journal of dentistry 38 (2010) 666670

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In vitro ability of a laser uorescence device in quantifying approximal caries lesions in primary molars
P. Celiberti, V.M. Leamari, J.C.P. Imparato, M.M. Braga, F.M. Mendes *
ria, Department of Pediatric Dentistry, Faculdade de Odontologia, Universidade de Sa o Paulo, Av. Lineu Prestes 2227, Cidade Universita Sa o Paulo 05508-000, SP, Brazil

article info
Article history: Received 4 March 2010 Received in revised form 5 May 2010 Accepted 6 May 2010

abstract
Objectives: This in vitro study aimed at evaluating the ability of Laser Fluorescence device (LFpen) in quantifying approximal caries lesions in primary molars. Methods: Two examiners assessed 123 approximal surfaces of primary molars using the DIAGNOdent pen (LFpen). Surfaces were determined to be either sound with white-spot lesions or have small cavitations. After sectioning, lesion depth was determined through polarized light microscopy. The intra-/inter-examiner agreement was calculated using intraclass correlation coefcient (ICC) and BlandAltman analyses. Furthermore, Spearman

Keywords: Laser uorescence Approximal caries DIAGNOdent Reproducibility Primary teeth

correlation coefcients (Rs) were calculated between LFpen readings and lesion depth. Results: Correlation between LFpen values and lesion depth was low for both examiners (Rs = 0.36 and 0.51), especially when cavitated lesions were excluded from the analysis (Rs = 0.22 and 0.40). For all surfaces, ICC revealed intra- and inter-examiner reproducibility values of 0.75 and 0.63, respectively, but when only non-cavitated surfaces were analyzed, these values decreased (0.41 and 0.33, respectively). Conclusions: LFpen readings present low correlation with approximal caries lesion depth and low reproducibility, especially in white-spot lesions. Therefore, the device could not be a suitable method for monitoring non-cavitated approximal caries lesion in primary molars. # 2010 Elsevier Ltd. All rights reserved.

1.

Introduction

The detection of caries lesions is normally accomplished using visual, tactile and radiographic methods, but these methods are subjective, which normally leads to a low reproducibility. The search for a less subjective and examiner-dependent diagnostic method has led to the development of devices, which aim at providing quantitative and more reproducible method.1 Recently, a new laser uorescence device, named DIAGNOdent pen (LFpen) (Kavo, Biberach, Germany), was introduced into the market.2,3 This new device is based on the same principles of an earlier device, the DIAGNOdent (Kavo,

Biberach, Germany) and has been developed to detect occlusal and approximal caries. The LFpen approximal probe is designed with a prism which deects the laser beam 1008, making it possible to access more properly the approximal surfaces, presenting accurate and reliable results in detecting approximal caries lesions.2,3 However, a method for caries diagnosis should not only be able to detect the presence of caries and its stage, but also be able to monitor its progression or assess its inactivation. For this, the method needs to be reproducible and present correlation with parameters of caries lesions, such as lesion depth, especially amongst non-cavitated lesions, which are in need to be controlled. Since LFpen has presented good

* Corresponding author. Tel.: +55 11 3091 7835; fax: +55 11 3091 7854. E-mail address: fmmendes@usp.br (F.M. Mendes). 0300-5712/$ see front matter # 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2010.05.005

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accuracy and reproducibility in detecting decay on approximal surfaces, its use in monitoring caries on these surfaces was proposed.3 This ability has, however, not yet been tested. Therefore, the aim of this in vitro study was to assess the potential use of LF in monitoring quantitatively approximal caries lesions in primary teeth through the assessment of its correlation with lesion depth and its reproducibility.

2.

Materials and methods

After obtaining approval from the local Committee for Ethics in Research, 84 primary molars, 42 primary canines and 42 rst permanent molars were selected. All primary teeth were extracted by dental practitioners in Sa o Paulo, Brazil (0.7 mg/L uoride in water supply). Prior to the extraction, written consent was obtained from the patients or the patients guardians, and they were informed that their teeth would be used for research purposes in the future. In regards to the rst permanent molars, the teeth were donated by the School of Dentistry, University of Sa o Paulo, using their Bank of Teeth. Following the experiments, the researchers returned the teeth to the university. All procedures were in accordance with Resolution 196/96 of the National Health Council (Brazil). After extraction, the teeth were stored frozen in individual containers at 20 8C with no contact with any storing solutions until use. During the experiment, the teeth were stored in individual plastic containers and thawed at room temperature (ca. 24 1 8C) for 4 h. To avoid dehydration of the samples, a cotton roll soaked in distilled water was placed, at the bottom of each individual container, assuring 100% humidity in the closed container and avoiding contact between the tooth and the cotton roll.4 The approximal surfaces were then cleaned using a rotating brush and pumice/water slurry and rinsed for at least 6 s. In order to simulate approximal contact points/areas, the teeth were placed in arch models and xed with melted utility wax in the following sequence: a primary canine, a rst primary molar, a second primary molar, and a rst permanent molar from the same arch (Fig. 1). Care was taken to simulate the contact points as best as possible, and its presence was conrmed using dental oss. The evaluations were performed only on the approximal surfaces of primary molars. Therefore, the distal surfaces of

