Community Dent Oral Epidemiol 2012; 40: 257266 All rights reserved

2011 John Wiley & Sons A/S

Implications of caries diagnostic strategies for clinical management decisions

Baelum V, Hintze H, Wenzel A, Danielsen B, Nyvad B. Implications of caries diagnostic strategies for clinical management decisions. Community Dent Oral Epidemiol 2011. 2011 John Wiley & Sons A S Abstract Objectives: In clinical practice, a visualtactile caries examination is frequently supplemented by bitewing radiography. This study evaluated strategies for combining visualtactile and radiographic caries detection methods and determined their implications for clinical management decisions in a low-caries population. Methods: Each of four examiners independently examined preselected contacting interproximal surfaces in 53 dental students aged 2037 years using a visualtactile examination and bitewing radiography. The visualtactile examination distinguished between noncavitated and cavitated lesions while the radiographic examination determined lesion depth. Direct inspection of the surfaces following tooth separation for the presence of cavitated or noncavitated lesions was the validation method. The true-positive rate (i.e. the sensitivity) and the false-positive rate (i.e. 1-specicity) were calculated for each diagnostic strategy. Results: Visualtactile examination provided a true-positive rate of 34.2% and a false-positive rate of 1.5% for the detection of a cavity. The combination of a visualtactile and a radiographic examination using the lesion in dentin threshold for assuming cavitation had a true-positive rate of 76.3% and a false-positive rate of 8.2%. When diagnostic observations were translated into clinical management decisions using the rule that a noncavitated lesion should be treated nonoperatively and a cavitated lesion operatively, our results showed that the visualtactile method alone was the superior strategy, resulting in most correct clinical management decisions and most correct decisions regarding the choice of treatment.

Vibeke Baelum1, Hanne Hintze2, Ann Wenzel2, Bo Danielsen3 and Bente Nyvad4
1 School of Dentistry and Institute of Public Health, Aarhus University Faculty of Health Sciences, Aarhus, Denmark, 2Department of Oral Radiology, School of Dentistry, Aarhus University Faculty of Health Sciences, Aarhus, Denmark, 3School of Oral Health Care, University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark, 4 Department of Dental Pathology, Operative Dentistry and Endodontics, School of Dentistry, Aarhus University Faculty of Health Sciences, Aarhus, Denmark

Key words: dental caries; diagnostic errors; oral diagnosis; radiography; routine diagnostic tests Vibeke Baelum, Department of Epidemiology, Institute of Public Health, Faculty of Health Sciences, Aarhus University, Bartholins Alle 2, DK-8000 Aarhus C, Denmark Tel.: +45 89426097 e-mail: baelum@soci.au.dk Submitted 28 March 2011; accepted 20 October 2011

Examinations for the purpose of disease detection in asymptomatic patients should be carefully evaluated in terms of both the anticipated health benets and the possible risks for the examined patients (1). In many contemporary populations, most people undergo regular dental check-up examinations, commonly initiated by dentists (2) who send calling cards to their patients reminding them. In the Nordic countries, 8790% of the adults have visited a dentist within the past 2 years (2, 3), and 6468% have visited within the past year (4, 5). While a dental visit does not necessarily mean that an oral examination has been carried out, there is a close correlation between the number of dental
doi: 10.1111/j.1600-0528.2011.00655.x

visits and the number of oral examinations made (5). For decades, it has been customary to supplement the visualtactile caries detection examination with bitewing radiography in the anticipation of an additional diagnostic yield, that is, detection of lesions remaining undetected by visualtactile examination alone (6). Although guidelines commonly stress that radiographs should be used only on specic individualized indication (7), and although radiographic screening for caries lesions among children with little caries experience carries too little benet (8, 9), the practice of screening using bitewing radiographs continues to be pro-

