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Diagnodent useful adjunct but not substitute for clinical exam of occlusal surfaces for caries
DIAGNOSIS & SCREENING
A RTICLE A NALYSIS &
Diagnodent useful adjunct but not substitute for clinical exam of occlusal surfaces for caries
E VALUATION Original Article
Level of Evidence
Purpose
Source of Funding
Type of Study/Design
Anttonen V, Seppa L, Hausen H. Clinical study of the use of the laser fluorescence device Diagnodent for detection of occlusal caries in children. Caries Res 2003;37(1):17–23.
3b
To evaluate the use of the laser fluorescence device Diagnodent as part of routine dental check-ups in children Not reported
Case-control study
Summary SUBJECTS n = 109, but total n of surfaces used is 1,049. The study took place in a Public Health Clinic in Ouhu, Finland, and the recruitment took place in public schools with clear inclusion and exclusion criteria. Presence or absence of disease was not known in recruitment. DIAGNOSTIC TEST Three diagnostic tests were used: visual examination (deemed the ‘‘gold standard’’), Diagnodent examination, and radiographic exam (where indicated by radiographic guidelines).
J Evid Base Dent Pract 2003;3:208-9 D 2003 Mosby, Inc. All rights reserved. doi:10.1016/med.2003.77
208
DISEASE OR CONDITION THAT IS TO BE DIAGNOSED Occlusal Dental Caries MAIN RESULTS The higher the visual exam caries score, the higher the Diagnodent score. Radiographic exam was the least accurate of the 3 methods. Variation in Diagnodent values was large.
Commentary CONCLUSIONS Diagnodent appears to be useful as an adjunct to clinical examination for occlusal caries in children. ANALYSIS Sackett et al1 suggest the following questions to consider when evaluating diagnostic tests: 1. Is this evidence about the accuracy of a diagnostic test valid? 2. Was there an independent blind comparison with a reference gold standard diagnosis? 3. Was the diagnostic test evaluated in an appropriate spectrum of patients? 4. Was the reference standard applied regardless of the diagnostic test result? 5. Was the test validated in a second, independent group of patients? 6. Does this evidence demonstrate an important ability of this test to accurately distinguish patients who do and don’t have a specific disorder? 7. Is the diagnostic test available, affordable, accurate, and precise in our setting? COMMENTARY AND ANALYSIS The conclusions of the authors are sound on the basis of the design and outcomes of the study. They clearly state the limitations of the design of the study and the limitations of the outcome measures obtained. The study does show that Diagnodent values are related to visual exam values. Although there is substantial variation, the authors correctly state the value of Diagnodent as adjunctive but not a substitute for the gold standard, visual examination. This article might affect the way a reader practices. There are many scenarios wherein the clinician identifies occlusal caries by virtue of clinical examination alone, however, he or she is unsure of the diagnosis because of the presence of stain or coalesced fissures. This study provides some evidence that Diagnodent can serve in a corroborative role in these scenarios. The study evaluated the reliability and the sensitivity/ specificity of the Diagnodent test. Visual examination
Journal of Evidence-Based Dental Practice Volume 3, Number 4
was used as the gold standard for each of these determinations. The specificity of 69% with visual examination as the control/standard suggests that one must be careful using Diagnodent alone to make the determination to perform surgical restorative intervention. The patients selected for this study were of the appropriate spectrum. Two distinct groups were selected (ages 7 – 8 and ages 13 – 14) to select patient having permanent first molars and primary molars, with some having only permanent first and second molars. This provides the basis for making the acrossthe-board statement that the Diagnodent device is ‘‘useful in children.’’ The authors accurately state that the study does not allow direct comparison of the 3 diagnostic methods. They also discuss clearly how the study was designed to provide useful evaluation of the Diagnodent device in ‘‘typical’’ clinical examination situations, wherein the patients may have sealants present (which herein were shown not to effect results if they were transparent), and where a prophylaxis treatment is not generally performed before clinical examination. The authors report that the Diagnodent results in this study are more variable when compared with visual examination as compared with other studies. Their explanation, which this author believes is valid, is that they designed the study to depict real clinical scenarios, exemplified by intentionally not performing a prophylaxis before treatment. Further works must show the relationship between these 3 caries diagnostic techniques with histological assessment of caries as an outcome. REFERENCE 1. Sackett DL, Straus S, Richardson S, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). London: Churchill Livingstone; 2000.
