Accepted Manuscript

Title: Detection of proximal secondary caries at cervical classII-amalgam restoration margins in vitro
Authors: K.W. Neuhaus, J.A. Rodrigues, R. Seemann, A. Lussi
PII : S0300-5712(12)00062-0
DOI : doi:10.1016/j.jdent.2012.02.014
Reference : JJOD 1858

To appear in : Journal of Dentistry

Received date : 21-9-2011
Revised date : 10-2-2012
Accepted date : 22-2-2012

Please cite this article as: Neuhaus KW, Rodrigues JA, Seemann R, Lussi A, Detection of proximal
secondary caries at cervical class II-amalgam restoration margins in vitro, Journal of Dentistry (2010),
doi:10.1016/j.jdent.2012.02.014

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Detection of proximal secondary caries at cervical class II-amalgam restoration margins
in vitro


Neuhaus KWa, Rodrigues JAb, Seemann Ra, Lussi Aa




aDepartment of Preventive, Restorative and Pediatric Dentistry, School of Dental Medicine,
University of Bern, Switzerland
bDepartment of Pediatric Dentistry, School of Dentistry, Federal University of Rio Grande do
Sul, Brazil



Short title: Detection of proximal secondary caries





Key Words: Caries detection, Approximal caries, Root caries, Secondary caries, Laser
fluorescence, Bitewing radiography









Corresponding author:
Dr. Klaus W. Neuhaus MMA
Department of Preventive, Restorative and Pediatric Dentistry
School of Dental Medicine
University of Bern
Freiburgstrasse 7
CH-3010 Bern
Switzerland
Tel: +41 31 632 2580
Fax: +41 31 632 9875
Email: klaus.neuhaus@zmk.unibe.ch

Abstract
Objectives:
To compare the performance of LFpen (DIAGNOdent pen) with two different wedge-shaped tips to
conventional bitewing radiography (BW) for detecting proximal secondary caries at thecervical
margin of amalgam restorations in vitro.
Methods:
Seventy-five molars with class II amalgam restorations were selected. Depending on the marginal
filling extension, data was subdivided into a crown group (C), when the filling ended in enamel, and
into a root group (R), when the filling ended beyond the cementum enamel junction. Bayesian
analysis including calculation of the area under the receiver operating curve (AUC) was performed.
Furthermore, Spearman correlations between caries and cofactors, such as presence of plaque or
stain, occlusal ditching, marginal gap size, filling overhangs, and shortfalls, were calculated.
Additionally, for group R the correlation coefficient between LFpen measurements and lesion depth
was calculated. Histology served as gold standard.
Results:
In group C both at the D1 and D3 levels, LFpen with two different tips showed a better performance
than bitewing radiography (AUC at D1: 0.83/0.79 (LFpen) and 0.63 (BW); at D3: 0.66/0.66 (LFpen)
and 0.53 (BW)). In group R, the respective AUC values were 0.53/0.56 (LF) and 0.59 (BW). A
significant medium correlation was observed for occlusal ditching and proximal caries. Stain
accumulation at the restoration margins especially in combination with filling overhangs interfered
with LFpen readings, resulting in false positive measurements.
Conclusions:
Compared to BW, LFpen enhances the detection of secondary caries lesions at the cervical margin of
amalgam restorations that do not extend below the cementum-enamel junction.

Introduction
Secondary caries is a problem often encountered in dental practice and is considered as one of the
most important reasons for amalgam restoration replacement.
1,2
Secondary caries is defined as a
lesion observed at the margins of an existing restoration.3 These lesions usually occur as an outer
lesion, which is histologically similar to a primary lesion next to a restoration, and/or as a wall
lesion, which is a narrower defect in the enamel or dentine at the cavity wall.4,5 Secondary caries
lesions on approximal surfaces are difficult to detect unless the lesion is relatively advanced, with
considerable loss of tooth structure
.6-8
In cases of a restoration extending to or close to the cementum-
enamel junction (CEJ), a secondary lesion in the rootdentine can occur. This region of the tooth is
highly irregular and represents a particularly vulnerable bacterial retention site.
9