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moted (7, 10, 11). Consequently, the practice of combining the visualtactile examination with a radiographic examination is very common among Swedish and Norwegian children (1214) and moderately common among Danish children (15). Much less is known about the use of bitewing radiographs among adults. However, the average adult Danish dental patient had 0.79 intraoral radiographs taken in the year 2000, rising to an average of 0.85 radiographs taken per dental patient in the year 2002 (16), and this may be taken as an indication of frequent use of bitewing radiographs in dental examinations. All caries diagnostic methods are error-prone, with less-than-perfect reliability (inter- and intraexaminer reproducibility) (17, 18) and less-thanperfect validity (1820). While this is well known, the consequences have not been given much attention (1, 6). Research on the effect of the combination of caries detection methods is inconclusive, with some nding that combining methods may decrease the reproducibility for both intraand inter-examiner comparisons (21), while others report the opposite effect (22, 23). Although two studies on extracted teeth indicate that combining diagnostic tests may increase both sensitivity and specicity relative to the isolated tests (23, 24), the case-mix, i.e. the distribution of lesions in the sample of teeth investigated, greatly inuence the results (22). A few have studied the implications for clinical management decisions of combining caries detection methods in occlusal surfaces (21, 25). One study (25) demonstrated that the use of additional methods for caries detection (bitewing radiographs, electric conductance measurement, quantitative light uorescence, DIAGNOdent) may lead to a slight reduction from 167 to 159 (5%) in the total number of correct treatment decisions and a substantial increase in the number of overtreatments from 46 to 81 (76%) compared with the use of the visual examination alone. In another study (21), the combination of methods resulted in a slight increase in the proportion of correct conservative restoration treatment decisions at the expense of a slight decline in the proportion of correct follow up or sealant treatment decisions. As far as we are aware, no study has assessed the implications of combining the visualtactile and bitewing examination methods for caries lesion detection in interproximal surfaces for the resulting clinical management decisions. The purpose of the present study was to address this question.

Material and methods

This analysis is a secondary analysis of data originating in a study of the validity and reliability of three commonly used diagnostic methods for the detection of cavitated interproximal carious lesions (19). Each of four examiners independently examined preselected contacting interproximal surfaces (for details, see later) in 53 dental and dental hygienist students aged 2037 years (mean 24.7 years) using a visualtactile examination, bitewing radiography or ber-optic transillumination (FOTI). However, the FOTI data are not further considered in the present study. The examiners, who had been trained and calibrated in the use of the criteria, independently assessed the interproximal surfaces based on a visualtactile and a bitewing examination carried out on separate days using the criteria described in Table 1. The visualtactile criteria used were those later described by Nyvad et al. (17, 26), but the lesion activity observations were not used in the original study, which focused on the detection of cavitated carious lesions. Thereby, the distinctions in the visualtactile diagnoses were between sound, noncavitated and cavitated carious lesions (19). For the visualtactile examination, straight probes and pigtail explorers were used to examine the surface contour and surface texture and to remove any debris present. No attempts were made to physically penetrate lesions. Debris which could not be removed completely by the probe was removed by dental oss, and the surfaces were kept dry by cotton rolls, compressed air and suction apparatus. Following each visualtactile interproximal diagnosis, the examiners expressed their condence in the diagnosis of the absence or presence of a cavitated lesion in the surface just examined. The condence scale used was the vepoint scale outlined in Table 1. The bitewing examination was based on two bitewing radiographs (one in each side of the mouth) taken using a dental X-ray unit (GX 1000; Gendex Corporation, Wilwaukee, WI, USA) operating at 70 kV, 10 mA and exposure times of 0.22 and 0.26 s. The focuslm distance was 36 cm, and the collimator was rectangular with a size of 3.4 4.4 cm. The lm used was Kodak Ektaspeed Plus (Eastman Kodak Company, Rochester, NY, USA) in Kwik-Bite (Hawe Neos Dental, Bioggio, Switzerland) lm holders. Development was performed in a Du rr automatic processor model 1330 AC245L (Du rr, Bietigheim- Bissingen, Germany) with

