Association between two visual criteria in assessing non-cavitated caries lesion activity on occlusal surfaces of permanent molars R. S. Oliveira, J. E. A. Zenkner, M. Maltz & J. A. Rodrigues
Clinical Oral Investigations ISSN 1432-6981 Volume 19 Number 2 Clin Oral Invest (2015) 19:565-568 DOI 10.1007/s00784-014-1375-2
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Author's personal copy Clin Oral Invest (2015) 19:565–568 DOI 10.1007/s00784-014-1375-2
SHORT COMMUNICATION
Association between two visual criteria in assessing non-cavitated caries lesion activity on occlusal surfaces of permanent molars R. S. Oliveira & J. E. A. Zenkner & M. Maltz & J. A. Rodrigues
Received: 8 April 2014 / Accepted: 20 November 2014 / Published online: 3 December 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Objective This study aimed to evaluate the association between two visual criteria in assessing non-cavitated caries lesion activity on occlusal surfaces of permanent molars. Materials and methods Thirty-nine patients with at least one permanent molar with non-cavitated caries lesion on the occlusal surface were selected. Molars were assessed according to their activity status following two criteria: ICDAS-LAA and a qualitative criterion based on clinical characteristics. Results The results showed that the LAA criterion seems to overestimate caries activity. A weak association between both criteria in assessing caries lesion activity and low specificity for ICDAS-LAA was observed. Conclusions The ICDAS-LAA criterion is not suitable to assess non-cavitated caries lesion activity on occlusal surfaces of permanent molars because it assesses the lesions to be active more frequently than the qualitative criterion. Clinical relevance The determination of caries lesion activity is a key decision point in the treatment of caries disease. This study discusses the best option to assess the activity of noncavitated occlusal caries lesions.
R. S. Oliveira : J. A. Rodrigues (*) Department of Pediatric Dentistry, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2492, Porto Alegre, RS, Brazil e-mail:
[email protected] J. E. A. Zenkner Department of Stomatology, School of Dentistry, Federal University of Santa Maria, Floriano Peixoto, 1184, Santa Maria, RS, Brazil M. Maltz Department of Social and Preventive Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Ramiro Barcelos, 2492, Porto Alegre, RS, Brazil
Keywords Occlusal surfaces . Caries activity . Permanent molars . Clinical study
Introduction The determination of caries lesion activity is a key decision point in the treatment of caries disease. The active noncavitated status of a lesion has been used in clinical studies since 1954 [1]. Enamel changes during lesion formation have been described in an elegant paper by Holmen et al. (1987) [2]. Nyvad et al. (1999) [3], based on the clinical features of lesion activity, suggested a visual set of criteria aimed at assessing the activity of caries lesions. Although (1) a consensus exists in the literature regarding the clinical features of caries disease activity and (2) lesion characteristics for determining the activity have been widely used in clinical studies [4–6], the use of these clinical criteria is still extensively discussed [7]. In 2007, a scoring system for determining caries activity Lesion Activity Assessment (LAA) was suggested for use in conjunction with International Caries Detection and Assessment System (ICDAS). ICDAS-LAA is an objective criterion, which is based on the combined knowledge of three clinical factors related to caries activity (visual appearance, the area where the lesion is located, and surface texture) [8]. These criteria receive an individual score based on their predictive value in determining caries activity, and the sum of these points is judged based on a cutoff point. Some studies compared the performance of both visual criteria, Nyvad and ICDAS-LAA, in assessing caries lesion activity on occlusal surfaces of deciduous teeth (in vitro study: Braga et al. (2009) [9]; in vivo study: Braga et al. (2010) [10]). Regarding noncavitated lesions, the level of association between the two sets of criteria was significant but low. The authors concluded that ICDAS-LAA seems to overestimate activity of cavitated
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lesions compared with the Nyvad criteria [10]. However, there is no study evaluating the clinical performance of ICDASLAA in assessing the activity of non-cavitated caries lesions in permanent teeth. Therefore, the aim of this clinical study was to evaluate the association between the ICDAS-LAA criteria and a qualitative criterion in assessing non-cavitated caries lesion activity on occlusal surfaces of permanent molars.