Fig. 1 Arch model used to simulate teeth position and the contact points.

canines and mesial surfaces of rst permanent molars were not evaluated. Surfaces with approximal restorations, hypoplastic pits, frank approximal cavitation extending to facial or buccal surface, or to the marginal ridge (the cavitation, when present, could not be detected visually when in contact with the adjacent tooth). Presence of large carious lesions on smooth or occlusal surfaces that could in some way interfere the approximal readings, and surfaces with difculty in simulating the contact point were excluded, yielding in nal sample of 123 approximal surfaces. All examinations were carried out by two trained examiners. One benchmark examiner (M.M.B.) trained the others to perform examinations using the laser uorescence method and visual inspection. For this purpose, the other 15 extracted teeth were used. No calibration procedures were performed. These teeth were not included in the samples. The examiners were directed to analyze each site independently and disagreements were discussed later. Before the examinations, teeth were defrosted as previously described and were again frosted after the examinations. A DIAGNOdent pen device (Kavo, Biberach, Germany) attached to Probe tip 1 (for approximal surfaces) was employed according to the manufacturers instructions. Before each measurement, the LF device was calibrated against a ceramic reference (standard calibration), as well as on a predetermined sound, smooth surface of every tooth, so that a zero value of uorescence could be obtained (individual calibration). This laser uorescence reading was electronically subtracted from the readings of the approximal site under examination. Teeth were kept humid and were air dried for 3 s with a 3-in-1 syringe previously to examination using LF. The detectionside of the LF device tip was introduced underneath the contact area and moved until the peak value was reached. One measurement on the facial and one on lingual interproximal space were carried out and the highest value from both measurements was recorded. One examiner, chosen randomly, repeated all measurements a week after to assess intraexaminer reproducibility. After all examinations were completed, the teeth were removed from the arch models and their surfaces were examined using visual inspection. Specimens were positioned about 30 cm from examiners eyes. With no magnication, an assessment was carried out after air drying for 5 s with aid of a ballpoint probe and light reector. The examiner (VML) classied the surfaces as sound, with either non-cavitated caries lesions or with cavitated caries lesions. This examiner was not aware from the results previously obtained when teeth were examined positioned in the arch model. Subsequently, teeth were embedded in acrylic resin and sectioned mesio-distally in slices ca. 250 mm thick, using a 0.3mm-thick diamond saw mounted in a microtome (Labcut 1010; Extec Co., Eneld, CT, USA). The sections were manually ground and polished with silicon carbide paper (400, 600, 1200 and 4000 grits in sequence) to about 100 mm. Then, the sections were examined in a microscope with transmitted polarized light (Leica DM750, Leica microsystems, Heidelberg, Germany) at 50 magnication and quartz plate. The sections were imbibed in distilled water. The contrast between sound enamel (negative birefringence) and the demineralized enamel (positive birefringence) was detected and the software (Leica

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Fig. 2 BlandAltman plots for intra- and inter-examiner reproducibility of all samples and only non-cavitated surfaces.

Qwin, Leica microsystems, Heidelberg, Germany) determined the depth of the body of the lesion (mm). The statistical unit in this study was the approximal surface. The intra-/inter-examiner agreement, using the entire values of the device, was calculated using intraclass correlation coefcient (ICC) and 95% condence interval (95%CI), and BlandAltman analyses. Furthermore, Spearman correlation coefcient (Rs) and 95% CI were calculated between LFpen readings and lesion depth. As cavitated lesion should undergo restorative procedures, all analyses were repeated after exclusion of the lesions which showed enamel surface discontinuity on visualtactile inspection. All analyses were carried out using statistical software (MedCalc 9.3.0.0; MedCalc, Mariakerke, Belgium), and the level of signicance was p < 0.05.

3.

Results

The visual and tactile inspection revealed 34 (27.6%) sound surfaces, 60 (48.8%) surfaces with non-cavitated caries lesions and 29 (23.6%) surfaces with cavitated caries lesions. The

correlation between the LFpen values and lesion depth for both examiners were low when all 123 surfaces were analyzed (Rs = 0.359; 95%CI = 0.1940.504 for examiner 1; Rs = 0.511; 95%CI = 0.3670.631, for examiner 2). This correlation was found to be even lower when cavitated surfaces were excluded from the analysis (Rs = 0.215; 95%CI = 0.0140.401; Rs = 0.396; 95%CI = 0.2100.554 for examiner 1 and 2, respectively). When all surfaces were analyzed, the ICC revealed a good intra-examiner agreement for the LFpen device (ICC = 0.745; 95%CI = 0.6580.813). The inter-examiner agreement was found to be lower and with larger range of differences between readings done by different examiners (Fig. 2). The ICC was 0.632 (95%CI = 0.5240.720). When only non-cavitated surfaces were analyzed, the intra-/inter-examiner reproducibilities were found to be considerably low. Intra-examiner reliability presented ICC = 0.411 (95%CI = 0.2450.553), and the value for interexaminer reproducibility was ICC = 0.328 (95%CI = 0.186 0.456). The mean of differences as well as the limits of agreement (mean 1.96SD) for both inter- and intra-examiner agreement can be seen on the BlandAltman plots (Fig. 2). When the plots were analyzed, we could observe that the

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disagreements are more pronounced in lesions with higher LFpen readings, indicating higher variability in measurements of more advanced caries lesions (Fig. 2).