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Implications of caries diagnostic strategies Table 1. Caries diagnostic criteria and condence ratings used in the study Examination method Visualtactile Condence scale Code 0 1 2 1 2 3 4 5 0 1 2 3 4 0 1 2 +3 +4 Classication used in original study (19) Sound Noncavitated lesion Cavitated lesion Certain cavity is present Almost certain cavity is present Uncertain Almost certain cavity is not present Certain cavity is not present Sound Radiolucency in outer half of enamel Radiolucency in inner half of enamel Radiolucency in outer third of dentin Radiolucency in inner two-thirds of dentin Sound Noncavitated lesion Cavitated lesion Classication in present study Sound Noncavitated Cavitated Certain Uncertain Uncertain Uncertain Certain Sound Enamel Enamel Outer dentin Inner dentin Sound Noncavitated Cavitated

Radiography

Validation

+3 +4

Readymatic developer and xer solutions (Kodak , Paris, France). Radiographs were examined Pathe blind in random order on a view box with 2 magnication (X-viewer, Lysta, Farum, Denmark) using the lesion depth scale outlined in Table 1. Each examiner read the radiographs at least 2 days after the clinical examinations independently of the results of these examinations and independently of the results obtained by the other examiners. The in vivo validation of the diagnostic ndings was carried out by each examiner using the visual tactile criteria (Table 1) following tooth separation by orthodontic rubber rings or separation springs for 3 days. This validation method precluded the inclusion of all contacting interproximal sites in the molar premolar areas. Sites were, therefore, preselected for inclusion and represented contacting interproximal surfaces involving one premolarto-premolar contact, one molar-to-molar contact and two premolar-to-rst molar contacts. Application of these criteria led to initial inclusion of eight interproximal surfaces per individual in 48 students, six surfaces in three students and four surfaces in two students. In 20 surface pairs, one of the surfaces was lled, and these were excluded. Further, 52 surfaces could not be diagnostically validated owing to premature loss of the separation device or no resulting tooth separation and were also excluded. Thereby, a total of 338 surfaces were available for evaluation by each examiner. The order of examiners was haphazard, and the examiners were unaware of the results obtained by the previous examiner(s). A slight variation in the number of diagnostic decisions contributed by each

Table 2. Examiner agreement on the caries validation recordings of the 338 surfaces. Disagreement sound noncavitated means that at least one examiner recorded the surface as sound and at least one examiner recorded the surface as non-cavitated, while no examiner recorded the surface as cavitated The four Surface examiners diagnosis Agree Disagree Number (%) of surfaces

Sound 134 (39.6) Noncavitated 46 (13.6) Cavitated 10 (3.0) Sound noncavitated 126 (37.3) Sound cavitated 1 (0.3) Sound noncavitated cavitated 8 (2.4) Noncavitated cavitated 13 (3.9)

examiner was noted, because the examiners did not consistently agree whether a given surface was recordable. All four examiners agreed in the validation (true state) of the surface in 190 of the 338 surfaces evaluated (Table 2). Most of the disagreements observed (126 of 148) involved a disagreement whether the surface was sound or had a noncavitated caries lesion; 13 discrepancies concerned disagreement whether a lesion was cavitated or not, and eight disagreements involved all three possible diagnoses: sound, noncavitated or cavitated lesion (Table 2). When the validation examination results were pooled across examiners, 811 surfaces were deemed sound, 444 surfaces had a noncavitated caries lesion, and 76 surfaces were found to be cavitated. No validation by consensus was attempted, as this does not reect the real-life situation. A number of diagnostic strategies were simulated for the combination of radiographic and