Subjects and methods Ethics This study was approved by the Federal University of Rio Grande do Sul Ethics Committee (Protocol number 75637/ 2012). A written informed consent was obtained from the children’s parents or legal guardians, and the children agreed to participate. Reproducibility Before the beginning of the study, the examiner (RSO) was trained and calibrated for all criteria used. The training session included the clinical examination of 20 patients who did not participate in the study. To assess intra-examiner reproducibility, seven patients were clinically examined. The interval between examinations was 1 week. Cohen’s unweighted kappa values obtained for each criterion were 0.90 for the ICDAS criterion, 0.89 for ICDAS-LAA, and 0.83 for clinical parameters [2–6, 11–13] (referred to in this study as qualitative criterion). Sample and eligibility criteria Thirty-nine patients, aged between 5 and 13 years old (9.1± 2.08, mean±SD), who sought treatment at the School of Dentistry, Federal University of Rio Grande do Sul (Porto Alegre, Brazil), were selected. To be included in the study, patients should have presented with at least one permanent molar (first or second) with a non-cavitated caries lesion on its occlusal surface. Permanent molars with sound occlusal surfaces (n=49), cavitated lesions (n=14), pit and fissure sealants (n=2), or enamel hypoplasia (n=2) were excluded. Data collection Clinical examinations were performed after professional prophylaxis using fluoridated toothpaste by the same examiner in a dental unit, using a light source, 3 in 1 air water syringe, dental mirror (Duflex, Rio de Janeiro, Brazil), and WHO probe (HuFriedy, Rio de Janeiro, Brazil). The permanent molars were classified according to the presence of non-
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cavitated caries lesions and their activity status. Caries presence was detected using ICDAS [14]. The activity assessment was performed according to two criteria: a qualitative criterion and ICDAS-LAA. In assessing activity according to the qualitative criterion, lesions were classified according to the clinical parameters that are a consensus in the literature and are based on the evaluation of brightness, color, and texture [2–6, 11–13]. Active caries was defined as a rough and opaque white spot lesion while inactive caries was defined as a smooth white or brownish lesion with shiny appearance. ICDAS-LAA was scored according to three evaluations: (1) clinical appearance (ICDAS score), (2) plaque stagnation, and (3) texture evaluated by drawing the probe across the surface [8]. The score obtained was used to determine whether the lesion was active or arrested (score >7 indicated an active lesion) (Table 1). Data analysis Scores were dichotomized into active or inactive according to the criteria used. The association between both criteria in determining caries activity was expressed as percentage of agreement and Cramer’s V contingency coefficient. The level of significance was set at p>0.05.
Results One hundred ninety-one permanent molars of 39 patients were examined. One hundred twenty-four teeth with non-cavitated caries lesions on the occlusal surface were included (teeth/ patient mean and SD 3±1.57). The results showed a weak, although significant, association between both criteria in assessing non-cavitated caries lesion activity (Cramer’s V coefficient 0.39, p7 is used. A study that evaluated the sensitivity and specificity of ICDAS-LAA considering the established cutoff (>7) and a new cutoff (>8) showed an increase in specificity for ICDASLAA when the new cutoff point was used [10]. We agree with Braga et al. (2010) [10] that further studies are needed to establish the optimal threshold for ICDAS-LAA in assessing caries activity. Thus, the results of this study point out that caution is required when using ICDAS-LAA in assessing caries activity, since it seems to overestimate disease activity. This overestimation is worrisome, as treatment choice is strongly related to disease activity. Thus, the use of ICDAS-LAA for assessing caries activity may lead to the overtreatment of patients. This situation is not desirable in view of the minimally invasive philosophy and current characteristics of caries, in which a slow progression rate of active initial lesions is observed [15, 16]. This indicates the need for using methods with high specificity, in which the number of false-positive results is minimal. Therefore, it is concluded that there is a difference between both methods and ICDAS-LAA criterion seems to assess the lesions to be active more frequently than the qualitative criterion. Therefore, ICDAS-LAA criterion is not suitable to assess
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non-cavitated caries lesion activity on occlusal surfaces of permanent molars, because it seems to overestimate lesion activity. Clinical features based on roughness, texture, and color still are the best option to assess the activity of noncavitated occlusal caries lesions. Conflict of interest The authors declare that they have no conflict of interest.
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