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ePaper created 2018-04-25, 08:59:39 | version 1.38.0
22 ◊Page 20 PAEDIATRIC Dental Tribune Middle East & Africa Edition | 2/2018 D(cid:25) diagnostic threshold AUC (SE) Sensitivity Specificity AUC: area under the curve; SE: standard error. ∗Statistically significant difference ( < 0.05). AC Impedance Spectroscopy Low-powered magnification + LED Examiner (cid:25) (cid:23).(cid:22)(cid:23) ((cid:23).(cid:25)(cid:21)) (cid:23).(cid:22)(cid:24) (cid:23).(cid:22)(cid:17) Examiner (cid:24) (cid:23).(cid:20)(cid:23) ((cid:23).(cid:25)(cid:31)) (cid:23).(cid:19)(cid:20) (cid:23).(cid:20)(cid:23) Examiner (cid:25) (cid:31).(cid:30)(cid:29) ((cid:31).(cid:31)(cid:28))∗ (cid:23).(cid:18)(cid:23) (cid:23).(cid:20)(cid:23) Examiner (cid:24) (cid:31).(cid:27)(cid:26) ((cid:31).(cid:31)(cid:30))∗ (cid:23).(cid:17)(cid:20) (cid:23).(cid:20)(cid:19) Table 3: Area under the ROC curve (standard error), sensitivity, and speci)city at D# diagnostic threshold AC Impedance Spectroscopy versus histology Low powered magnification and LED versus histology ∗Correlation significant at the (cid:23).(cid:23)(cid:19) level. Examiner (cid:25) Examiner (cid:24) (cid:23).(cid:31)(cid:20) (cid:31).(cid:26)(cid:27)∗ (cid:23).(cid:31)(cid:22) (cid:31).(cid:26)(cid:29)∗ Table 4: Spearman’s correlation coe3cients using Downer classifi cation systems. again and new examinations were performed until a consensus deci- sion was reached. Data Management and Statistical Evaluation ICDAS-II scores using LPMLED and ACIS device readings and histol- ogy scores were recorded on special sheets and transferred to an Excel table. The statistical analysis was per- formed using MedCalc v.9.0.1.1 sta- tistical package (MedCalc Software, Mariakerke, Belgium). For the ICDAS- II scores, inter- and intraexaminer reproducibility was measured using kappa-Cohen statistical test. Kappa values above 0.75 denoted excellent agreement, while values between 0.40 and 0.75 indicated good agree- ment.13 For each examiner, the relationships between both techniques and the histological scoring system (Downer) were assessed using the Spearman rank correlation. Data obtained from these measurements were used to calculate sensitivity and specifi city at the D1 diagnostic threshold as gold standard. The use of a gold standard is a prerequisite in assessing the re- ceiver operating characteristic (ROC) curve.14 This analysis involves a plot of pairs of sensitivity and “1-specifi c- ity” for a given cut-off value of a di- agnostic test.15 Since this study is fo- cusing on early detection of carious lesions, we select D1 level as diagnos- tic threshold. Using these sensitiv- ity and specifi city values, area under ROC curve (AUC) was carried out for each investigator and method. The performance of each method for AUC was interpreted by using the following classifi cation: 0.50–0.60 fail, 0.60-0.70 poor, 0.70-0.80 fair, 0.80-0.90 good, and 0.90-1.0 excel- lent.14,15 The McNemar test was used to compare the sensitivity, specifi c- ity, and AUC between examiners and examinations. Results A total of 18 teeth were examined with both methods by two examin- ers and by histology. Table 2 shows intra- and interexaminer repro- ducibility analysis. The degree of intraand interexaminer reproduc- ibility for ACIS device was good. The weighted kappa values for intra- and interexaminer reproducibility for ICDAS-II using LPMLED were good to excellent (Table 2). Area under curve (AUC) values, sensitivity, and specifi fi city of the examination methods based on D1 36.9ºC PATIENT SAFETY IS MEASURED IN CELSIUS. Thonks to Bien-Air’s potented CoolTouch+TM heot-orresting technology, EVO.15 is the only contro-ongle thot never exceeds humon body temperoture*. Be the one they trust. UP TO 3 YEARS WARRANTY ** www.bienair.com EVO.15 CONTRA-ANGLE ** 2-year standard warranty and 1-year optional warranty available through Bien-Air’s PlanCare extended warranty program. *at 200,000 rpm when 8N force applied on push button during 10 seconds. Bien-Air Dentol SA Länggasse 60 Case postale 2500 Bienne 6 Switzerland Tel. +41 (0) 32 344 64 64 dental@bienair.com www.bienair.com diagnostic threshold are presented in Table 3 for each examination. The overall AUC performance was 0.60 to 0.65 for ACIS device and 0.87 to 0.93 for ICDAS-II using LPMLED. IC- DAS-II scores using LPMLED showed statistically signifi cant higher AUC performance than ACIS device read- ings. Spearman’s correlation coeffi cients in relationship between examina- tions using Downer classifi cation system are presented in Table 4. It is generally accepted that a correlation coeffi cient of 0.70 or above repre- sents a strong relationship between two variables. There was a statisti- cally signifi cant correlation between histology and ICDAS-II scores using LPMLED. Discussion Occlusal surfaces account for the majority of new carious lesions, ef- fecting both primary and permanent dentitions in children. Although oc- clusal surfaces are the most visited sites during clinical examination, complex occlusal anatomy and his- topathology of the disease makes detection of early caries lesions diffi cult.16-21 If dentistry is to move from restorative to a preventive and therapeutic based approach, early caries detection and quantifi cation of lesions to monitor their arrest or progression over the time is es- sential. One of the purposes of the ICDAS-II system and ACIS device is to overcome this short fall and describe the earliest visible changes on all tooth surfaces. Clinical