Reviewer: Joel Berg, DDS, MS University of Washington Seattle, Washington
Anttonen et al 209
A RTICLE A NALYSIS &
Diagnodent useful adjunct but not substitute for clinical exam of occlusal surfaces for caries
E VALUATION Original Article
Level of Evidence
Purpose
Source of Funding
Type of Study/Design
Anttonen V, Seppa L, Hausen H. Clinical study of the use of the laser fluorescence device Diagnodent for detection of occlusal caries in children. Caries Res 2003;37(1):17–23.
3b
To evaluate the use of the laser fluorescence device Diagnodent as part of routine dental check-ups in children Not reported
Case-control study
Summary SUBJECTS n = 109, but total n of surfaces used is 1,049. The study took place in a Public Health Clinic in Ouhu, Finland, and the recruitment took place in public schools with clear inclusion and exclusion criteria. Presence or absence of disease was not known in recruitment. DIAGNOSTIC TEST Three diagnostic tests were used: visual examination (deemed the ‘‘gold standard’’), Diagnodent examination, and radiographic exam (where indicated by radiographic guidelines).
J Evid Base Dent Pract 2003;3:208-9 D 2003 Mosby, Inc. All rights reserved. doi:10.1016/med.2003.77
208
DISEASE OR CONDITION THAT IS TO BE DIAGNOSED Occlusal Dental Caries MAIN RESULTS The higher the visual exam caries score, the higher the Diagnodent score. Radiographic exam was the least accurate of the 3 methods. Variation in Diagnodent values was large.
Commentary CONCLUSIONS Diagnodent appears to be useful as an adjunct to clinical examination for occlusal caries in children. ANALYSIS Sackett et al1 suggest the following questions to consider when evaluating diagnostic tests: 1. Is this evidence about the accuracy of a diagnostic test valid? 2. Was there an independent blind comparison with a reference gold standard diagnosis? 3. Was the diagnostic test evaluated in an appropriate spectrum of patients? 4. Was the reference standard applied regardless of the diagnostic test result? 5. Was the test validated in a second, independent group of patients? 6. Does this evidence demonstrate an important ability of this test to accurately distinguish patients who do and don’t have a specific disorder? 7. Is the diagnostic test available, affordable, accurate, and precise in our setting? COMMENTARY AND ANALYSIS The conclusions of the authors are sound on the basis of the design and outcomes of the study. They clearly state the limitations of the design of the study and the limitations of the outcome measures obtained. The study does show that Diagnodent values are related to visual exam values. Although there is substantial variation, the authors correctly state the value of Diagnodent as adjunctive but not a substitute for the gold standard, visual examination. This article might affect the way a reader practices. There are many scenarios wherein the clinician identifies occlusal caries by virtue of clinical examination alone, however, he or she is unsure of the diagnosis because of the presence of stain or coalesced fissures. This study provides some evidence that Diagnodent can serve in a corroborative role in these scenarios. The study evaluated the reliability and the sensitivity/ specificity of the Diagnodent test. Visual examination
Journal of Evidence-Based Dental Practice Volume 3, Number 4
was used as the gold standard for each of these determinations. The specificity of 69% with visual examination as the control/standard suggests that one must be careful using Diagnodent alone to make the determination to perform surgical restorative intervention. The patients selected for this study were of the appropriate spectrum. Two distinct groups were selected (ages 7 – 8 and ages 13 – 14) to select patient having permanent first molars and primary molars, with some having only permanent first and second molars. This provides the basis for making the acrossthe-board statement that the Diagnodent device is ‘‘useful in children.’’ The authors accurately state that the study does not allow direct comparison of the 3 diagnostic methods. They also discuss clearly how the study was designed to provide useful evaluation of the Diagnodent device in ‘‘typical’’ clinical examination situations, wherein the patients may have sealants present (which herein were shown not to effect results if they were transparent), and where a prophylaxis treatment is not generally performed before clinical examination. The authors report that the Diagnodent results in this study are more variable when compared with visual examination as compared with other studies. Their explanation, which this author believes is valid, is that they designed the study to depict real clinical scenarios, exemplified by intentionally not performing a prophylaxis before treatment. Further works must show the relationship between these 3 caries diagnostic techniques with histological assessment of caries as an outcome. REFERENCE 1. Sackett DL, Straus S, Richardson S, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM (2nd Edition). London: Churchill Livingstone; 2000.
Reviewer: Joel Berg, DDS, MS University of Washington Seattle, Washington
Anttonen et al 209