Currently, the methods for proximal secondary caries detection comprise visual-tactile
examination in order to assess the degree of demineralization at restoration margins, and bitewing
radiographs in combination. The visual interpretation of the colour changes (i.e. brown or grey
discoloration) on the buccal and lingual surfaces of class II-amalgam restorations is subjective and
may lead to false diagnostic outcomes.
10
Furthermore, the adjacent tooth and gingival tissue hamper
the visual access to the proximal surface, especially at the cervical margin of a proximal restoration,
which is the predominant region of secondary caries development.
2
Temporary tooth separation,
when applied to allow for better visual access, has limited diagnostic gain with respect to the
detection of cavity formation on a proximal surface.11 Bitewing radiographs can help the clinician to
detect advanced mineral loss, but even under optimal conditions in vitro a high degree of diagnostic
uncertainty was reported for small lesions.
12
Besides, it is known that the lesion size can be
underestimated in radiographs.
8

Because of the difficulties encountered in detection of proximal secondary lesion detection
with traditional means, it seems advisable to test additional caries detection methods. Laser
fluorescence (LF) was studied for secondary lesion detection around amalgam restorations.
7,13
For
occlusal amalgam restorations, a somewhat higher sensitivity was reported for LF (0.77) than for
bitewing radiography (0.65) with specificities being the same for both methods (0.81) (7). However,
an in vivo study with 51 restorations in 21 patients showed, that on occlusal surfaces the sensitivity
and specificity to detect secondary caries next to amalgam restorations was 0.60/0.81 compared
0.56/0.91 in bitewing radiography.
13
Although the LF method showed the highest diagnostic accuracy compared to
radiography and visual-tactile inspection in that study, a particular problem
with false-positive measurements at restoration margins was reported.13 LF
measurements are prone to falsepositive readings due to fluorescent media like
bacterial plaque or stain.14 In another in vitro study, LF was compared with
several means of visual inspection (taking into account signs of
demineralization, ditching and discoloration) and with quantitative light induced
fluorescence (QLF).15 Both LF and QLF were reported to be promising tools to
detect small lesions around amalgam restorations.

A new laser fluorescence device (LFpen; DIAGNOdent 2190, Kavo, Biberach,
Germany) was developed and its performance in detecting approximal caries lesions
has been evaluated.16 Lussi et al. showed that the LFpen is capable of detecting
decay on approximal surfaces with good accuracy.16 Although the LFpen showed
acceptable performance in a prospective clinical bi-center study for approximal
lesion detection17, it was criticized that the thickness of the 0.4 mm sapphire
tip was still too big to assess the region of approximal caries, which normally
forms beneath the contact area of two neighbouring teeth. However, in class-II-
restorations the contact areas are utterly different from those of unfilled
teeth, because usually the proximal box preparation extends below the tight
contact area. A wedge is then normally used to separate the neighbouring teeth
and to fixate the matrix. The anatomical space should allow accessibility of the
LFpen at the gingival region adjacent to the filling. This was tested with a set
of randomly chosen bitewing radiographs of good quality (parallel technique, no
overlaps). In 48/50 teeth with approximal amalgam restorations the measured
distances were 0.4 mm or more (unpublished results), thus allowing penetration of
the sapphire tip. Therefore, this study aimed at comparing the capability of
bitewing radiography and LFpen with two different optical tips to detect proximal
secondary caries associated with amalgam restorations. We also wanted to assess
the impact of plaque/stain retention sites such as filling overhangs and ditches
on LFpen readings.


Materials and Methods
Set up
Eighty permanent human molars with class II amalgam restorations were selected
from a pool of extracted teeth, which had been stored frozen at -20C until use.
One aspect beneath the proximal restoration (cervically of the restoration
margin) was chosen (Fig 1). Teeth with either a visually sound surface or signs
of demineralisation (whitish or brownish appearance with or without cavitation in
enamel, yellowish to brownish or black appearance in root dentine) were included
in this study. Previous studies showed that the fluorescence and cutoff values do
not change when the teeth are stored under these conditions.18 Marginal calculus
was removed using a scaler (Cavitron, Dentsply, York, PA, USA) and working
movements parallel to the tooth axis, and the teeth were cleaned from the
occlusal aspect only for 15 s with water and then for 10 s with Prophyflex (KaVo,
Biberach, Germany) and sodium bicarbonate powder. To remove powder remnants from
the fissures, the teeth were rinsed using the 3-in-1 syringe for 10 s.
Photographs (magnification 6.5X) were taken of the occlusal surfaces to identify
the teeth and were taken of the approximal surfaces to determine the exact sites
for examination and later histological preparation. The study teeth were mounted
in pairs between two sound teeth, whose roots were embedded in composite resin,
in order to obtain a tight contact. The blocks were stored frozen at -20C under
100% humidity throughout the study.