4.

Discussion

The present study evaluated the potential use of LFpen in monitoring quantitatively approximal caries lesions in primary teeth through the assessment of its reliability and correlation with lesion depth. Previous studies have investigated the performance of the device in detecting approximal caries lesions,3,5,6 but the ability of LFpen in quantifying these lesions has not been assessed. Our results showed that the device presented low correlation with lesion depth and poor reproducibility. These ndings, therefore, could contradict the previous assertion that the device could be able to monitor caries progress or arrest.3 In order to determine the agreement using absolute LF readings, ICC was carried out.7 The method of Bland and Altman8 was additionally performed in order to show deviations from the LF readings and indicate the range between the upper and the lower limit of agreement between LF readings performed by different examiners. Both analyses were performed twice, rstly using all samples and then, strictly considering non-cavitated surfaces. This last step was carried out in order to assess the reproducibility of LF pen on surfaces in need of non-operative treatment, according to the concepts of minimal intervention dentistry, which advocate the adoption of preventive measures on non-cavitated lesions in enamel and dentine.9 After being submitted to preventive measures, noncavitated surfaces need to be monitored over time in order to state the success of the treatment or to detect lesion progression. However, approximal caries lesions diagnosis and control has seen limited success by means of clinical examination, due to restricted access in this area and the location of these lesions. Radiographs are able to aid detection of approximal lesions within enamel or already progressed into dentine,10 estimating lesion depth. However, besides the hazards of ionizing radiation, radiographs with similar lm position and X-ray beam angulation, which would provide an adequate control of lesion progression, are more difcult to achieve. Thus, a quantitative, valid and reproducible method in monitoring approximal caries lesions and that reduces the need of frequent control radiographs is wished. Although a previous study has claimed that the LFpen could be useful in monitoring approximal caries lesions due to its high reproducibility,3 we have found low intra-/interexaminer reproducibility, especially when cavitated lesions were not considered. This is consistent with a previous in vivo study on primary molars, which also showed a lower agreement values at white-spot threshold.6 Furthermore, higher ICC values and lower range values were observed in the intra-examiner analysis than in the inter-examiner one, what is in agreement to an earlier study performed on occlusal surfaces.11 The Bland and Altman analysis showed that the lowest range between the upper and the lower limits of agreement could be seen for intra-examiner agreement, in spite of surface condition, meaning that a lower measurement

deviation could be observed when the same examiner performed both LFpen readings. As to the presence of cavitated surfaces in the analysis, lower range values were observed only when non-cavitated surfaces were included. As this lower range does not mean that a smaller deviation in the measurements occurred, this comparison is not acceptable. The range is dependent on the measurement value available for the device. Non-cavitated surfaces are likely to exhibit a lower range, as these surfaces yield lower LFpen values than cavitated ones. A previous study on occlusal surfaces divided the sample in two intervals, and showed a lower range for the samples under the cut-off point of 30.11 Besides the low reliability, a low correlation between LFpen values and histological lesion depth was observed in the present study. This correlation was even lower when cavitated lesions were removed from the sample. This low correlation between LFpen values and histological examination indicates that the method did not properly measure the actual status the disease. Despite the fact that the device shows numerical values from 0 to 99, LFpen does not work as a quantitative method in assessing approximal caries lesions. Therefore, the method can detect accurately approximal caries lesions,3,5,6 working as a qualitative method, but it cannot quantify these lesions. The rst version of the device presented higher correlation with smooth surface caries lesions in primary teeth,12 probably because of the easier access to this type of lesion and direct contact of the tip with the lesion, what probably did not happen in approximal assessments with the new device. Some authors have afrmed that lesion depth assessed by polarized light microscope is not the main property of caries lesions to indicate the severity, and the mineral loss would be more appropriated. However, lesion depth is the second most important property which indicates severity of caries lesions. Furthermore, signicant correlation has been observed between mineral loss and lesion depth.13 Despite of this, further studies should be conducting evaluating the ability of LFpen in quantifying mineral loss of caries lesions instead of lesion depth. When only non-cavitated caries lesions were considered, LFpen was shown to perform worse than in detecting cavitated lesions at the approximal surface, corroborating previous ndings.6,14 This can be due to its mode of function, where uorescence is detected from changes in the organic content due to bacterial metabolites, rather than demineralization. As a cavitated lesion is obviously more infected than a non-cavitated one,15 a better performance of the LFpen device is to be expected in these lesions. In conclusion, LFpen is not able to quantify approximal caries lesion depth and presents low reliability in primary molars, using an in vitro study design. Therefore, the results suggest that method could not be a suitable method for quantitatively monitoring approximal caries lesion in primary molars, especially non-cavitated lesions.

references

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