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visualtactile recordings. As each examiner had recorded the surfaces using each detection method separately, the results could be combined to reect the use of different diagnostic strategies for the detection of noncavitated and cavitated caries lesions. Table 3 shows how recordings made with each caries detection method were interpreted in each diagnostic strategy to arrive at the classication for each surface as sound, with a noncavitated caries lesion or with a cavitated caries lesion. The results of the visualtactile examination alone needed no interpretation, whereas the bitewing radiographic results were subject to two interpretations: In one strategy, called Radiography I, any lesion extending into dentin was assumed cavitated, while in the Radiography II strategy, only lesions extending into the inner two-thirds of the dentin were assumed cavitated. In the diagnostic strategy combining the visualtactile results and the condence assessment, visualtactile cavity diagnoses were changed to noncavitated lesion diagnoses when uncertainty (Table 1) was expressed about the diagnosis. The visualtactile and both radiographic strategies were further combined using the additional yield principle, i.e. the more severe caries lesion found with either method determined the nal classication (Table 3). In the present analysis, the results have been pooled across the four examiners, which means that each surface is represented four times (one for each examiner) in the data. The results of each diagnostic strategy shown in Table 3 were cross-tabulated with the results of the validation method, and sensitivity and specicity values

were calculated for the diagnosis of a cavitated lesion, respectively, any caries lesion. The sensitivity of a test (diagnostic strategy) for the detection of, say, a cavitated caries lesion is the proportion of truly cavitated caries lesions (as determined by the validation method) that are detected by the test. Similarly, the specicity of the test is the proportion of truly noncavitated caries lesions that are detected by the test. The sensitivity is also called the true-positive rate, while 1-specicity is called the false-positive rate. For the purpose of assessing the effect of the different caries diagnostic strategies on the correctness of the treatment decisions that would have followed from these strategies, it was assumed that a cavitated caries lesion needs a restoration and that a noncavitated caries lesion needs nonoperative treatment.

Results
The number of visualtactile diagnoses for which uncertainty was expressed on the condence scale amounted to 108, corresponding to 8% of all visual tactile diagnoses. Most of these (55) concerned surfaces with noncavitated lesions according to the validation examination, while 24 concerned sound surfaces and 29 concerned cavitated lesions according to the validation examination. Thereby, the probability of uncertainty regarding a sound surface was 3% (24 of 811), and 12.4% (55 of 444) and 38.2% (29 of 76) for noncavitated and cavitated surfaces, respectively.

Table 3. The interpretation of recordings from the different examination methods, alone and in combinations, used in each diagnostic strategy to arrive at a nal classication of the approximal surfaces as either sound, with noncavitated caries lesion, or with cavitated caries lesion Final diagnosis after combination of recordings Diagnostic strategy Visualtactile alone Visualtactile + condence Radiography I alone Radiography II alone Visualtactile + Radiography I Visualtactile + Radiography II Visualtactile + condence + Radiography I Visualtactile + condence + Radiography II Sound Sound Sound Sound Sound Sound Sound Sound Sound Noncavitated Noncavitated Noncavitated or cavitated if uncertain In enamel In enamel or in outer dentin Noncavitated or in enamel Noncavitated or in enamel or in outer dentin Noncavitated or in enamel if uncertain Noncavitated or in enamel if uncertain or in outer dentin if uncertain Cavitated Cavitated Cavitated, certain In dentin In inner dentin Cavitated or in dentin Cavitated or in inner dentin Cavitated, certain or in dentin Cavitated, certain or in inner dentin

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Table 4 shows the results of cross-tabulating the validation results with the results of each diagnostic strategy. The highest number of caries lesions (705 = 544 + 161) was detected when the visual tactile examination was combined with radiography (Radiography I) for all surfaces, and the number of lesions detected exceeded the true number of lesions (520) by 36%. This diagnostic strategy resulted in the highest true-positive rates for the detection of cavities and any caries lesion (76.3% and 97.4%, respectively). However, these high true-positive rates came at the price of the highest false-positive rates (8.2% and 34.5%, respectively) among any of the examination strat-

egies considered. The lowest false-positive rate (0.6%) for the detection of a cavity was observed using the visualtactile examination combined with the decision to change the diagnosis to noncavitated if uncertainty was expressed about cavitation. The true-positive rate for this diagnostic strategy was 21.1% for cavity detection. Table 5 shows that the diagnostic strategy resulting in most correct treatment decisions was the visualtactile examination, either alone or + condence (73.6% and 73.3%, respectively), closely followed by the two diagnostic strategies employing radiographs only in the case of uncertainty about the visualtactile diagnosis (73.3% and

