials. Standard designs may not be appropriate for all patients because of ethnic variations in tooth shape, pulp size and dentine thickness. Accurate data on these features could assist clinicians to minimize the risk of accidental pulpal injury. The aim of this study was to compare the first molar crown and pulp dimensions between Asian (Chinese, Korean, Malay) and other ethnic groups, using measurements from the bitewing radiographs of 121 subjects. Comparisons revealed the following significantly different features of Asian first molars: larger total pulp areas in uppers (P < 0.0005); shorter crowns (P < 0.0005); narrower upper teeth at the cervix (P < 0.0005); wider pulps at the cervix of lowers (P < 0.02); more bulbous crowns (P < 0.0005 for uppers; P < 0.01 for lowers), and finally significantly thinner dentine interproximally at the cervix (P=0.001 for uppers; P=0.011 for lowers). Preparations with wide shoulders could pose hazards to the pulps in Asian subjects. This study emphasizes the value of bitewing films in assessing crown and pulp size and shape before making crown preparations. The experienced practitioner may intuitively include tooth and pulp morphology in treatment planning, but this appears not to be taught or documented in textbooks.

Adult↗