Radiographic examination
Bitewing radiographs (BW) were taken of all blocks using an X-ray machine (HDX
Dental EZ, USA) and double Kodak Insight films (22 mm X 35 mm, Kodak, Rochester,
Minn., USA) at 65 kV, 7 mA and an exposure time of 0.09 seconds. The source-to-
film distance was 6100mm. Close to the object on the focus side, a 5-mm-wide
plastic mould was placed to simulate soft tissues. Two trained examiners assessed
the radiographs independently by using a negatoscope/ light-box (Imatec
Rntgentechnik, Switzerland) and an X-ray film magnifier (2X magnification;
Svenska Dental Instrument, Sweden). Radiographic assessments were repeated after
one week under the same conditions. For crown and root caries, the following
scoring system to assess the cervical restoration margin was used: no
radiolucency (0), radiolucency in enamel (1) and radiolucency in dentine (2).

Assessments with the LFpen
LFpen measurements were carried out using two different tips of 0.4 mm thickness
and with the following width: WDG (wedge-shaped) 1.1 mm and TWDG (tapered wedge-
shaped) 0.7 mm. The device was calibrated before each measurement according to
the manufacturers instructions. The approximal surfaces were carefully assessed
with the LFpen by one examiner. The tips were moved from the buccal toward the
lingual side, underneath the contact area. The procedure was repeated moving the
tips from the lingual toward the buccal side. The two peak values were recorded,
and the higher of these values was considered for further statistical analysis.
The same examiner repeated the measurements after one week under the same
conditions to establish intra-examiner reliability.

Histological validation (gold standard)
After the assessments, the teeth were ground longitudinally until 1 mm before the
site of measurement using a rotating polishing machine (Knuth-Rotor, Struers,
Copenhagen, Denmark) with 60-m grain size silicon carbide paper cooled under
tap water. When the periphery of the site was reached by the grinding process,
papers of grain size 30, 18, 8 and 5 m were used. Afterwards, the cut surfaces
were cleaned and dehydrated in solutions of increasing alcohol concentration with
the addition of basic 0.5% fuchsine (Inselspital- Apotheke, Bern, Switzerland) to
achieve block staining.19 The alcohol was removed with acetone, and the teeth
were embedded in methyl methacrylate (Merck, Darmstadt, Germany). The embedded
samples containing the tooth section were contrast-stained with light green in
acetic acid solution (0.25% light green dissolved in 0.20% acetic acid) for 2
min, cut and ground until slices of 300 m thickness were obtained. For cutting,
a diamond abrasion wheel (Isomet, 11-1, 180 Low Speed Saw, Buehler Ltd., USA) and
the polishing machine described above were used. Hardness measurements of the
histological specimens were performed to aid the histological classification in
cases of doubt. This measure used a Knoop diamond (KNH) under a force of 100g,
which is equivalent to a force of 0.981 N, with a load time of
15 seconds (Leitz Wetzlar, Germany). Sound enamel and sound dentine surfaces were
measured to obtain a baseline KNH value. Cross-sectional KNH measurements were
made in a horizontal (wall lesion) and a vertical direction (outer lesion). For
enamel, hardness values below 200 KHN20 and for dentine/ root dentine, values
more than 10 KNH21 levels below baseline were considered indicative of caries.
Photographs of the cut coloured surfaces were taken (Leica DC300 camera, Leica,
Heerbrugg, Switzerland). Two examiners assessed the sites (magnification 10X) to
reach a consensus and classify the lesion. The samples were divided according to
the histological assessments into coronal caries and root caries groups.
The samples were considered to have root caries if no enamel was observed and
if the restoration reached at least the cemento-enamel junction. The coronal
lesions (group C) under the restoration were then classified as: caries-free
(D0), caries extending up to halfway through the enamel (D1), caries extending
into the inner half of the enamel (D2), caries in the dentine (D3) and deep
dentine caries (D4). For root caries (group R), the sites were classified as:
caries-free (D0R) and root caries (D1R). Separate caries records were taken for
wall lesions (residual caries/ horizontal caries extension) and for outer
lesions (recurrent caries/ vertical caries extension). For statistical analysis
we only considered overall lesions with respect to the greatest extension in
either horizontal or vertical direction. Using the digital photographs, the width
of the occlusal and cervical marginal ditches between restoration and tooth were
measured as well as the dimension of overhang and shortfall of the restoration
(IM500, Leica, Heerbrugg, Switzerland). Furthermore, the depth of the root caries
lesions was digitally measured (ImageJ, Washington, NIH, USA). For root caries,
lesion depth was measured using imageJ software (NIH, Bethesda, Maryland)
according to Karlsson et al.22 Lesion depth 1 was the actual lesion depth, while
lesion depth 2 additionally extrapolated the tooth substance loss caused by
caries