Table 4. Relationship between the diagnoses made following each diagnostic strategy and the validation results. Also given are the true-positive (TP) and false-positive (FP) rates (TPR and FPR) for the detection of a cavity, respectively, for the detection of any caries lesion
Validation examination Level of detection Cavity Diagnostic strategy Sound N = 811 724a Noncavitated N = 444 410a 150 281 13 150 288 6 217 142 51 217 189 4 93 288 63 Ic 150 278 16 93 334 17 IId 150 286 8 Cavitated N = 76 74a 14 36 26 14 46 16 13 14 47 13 50 11 2 16 58 12 38 26 2 38 36 12 52 12 Total N = 1331 1208a 836 450 45 836 472 23 762 313 133 762 427 19 626 544 161 834 449 48 626 642 63 834 475 22 76.3 8.2 97.4 34.5 TP rate % 34.2 FP rate % 1.5 Any lesion TP rate % 81.6 FP rate % 17.1

Visualtactile Sound 672 Noncavitated 133 Cavitated 6 Visualtactile + condenceb Sound 672 Noncavitated 138 Cavitated 1 Radiography Ic Sound 532 Lesion in enamel 157 Lesion in dentin 35 Radiography IId Sound 532 Lesion in 188 enamel or outer dentin Lesion in inner dentin 4 Visualtactile + radiography Ic Sound 531 Noncavitated 240 Cavitated 40 Visualtactile + condenceb + radiography Sound 672 Noncavitated 133 Cavitated 6 Visualtactile + radiography IId Sound 531 Noncavitated 270 Cavitated 10 Visualtactile + condenceb + radiography Sound 672 Noncavitated 137 Cavitated 2
a b

21.1

0.6

81.6

17.1

63.5

6.9

80.3

26.5

14.9

0.6

80.3

26.5

34.2

1.8

84.2

17.1

47.4

2.2

97.4

34.5

15.8

0.8

84.2

17.1

A number of surfaces could not be read in radiographs. Clinical recordings of cavitated lesions changed to noncavitated lesions, when uncertainty was expressed. c Radiographic lesions extending into dentin interpreted as evidence for cavitation. d Radiographic lesions extending into the inner two-thirds of dentin interpreted as evidence for cavitation.

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Baelum et al. Table 5. Correctness of treatment decisions following different diagnostic strategies assuming that a cavitated lesion needs a restoration and a noncavitated caries lesion needs nonoperative treatment Under treatment Diagnostic strategy Visualtactile Visualtactile + condenceb Radiography Ic Radiography IId Visualtactile + radiography Ic Visualtactile + condenceb + radiography Ic Visualtactile + radiography IId Visualtactile + condenceb + radiography IId
a b

Overtreatment Correct decisions 979 976 721 732 877 (73.6) (73.3) (59.7) (60.6) (65.9) Nonoperative 133 138 157 188 240 (10.0) (10.4) (13.0) (15.6) (18.0) Operative 19 7 86 8 103 (1.4) (0.5) (7.1) (0.7) (7.7) Total 1331 1331 1208a 1208a 1331 1331 1331 1331

No treatment 164 164 230 230 95 (12.3) (12.3) (19.0) (19.0) (7.1)

Nonoperative 36 46 14 50 16 (2.7) (3.5) (1.2) (4.1) (1.2)

162 (12.2) 95 (7.1) 162 (12.2)

38 (2.9) 38 (2.9) 52 (3.9)

976 (73.3) 901 (67.7) 970 (72.9)

133 (10.0) 270 (20.3) 137 (10.3)

22 (1.7) 27 (2.0) 10 (0.8)

A number of surfaces could not be read in radiographs. Clinical recordings of cavitated lesions changed to noncavitated lesions, when uncertainty was expressed. c Radiographic lesions extending into dentin were interpreted as evidence for cavitation. d Radiographic lesions extending into the inner two-thirds of dentin were interpreted as evidence for cavitation.

