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20 PAEDIATRIC Dental Tribune Middle East & Africa Edition | 2/2018 The performance of ICDAS-II using low-powered magnifi cation with light-emitting diode headlight and alternating current impedance spectroscopy device for detection of occlusal caries on primary molars Research Article By Prof Timucin Ari and Prof Nilgun Ari, UK It is well established that caries lev- els in industrialized nations have decreased over the last few decades with the greatest reductions occur- ring on the smooth and approximal surfaces.1–4 Because of the complex occlusal anatomy, more sensitive and reproducible diagnostic tools for precise caries detection in children are needed.5 Visual examination still is the most commonly used meth- od for detecting dental caries, but various studies showed problems for sensitivity and reproducibility problems.6–8 A standardized scoring system, International Caries Detec- tion and Assessment System (ICDAS- II), has been developed for clinical practice and research to overcome these problems.9 A complimentary approach to visual examination is to use visual aids such as low-pow- ered magnifi cation (dental loupes) and special headlights mounted on them. These visual aids became popular among dentists to improve precision of visual examination and for ergonomic reasons.10,11 Advances in caries research led novel technolo- gies to help dentists in the diagnosis of early lesions. ACIS device (CarieS- can PRO, Dundee, Scotland) is one of the recent examples of the novel technologies. This device relies on the application of a small alternat- ing electrical signal (undetectable by the patient) through the tooth while monitoring the response at the sensor. By changing frequency of the applied signal, a spectrum is cap- tured which provides valuable in- sights into the physical and chemical properties of the tooth.The result is displayed on the LCD screen and the color LED display that enables dental professionals to evaluate the depth of the carious lesion. Pediatric den- tistry, with its small operating fi eld and its demands for manual skills and precision, is particularly suited to the use of novel technologies and visual aids. Therefore the aim of this study was to compare in vitro the diagnostic performance of low-powered mag- nifi cation (2.5x) with mounted LED headlight illumination using ICDAS- II criteria and AC Impedance Spec- troscopy device, on occlusal surfaces of primary molars. Materials and Methods Prior to undertaking the study, ethi- cal approval was granted by Western University Research Ethics Board for Health Sciences Research (File no. 101093). Eighteen recently extracted second primary molars (n = 18) were selected for this in vitro study. Ex- tracted teeth were kept in #"% neu- tral buffered formalin immediately following extraction. Only teeth with sound to incipient lesions were selected; teeth with occlusal restora- tions, occlusal fi ssure sealants, and hypoplastic pits were excluded from this study. Prior to examinations, each tooth surface was cleaned with pumice and water slurry to remove any debris and rinsed thoroughly in sterile water. The teeth were mount- ed to impression putty (VP Mix Put- ty, Henry Schein Inc., USA) in order to mimic intraoral anatomical position for mixed dentition. The details of each score for ICDAS- II examination and ACIS device instructions were discussed. Exam- iners were calibrated by a training exercise on both techniques fol- lowed by discussion to consensus of any uncertainties. In order to assess intra- and interex- aminer reproducibility, 15 primary molars (7 primary 1st molars and 8 primary 2nd molars) that were not included in the present study were examined on two separate oc- casions with two weeks interval by both examiners. All examinations were conducted under standard conditions in dental surgery, with conventional dental light (A-dec,OR, USA) and 3 : 1 syringe. The teeth were positioned 40 cm to examiners’ eyes and kept wet during the examina- tions unless when dried for ICDAS-II examination. One site on each tooth was selected on the occlusal surface, and examiners were guided by black and white photographs printed on draft quality paper containing a dot on the test site to allow the precise assessment of the same area. The examinations were fi rst carried out with custom made dental loupe (2.5x magnifi cation) with mounted LED headlight (Univet Optical Technolo- gies, Italy) and then AC Impedance Spectroscopy device (CarieScan PRO, Dundee, Scotland) on separate occa- sions. After all examinations were com- pleted, the roots of the teeth were re- sected just apical to the cementum- enamel junction prior to histological examination. A marker was placed on the mesial cervical area of each tooth, and nail varnish was applied to this mesial groove to aid identifi - cation of tooth surfaces and there- fore orientation after sectioning. To obtain the histological sections, each tooth was immersed in orthodon- tic resin (Caulk Orthodontic Resin, Dentsply, USA) and allowed to set into blocks (18 individual blocks), with approximately 1 cm to one side. Each mounted block was then serial- ly sectioned in a longitudinal bucco- lingual direction with a water-cooled diamond disc on a thin sectioning machine (Gillings-Hamco, NY, USA). Each section was approximately 350 micron thick, and based on visible caries location the cuts were done approximately every 200 microns. The sections were separated from the block and numbered for exami- nation. After sectioning the grooves and artifacts left by the diamond disc were polished with a fi ne-grained pa- per coated with 600, 1200, and 2400 grade aluminum oxide (Al2O3). In total 7-10 sections were produced per crown and 1-4 sections were available to view for each investigation site. Histological sections were examined under a Nikon SMZ-1500 stereomi- croscope (Nikon Instruments, Inc., Melville, NY) and digital images were captured with incident light at ×16 magnifi cation. All histological sections for each tooth were assessed by both exam- iners who were blind to each other according to fi ve-point scale Downer histological classifi cation system (Ta- ble 1).12 Caries extent was based upon colour and structural changes in enamel and dentine, with emphasis being placed on differentiating cari- ous changes from protective chang- es of the pulp-dentine complex, such as tubular sclerosis and reactionary dentine formation. A histological score was given to each section and the deepest score section was taken as the defi nitive for further analysis. Where there was disagreement, two examiners reviewed the sections ÿPage 22 sal ed ci- ed in red ith sal its ach to ter. ix ral nd ere Score Criteria used in the Downer histological examination [(cid:30)(cid:31)] (cid:29) (cid:30) (cid:31) (cid:27) (cid:20) No enamel demineralisation or a narrow surface zone of opacity (edge phenomenon) Enamel demineralisation limited to the outer (cid:23)(cid:29)% of the enamel layer Demineralisation involving the inner (cid:23)(cid:29)% of the enamel, up to the enamel-dentine junction Demineralisation involving the outer (cid:23)(cid:29)% of the dentine Demineralisation involving the inner (cid:23)(cid:29)% of the dentine Table 1: Criteria used in the histological examination12 Examiner (cid:30) Examiner (cid:31) AC Impedance Spectroscopy (cid:29).(cid:14)(cid:31)(cid:21)(cid:14) (cid:29).(cid:14)(cid:23)(cid:22)(cid:31) Low powered magnification + LED (cid:29).(cid:28)(cid:29)(cid:23)(cid:22) (cid:29).(cid:28)(cid:23)(cid:30)(cid:23) SE Examiner (cid:30) versus Examiner (cid:31) (cid:29).(cid:14)(cid:20)(cid:22)(cid:27) (cid:29).(cid:21)(cid:29)(cid:21)(cid:28) SE = (cid:29).(cid:30)(cid:29)(cid:14)(cid:30) Table 2: Intra- and interexaminer reproducibility (weighted kappa)