Results
Eighty teeth with proximal amalgam restorations were available for this study.
After histological processing, five teeth were excluded from the study due to
fractures. Thirty teeth had proximal restoration margins that extended beyond the
CEJ (group R), in 45 teeth the proximal restoration margins ended in enamel
(group C). In group C, 11 teeth were scored as D0, 16 as D1, 7 as D2, 17 as D3,
and 1 as D4 with respect to wall lesions; with respect to outer lesions we
detected 21 D0, 11 D1, 6 D2 and 7 D3 lesions. The distribution of overall
caries depths was: D0: 5; D1: 15; D2: 8; D3: 16; D4: 1In group R, 10 lesions were
rated D1R for wall lesions, and 10 as D1R for outer lesions. The overall caries
distribution in this group was: D0R: 10; D1R: 20.

Table 1 shows the results of the Bayesian analysis with respect to overall
caries levels sound (D0), enamel caries (D1,2), dentine caries (D3,4) and sound
and carious roots (D0R and D1R, respectively). The cutoff values used were those
of Lussi et al. (16). For root caries, using ROC analysis optimum cutoff values
were identified at 46 (WDG) and 62 (TWDG).

In group R, only weak correlations could be detected for laser fluorescence
measurements and lesion depth (Table 2).

Table 3 gives cross tabulations of LFpen measurements with histology. It can be
seen, that there is a clear tendency for false positive measurements and over-
estimation of lesion depth in enamel caries.


Discussion
In this study we compared the performance of the LFpen device with two different
wedgeshaped tips to caries detection with bitewing radiography. A moderate
agreement between WDG and TWDG could be detected. This might be explained by the
different design of the two tips, the thinner TWDG tip being less capable of
collecting back-scattered fluorescence signals than the broader WDG tip. The
laser fluorescence measurements of the WDG and TWDG indicated a better diagnostic
accuracy for secondary enamel caries than radiography. Also, the sensitivities
measured were considerably higher for LF than for radiography at the enamel
threshold (WDG: 0.82 and TWDG: 0.78 vs. BW: 0.3). The LF method has been already
tested for the detection of occlusal secondary caries around amalgam fillings in
extracted permanent
7
and primary teeth.
23
It is not possible to directly compare
our results with the study of Bamzahim et al.,
7
because in that study the first
LF device (DIAGNOdent 2095) was used and because only an overall accuracy was
reported, independent of the histological lesion depth. For occlusal secondary
caries in primary teeth, the accuracy at the D3-level was reported to be 0.69,
23

while in the present study slightly lower accuracies of 0.62 (TWDG) and 0.56
(WDG) for proximal surfaces were found. Compared to results that have been
achieved for approximal primary caries in permanent teeth in vivo, (Huth et al.
17
:
sensitivity 0.6, specificity 0.83 at dentine threshold), our results for the
detection of secondary caries around amalgam restorations are considerably lower.
The in vivo application for the mentioned purpose may be questionable as
indicated at D3-level by the low positive predictive values of 0.5 (TWDG) and
0.45 (WDG), which equals pure chance.