72.9%, respectively). The incorrect treatment decisions were fairly balanced with respect to their distribution among under- and overtreatment except for the two diagnostic strategies involving the combination of visualtactile bitewing examination of all surfaces. When these strategies were used, most of the incorrect treatment decisions represented overtreatment (Table 5). Table 6 summarizes the results in terms of the number of correct treatment decisions under each

diagnostic strategy. Overall, the visualtactile method alone was better than any other diagnostic strategy in terms of the total number of correct clinical decisions (74%) and the number of correct decisions to treat (62%). When the visualtactile method was used in such a way that uncertain cavity diagnoses were considered noncavitated and subsequently treated nonoperatively, 73% of all decisions were correct, and 61% of the treatment decisions were correct. The main distinction be-

Table 6. Summary of the correctness of the clinical management decisions made following different combinations of the visualtactile and the radiographic method for caries lesion detection. Underlying assumptions are that cavitated carious lesions need operative treatment, while that noncavitated carious lesions need nonoperative treatment Clinical management decision based on diagnostic ndings Operative Diagnostic strategy Visualtactile Visualtactile + condencea Radiography Ib Radiography IIc Visualtactile + radiography Ib Visualtactile + condencea + radiography Ib Visualtactile + radiography IIc Visualtactile + condencea + radiography IIc
a b

Nonoperative N 450 472 313 427 544 449 642 475 N correct (%) 281 288 142 189 288 278 (62) (61) (45) (44) (53) (62)

Any treatment N 495 495 446 446 705 497 705 497 N correct (%) 307 304 189 200 346 304 (62) (61) (42) (45) (49) (61)

No treatment N 836 836 762 762 626 834 626 834 N correct (%) 672 672 532 532 531 672 (80) (80) (70) (70) (85) (81)

All N correct (%) 979 976 721 732 877 976 (74) (73) (54) (55) (66) (73)

N 45 23 133 19 161 48 63 22

N correct (%) 26 16 47 11 58 26 (58) (70) (35) (58) (36) (54)

36 (57) 12 (55)

334 (52) 286 (60)

370 (52) 298 (60)

531 (85) 672 (81)

901 (68) 970 (73)

Clinical recordings of cavitated lesions changed to noncavitated lesions, when uncertainty was expressed. Radiographic lesions extending into dentin were interpreted as evidence for cavitation. c Radiographic lesions extending into the inner two-thirds of dentin were interpreted as evidence for cavitation.

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tween the two strategies was that abstention from operative treatment decisions for cavitated lesions for which doubt was expressed increased the proportion of correct operative treatment decisions from 58% to 70% (Table 6). The combinations of the visualtactile method with radiography when clinically uncertain came close to the performance of the visualtactile method alone, yielding 73% correct decisions, and 61%, respectively, 60% correct treatment decisions. The combination of the visualtactile and radiographic methods for all surfaces resulted in fewer correct decisions (66% and 68%, respectively) and fewer correct decisions to treat (49% and 52%, respectively).

Discussion
Countless studies have reported estimates of the sensitivity (the true-positive rate) and the specicity (the true negative rate) for the diagnosis of caries lesions (20, 27). These estimates are typically obtained by comparing the detection results with a histological reference, the caries lesion gold standard (27). However, this approach is based on a traditional notion of caries-related treatment decisions, which holds that a caries diagnosis precedes and is separated from the treatment decision. However, this notion does not hold, and dentists base their caries-related treatment decisions on caries scripts (28). Caries scripts consist of salient features describing the distinguishing characteristics of a particular expression of caries (28), and the caries lesion detection process is a process of script matching in which the lesion observed in a patients tooth is matched with a pattern for which the dentist routinely recommends a specic treatment. Thereby, the decisions made are this kind of lesion needs this kind of treatment decisions, and the hypothetico-deductive method and differential diagnosis play no role (6, 28). The results of the present study are based on the assumption that the examiners would match their observation of a cavity with the need for a restoration and their observation of a noncavitated caries lesion with the need for nonoperative caries therapy (29). We have thus assumed that their treatment prescription strategy is the same, and the variation, therefore, stems from the examiners observations during the caries examinations and their interpretations of what they observe. Our use of the validation data to estimate the correctness of the caries lesion observations and the ensuing

