Why is it important to improve dental caries (tooth decay) detection?
Dentists often aim to identify tooth decay that has already advanced to a level which needs a filling. If dentists were able to find tooth decay when it has only affected the outer layer of the tooth (enamel) then it is possible to stop the decay from spreading any further and prevent the need for fillings. It is also important to avoid a false-positive result, when treatment may be provided when caries is absent.
What is the aim of this review?
This Cochrane Review aimed to find out how accurate different forms of light-based tests are for detecting early tooth decay in patients who regularly visit their dentist. Researchers in Cochrane included 23 studies published between 1988 and 2019 to answer this question.
What was studied in the review?
We included three different types of light-based devices in this review: optical coherence tomography (OCT), near-infrared (NIR), and fibre-optic (FOTI/DIFOTI) technology. All devices rely on shining different types of light on the tooth and can improve the dentist's ability to identify tooth decay.
What are the main results of the review?
The review included 23 studies with a total of 16,702 tooth surfaces. The results of these studies indicate that if the illumination devices were used by a dentist for a routine dental examination of 1000 tooth surfaces, of which 570 (57%) have early tooth decay:
• an estimated 484 would be found to have tooth decay using one of the illumination detection methods, and of these 56 (12%) would not have tooth decay (false positive - incorrect diagnosis);
• of the 516 tooth surfaces in which a device indicated that tooth decay is not present, 142 (28%) tooth surfaces will truly have early tooth decay (false negative - incorrect diagnosis).
In this example illumination devices produce a relatively high proportion of false-negative results, whereby patients do not receive treatment for early tooth decay, for example, high fluoride toothpaste or oral health advice and guidance from the dentist, as they should. Of the data collected from three types of illumination devices, it seems that the OCT device is more sensitive (produces fewer false-negative results) than NIR or fibre-optic technology.
How reliable are the results of the studies in this review?
We only included studies that assessed healthy teeth or those that were thought to have early tooth decay, as teeth with deep tooth decay would be easier to identify. There were some shortcomings in how the studies were conducted, and this may have resulted in the illumination devices appearing more accurate than they really are, increasing the number of correct classifications (green rectangles in the diagram). Many studies evaluated the performance of the devices on extracted teeth, which is very different from when the devices are used inside a person's mouth, where is difficult to see clearly and where teeth may be stained or have a covering of plaque.
Who do the results of this review apply to?
Studies included in the review were carried out in the United States, Europe, Japan, Brazil, China, Malaysia, and Australia. Most studies were completed in dental hospitals, general dental practices, or schools.
What are the implications of this review?
Optical coherence tomography (OCT) shows potential as a device to detect early/enamel caries but more high-quality research and development are required as OCT is not currently available to general dental practitioners. The analysis suggests that OCT is superior to NIR and fibre-optic technologies.
How up-to-date is this review?
The review authors searched for and used studies published up to 15 February 2019.
Of the devices evaluated, OCT appears to show the most potential, with superior sensitivity to NIR and fibre-optic devices. Its benefit lies as an add-on tool to support the conventional oral examination to confirm borderline cases in cases of clinical uncertainty. OCT is not currently available to the general dental practitioner, and so further research and development are necessary. FOTI and NIR are more readily available and easy to use; however, they show limitations in their ability to detect enamel caries but may be considered successful in the identification of sound teeth.
Future studies should strive to avoid research waste by ensuring that recruitment is conducted in such a way as to minimise selection bias and that studies are clearly and comprehensively reported. In terms of applicability, any future studies should be undertaken in a clinical setting that is reflective of the complexities encountered in caries assessment within the oral cavity.
Caries is one of the most prevalent and preventable conditions worldwide. If identified early enough then non-invasive techniques can be applied, and therefore this review focusses on early caries involving the enamel surface of the tooth. The cornerstone of caries detection and diagnosis is a visual and tactile dental examination, although alternative approaches are available. These include illumination-based devices that could potentially support the dental examination. There are three categories of illumination devices that exploit various methods of application and interpretation, each primarily defined by different wavelengths, optical coherence tomography (OCT), near-infrared (NIR), and fibre-optic technology, which incorporates more recently developed digital fibre optics (FOTI/DIFOTI).
To estimate the diagnostic test accuracy of different illumination tests for the detection and diagnosis of enamel caries in children or adults. We also planned to explore the following potential sources of heterogeneity: in vitro or in vivo studies with different reference standards; tooth surface (occlusal, proximal, smooth surface, or adjacent to a restoration); single or multiple sites of assessment on a tooth surface; and the prevalence of caries into dentine.
Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 15 February 2019); Embase Ovid (1980 to 15 February 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 15 February 2019); and the World Health Organization International Clinical Trials Registry Platform (to 15 February 2019). We studied reference lists as well as published systematic review articles.
We included diagnostic accuracy study designs that compared the use of illumination-based devices with a reference standard (histology, enhanced visual examination with or without radiographs, or operative excavation). These included prospective studies that evaluated the diagnostic accuracy of a single index test and studies that directly compared two or more index tests. Both in vitro and in vivo studies of primary and permanent teeth were eligible for inclusion. We excluded studies that explicitly recruited participants with caries into dentine or frank cavitation. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.
Two review authors extracted data independently and in duplicate using a standardised data extraction form and quality assessment based on QUADAS-2 specific to the clinical context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence regions. The comparative accuracy of different illumination devices was conducted based on indirect and direct comparisons between methods. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.
We included 24 datasets from 23 studies that evaluated 16,702 tooth surfaces. NIR was evaluated in 6 datasets (673 tooth surfaces), OCT in 10 datasets (1171 tooth surfaces), and FOTI/DIFOTI in 8 datasets (14,858 tooth surfaces). The participant selection domain had the largest number of studies judged at high risk of bias (16 studies). Conversely, for the index test, reference standard, and flow and timing domains the majority of studies were judged to be at low risk of bias (16, 12, and 16 studies respectively). Concerns regarding the applicability of the evidence were judged as high or unclear for all domains. Notably, 14 studies were judged to be of high concern for participant selection, due to selective participant recruitment, a lack of independent examiners, and the use of an in vitro study design. The summary estimate across all the included illumination devices was sensitivity 0.75 (95% confidence interval (CI) 0.62 to 0.85) and specificity 0.87 (95% CI 0.82 to 0.92), with a diagnostic odds ratio of 21.52 (95% CI 10.89 to 42.48). In a cohort of 1000 tooth surfaces with a prevalence of enamel caries of 57%, this would result in 142 tooth surfaces being classified as disease free when enamel caries was truly present (false negatives), and 56 tooth surfaces being classified as diseased in the absence of enamel caries (false positives). A formal comparison of the accuracy according to device type indicated a difference in sensitivity and/or specificity (Chi2(4) = 34.17, P < 0.01). Further analysis indicated a difference in the sensitivity of the different devices (Chi2(2) = 31.24, P < 0.01) with a higher sensitivity of 0.94 (95% CI 0.88 to 0.97) for OCT compared to NIR 0.58 (95% CI 0.46 to 0.68) and FOTI/DIFOTI 0.47 (95% CI 0.35 to 0.59), but no meaningful difference in specificity (Chi2(2) = 3.47, P = 0.18).
In light of these results, we planned to formally assess potential sources of heterogeneity according to device type, but due to the limited number of studies for each device type we were unable to do so. For interpretation, we presented the coupled forest plots for each device type according to the potential source of heterogeneity.
We rated the certainty of the evidence as low and downgraded two levels in total due to avoidable and unavoidable study limitations in the design and conduct of studies, indirectness arising from the in vitro studies, and imprecision of the estimates.