results of the ICDAS-II system provide an accept- able prediction of caries depth22,23 and scientifi c data for reproduc- ibility of ICDAS-II caries detection are promising. According to Ismail et al.,24 the ICDAS-II presents good to excellent reproducibility (kappa coeffi cients ranged between 0.59 and 0.91). In a study where ICDAS- II codes were used in both primary and permanent teeth,25 intra- and in- terexaminer reproducibility values were found to be excellent (weighted kappa values > 0.82). Even when using a detailed system (ICDAS-II), there might be a degree of subjective interpretation due to perhaps visual perception and lighting problems. This is why we assessed the impact of low-powered magnifi cation (2.5x) and LED headlight illumination us- ing ICDAS-II criteria. Surprisingly, very little scientifi c research with diverging results about the infl u- ence of visual aids on caries detec- tion has been published so far. One study showed that the use of low powered magnifi cation signifi cantly improved the accuracy of exami- nation,26 and a more recent article found that the use of magnifi cation caused a drop in reproducibility of the ICDAS-II scores.27 Although both examiners started to use these visual aids for the fi rst time with this study, our results showed excellent intraex- aminer (0.90–0.95) and interexam- iner reproducibility (0.80) ICDAS-II using LPMLED. Our results indicate that the use of a standard criterion for visual inspection with the help of visual aids tends to increase the intra- and interexaminer agreement and makes ICDAS-II system a highly reproducible diagnostic modality for occlusal caries diagnosis. Unfortunately there are not many published materials for the perfor- mance of ACIS device. One in vivo study demonstrated substantial agreement for both intra- and in- terexaminer repeatabilities of ACIS device.28 When compared with this study, our study showed relatively low intraexaminer (0.62–0.65) and interexaminer reproduc- ibility. A possible explanation of this problem is the problems that both examiners encountered on the tip (0.64) of the device sensor. The sensor tip easily bends after each application and this affects both the angulation and the pressure applied on tooth surface. From a clinical standpoint, care should be given not to push the sensor on tooth forcefully for the consistency of the readings. In vitro studies usually establish the validity of a detection system by us- ing histology as gold standard. Histo- logical validation of caries is diffi cult as preparing thin sections entails tooth tissue loss, and hemisecting a tooth through the lesion may not always pass through the deepest as- pect of the lesion in question. These problems arise because of the three- dimensional nature of the spread of caries dictated by the complex anat- omy of the occlusal surface. A lesion may originate at one site on the sur- face of the tooth but spread oblique- ly and nonsymmetrically beneath the tooth surface. To overcome this problem and to record the deepest aspect of the lesion, we examined 1-4 sections from each tooth depend- ing on the severity of the lesion. The worst histological score from these histological sections was recorded as reference section. Downer histol- ogy classifi cation system12 was used in this study to calculate sensitivity and specifi city at the D1 diagnostic threshold for each examiner and examination methods. When ICDAS- II examination using LPMLED was used, the sensitivity and specifi city scores for examiners were 0.87–0.90 and 0.70–0.75, respectively, at the D1 diagnostic threshold. Tese scores were similar with previous studies where sensitivity scores ranged from 0.69, to 0.92 and specifi city scores ranged from 0.79, to 0.82 at the D1 diagnostic threshold.16,29 When ACIS device was used lower values of sensitivity (0.57-0.62) and specifi city (0.68-0.70) were achieved. In a previous study where perma- nent teeth and a microcomputer- ized tomography technique for his- tology was used, better sensitivity (0.92) and specifi city (0.92) values were recorded.30 This difference can be explained with the anatomical variations on the occlusal surfaces of permanent and primary teeth and perhaps the difference for the histol- ogy technique. When ICDAS-II examination using LPMLED was used, excellent AUC performance and strong correlation with histology were found by both examiners. Despite its potential, the AUC performance for ACIS on prima- ry teeth was low. Since the previous studies showed promising results for ACIS device, a possible reason for this low performance would be the varia- tion in the conductance of electrical impulses due to enamel thickness of primary teeth. To our best knowledge, this is the fi rst study carried out using both systems on extracted primary teeth. Accord- ing to our results visual aids had a remarkable positive impact on early caries detection in primary molars. A good explanation for this impact might be the increase in the depth of vision and the intensity/brightness of white light, which enhances the visibility of occlusal anatomy. Conclusion Within the limitations of this in vitro study it can be concluded that the use of low-powered magnifi cation (2.5x) and LED headlight illumina- tion compliments ICDAS-II system in caries detection. Clinicians should keep in mind that visual aids have the potential to improve the perfor- mance of early caries detection and clinical diagnostics in children. Editorial note: The references list is available from the publisher.