treatment consequences is not an attempt to state that the results of the validation examination represent a diagnostic truth. We are indeed aware of the between-examiner disagreements in the results of the validation examination following tooth separation, which implies limited utility of this method as a validation method (19). Instead, we use the validation method results as the best representation of the observations upon which the examiner would have liked to act when matching caries lesion presentations with caries scripts. In their daily clinical practice, dentists have no key to the caries diagnostic truth if such exists (6), and they practice on the basis of their own observations and their interpretations thereof. Dentists place more focus on the detection of caries lesions than on the exoneration of sound surfaces. This strategy is understandable because the error of overlooking a lesion, particularly a deep lesion, is perceived as a very serious error. It is therefore not surprising that dental practitioners have a propensity to use additional caries detection methods to reduce the risk of overlooking caries lesions. The most common combination consists of a visualtactile examination supplemented by bitewing radiography, and most guidelines on the use of radiographs endorse routine or screening examinations (7) using this combination, either for specic age cohorts (10) or for the population at large at intervals not exceeding 24 months (7, 11). However, the results of the present study indicate that if the nding of a radiographic demineralization extending into dentin is considered evidence of cavitation and hence of operative treatment, the use of radiography as an ancillary caries diagnostic method does not lead to better treatment of the patients than a diligently exercised visualtactile examination would do. The ancillary use of radiography resulted in a 40% increase in the number of treatment decisions made (from 497 to 705), but the proportion of correct treatment decisions decreased from 62% for the visualtactile method alone to 49% and 52%, respectively, for the combination of the visualtactile and the radiographic methods. The diagnostic strategy combining a visual tactile examination and bitewing radiography only in case of clinical doubt did not appear superior to the use of the visualtactile method alone. This is remarkable because one might have expected such discretionary use of bitewings to result in improved clinical decisions. If anything, discretionary use of bitewing radiography as an ancillary diag-

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nostic method results in slightly inferior clinical decision making, compared with the visualtactile method alone. However, relatively few clinical diagnoses were perceived as uncertain, as doubts were expressed in only 8% of the clinical diagnoses, and it is clear that even if bitewings in such cases would lead to more correct clinical decisions, the impact on the overall proportion of correct clinical decisions would be limited. Importantly, the results clearly indicate that bitewing radiography should not be considered a means of correcting errors made with the visualtactile method, as it results in the addition of errors to an already lessthan-perfect visualtactile caries diagnostic method. Clearly, the conclusion regarding the additional value of bitewing radiography hinges on the diagnostic criteria used with the visualtactile method. The number of caries lesions found by means of a visualtactile examination depends on the diagnostic criteria and methods used, and a review (30) has shown that these criteria may vary considerably in terms of the stages of lesion formation considered, use of probes for tactile assessment and intensity of drying for disclosure of the early stages of lesion formation. The studies suggesting an additional value of radiographs for the detection of caries lesions have typically employed rather crude visualtactile criteria, considering only cavitated or rather late stages of the caries process (3137). When more rened clinical criteria are used, such as the Nyvad criteria (17), which aim to detect the early stages of caries lesion formation by means of a diligently exercised visualtactile examination, the additional benet of bitewing radiography is not clear (38, 39). Regular dental check-ups were generally implemented at a time when the caries prevalence and experience were substantially higher than seen today. However, the caries decline has now been evident for almost half a century (40, 41) and continues. The percentage of Danish 15 year olds who have experienced one or more cavitated caries lesions has decreased from 88% in 1988 to 50% in 2010, and the mean DcavMFS has dropped from 6.7 in 1988 to 2.1 in 2010 (42). Obviously, the probability that new caries lesions will develop within the next few years in 15 year olds, who so far have not developed caries lesions, is rather low, and this may call for a reassessment of both the recall intervals and the contents of the caries examinations. The low caries occurrence in many contemporary populations means that the a priori