According to the findings of this in vitro study, the use of bitewing radiographs
for proximal lesion detection is fraught with limited caries detection gain,
while this effect was more pronounced for enamel caries than dentine caries
compared to LF (Tab. 1). Although radiographs showed high specificities,
sensitivities were generally low, resulting in clinically not acceptable values
of accuracies (D1:0.37; D3:0.64; D1R: 0.66). This is in line with findings from
Kidd et al., who reported that in non-cavitated teeth the sensitivity was 0.
18
,
while the specificity was high (0.98).
24
In cavitated proximal lesions, a
considerable rise of accuracy by radiographic examination could be detected
(sensitivity 0.88). Reduced sensitivities for proximal secondary lesion detection
around amalgam fillings was also reported by Espelid et al. who found a
sensitivity of 0.47 and specificity of 0.88.
25
The diagnostic performance of
bitewing radiography in this study (AUC D1: 0.63, D3: 0.53; D1R: 0.59) was
comparable to other studies (AUC D1: 0.35, D3: 0.68; D1R: 0.50).20 However, the
prevalence of non-carious teeth in this study was low (5 in group C, 10 in group
R), leading to a risk of over-estimation of sensitivity and under-estimation of
specificity.

We found a significant correlation between occlusal ditching and approximal
secondary caries (p=0.04). This is in line with the literature stating, that the
occlusal quality of an amalgam filling has some predictive value for the presence
of approximal caries. Eriksen et al. found in a cross-sectional study including
1694 class-II-amalgam fillings in 144 patients that the occlusal deterioration of
the margin to a clinically not acceptable or nearly not acceptable extent was
associated with approximal secondary caries in 23.6% and 9.2%, respectively.
26
However, in our study we found that an occlusal gap > 0.4 mm was associated with
approximal crown caries in 19/20 cases, and with approximal root caries in 13/14
cases. Even considering the fact that our sample included only 5 histologically
sound crowns, aclinical conclusion from our findings could be that in cases of
class-II-amalgam fillings with occlusal gaps exceeding 0.4 mm one should rather
replace the whole amalgam restoration as there might be a good chance of
secondary caries on the proximal side, even if it was not detected clinically or
with radiography.

It was stated earlier, that in amalgam fillings a gap size of >0.4mm harboured
significantly more bacteria than smaller gap sizes.
27
In teeth with cervical gaps
exceeding this threshold, we could detect more secondary caries in crowns (29/31)
than in roots (8/23). A reason might be that restoration margins that clinically
extend to root cementum are more likely to be protected by gingival crevicular
fluid, which pH is known to be neutral in healthy individuals, and increasing
with gingival inflammation.
28
However, we did not estimate the former attachment
level of the teeth and the respective distance from restoration margin to the
gingiva in this study. It appears thus, that defective proximal amalgam
restoration margins, as established for occlusal restorations before are not per
se indicative for the presence of secondary caries.
29,30
It was shown in a clinical
trial that only 14% of the teeth with clinically defective margins also presented
caries in the radiograph.31 In our study, the presence and size of a marginal gap
did not correlate with the presence of caries either (=0.006). The presence of
defective margins in amalgam restoration seems to lead to different operation
outcomes in private practitioners. In a questionnaire survey among American
dentists (n=901), it became evident that 48% of the dentists would replace an
amalgam filling with a defective margin, while 65% would replace a composite
filling with the same defective margin.
32

Because the marginal gap size itself was shown not to be indicative for secondary
caries, and because accumulated stain or bacteria can positively influence LFpen
readings, it would be advisable to refinish and polish the proximal parts of
amalgam restorations prior to LFpen assessments, e.g. using oscillating files.
Apart from purported beneficial effect for the surrounding tissues, this
procedure also enables better visual-tactile diagnostics at the restoration
margin. This recommendation is in line with earlier findings, that unpolished
filling materials can lead to false positive LF signals, while the same materials
are below dentine caries detection threshold after polishing.
33

Conclusions
In summary, our results indicate that compared to conventional bitewing
radiography the use of the LFpen for proximal lesion detection at the cervical
margin of amalgam restorations might lead to a better diagnostic performance for
secondary caries that does not extend beyond the cementum-enamel junction.
Whether or not this contributes to clinical decisionmaking should best be studied
in vivo.

Figure 1












Figure 2













































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