probability of caries in a surface is quite low, and from a clinical management point of view, the desire would be for caries detection methods that correctly rule out the presence of caries, rather than for methods that focus on identication of lesions. It is thus of utmost importance to avoid falsepositive diagnoses, and in particular those falsepositive diagnoses that may lead to unnecessary restoration of intact teeth. Unfortunately, the sensitivity and specicity values reported for the methods available for caries lesion detection leave much to be desired (20), and the less-than-perfect specicity of the methods is particularly problematic in the context of the regular check-up examinations carried out among asymptomatic and possibly caries-free patients. The participants in this study were dental or dental hygienist students from a Danish population with a rather low caries experience, and one may, therefore, expect the results to apply in low-caries populations. Caries diagnosis among the middleaged and elderly may be compounded by their often much greater restorative experience, and the results of the present study may not necessarily be extrapolated to those populations. Other caveats include the somewhat articial diagnostic situation, which was created for the purpose of ensuring independence of the recordings made using the visualtactile and radiographic methods. Securing independence has the advantage that the contribution of each method can be assessed, but this deviates from the typical clinical circumstances where the clinician would have both sources of diagnostic information available simultaneously when assessing the salient features of a lesion. However, the use of a more typical clinical approach would preclude us from disentangling the contribution of each diagnostic information source as these are not processed independently during the clinical decision-making process (28). The results presented here are based on the pooled observations of four examiners representing considerable experience in both visualtactile and radiographic methods for caries diagnosis. While some variation was observed between examiners in terms of their observations using each of the examination methods as well as using the validation method (19), the data material is too small to allow rm conclusions whether different caries diagnostic combinations might work better in the hands of some than others. Each examiner assessed 319338 interproximal surfaces, of which, only 1625 were found to be cavitated, and this is

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insufcient for valid inference regarding the performance of different examiners using different methods. So far, most studies of clinical decision making following the use of different diagnostic methods and strategies have been based on extracted teeth (21, 25). In this situation, the proportion of lesions for detection is typically much higher than would be the norm in any real-life setting (20), and conclusions may, therefore, be distorted by the articial case-mix. Such distortion is amply illustrated by the results of two apparently similar studies of the effect of combining a visual and a radiographic method for the detection of dentin caries in occlusal surfaces (23, 24). In one study (24), visual detection of occlusal dentin caries had sensitivity and specicity values of 0.72 and 0.41, while the other study (23) reported sensitivity and specicity values of 0.12 and 0.93 for the visual detection of occlusal dentin caries. However, when cavitated teeth were allowed in the latter case-mix (22), the sensitivity value for the visual diagnosis of occlusal dentin caries increased from 0.12 to 0.62. It is, therefore, a great advantage of the present study that it is based on a real-life study group. The results of the present study are less prone to bias from case-mix issues, and the study design is more relevant for the daily clinical practice situation than is an in vitro study of extracted teeth. Imperfect caries diagnostic methods are used on a regular basis for the detection of dental caries lesions in a substantial number of asymptomatic individuals who visit their dentist for routine check-ups, and the implications of the inevitable diagnostic errors, therefore, become of great concern. The present results show that the observation of a radiographic lesion into dentin should not in and of itself lead to the decision of operative treatment. This conclusion is consistent with observations that lesion depth (43) and density of the radiographic dentinal demineralization (44) are inaccurate in distinguishing cavitated and noncavitated lesions in interproximal surfaces. If radiographic dentinal lesions are interpreted as evidence for cavitation, a substantial number of errors may occur when bitewing radiography is added to the visualtactile examination, and this problem will be particularly severe in low-caries prevalence populations. In this perspective, it may, therefore, be unfortunate that detecting more caries lesions for treatment is deeply ingrained in the practitioners mind as doing good and that contemporary international guidelines (7, 11) continue to recom-

mend frequent screening for caries by bitewing radiography.

References
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