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Clinical Diagnosis of Dental Caries: A European Perspective

Article in Journal of Dental Education · November 2001

DOI: 10.1002/j.0022-0337.2001.65.10.tb03472.x · Source: PubMed

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 Clinical Diagnosis of Dental Caries:
A European Perspective
Nigel B. Pitts, B.D.S., Ph.D., F.D.S., R.C.S., M.F.P.H.M., F.F.G.D.P. (U.K.)
Abstract: The aim of this paper is to provide a broad international perspective on aspects of the RTI/UNC systematic review, to
introduce relevant literature not cited, and to make recommendations for clinical practice education and research suggested by the
evidence. Clinical caries diagnosis represents the foundation on which the answers to most of the consensus questions will be
based. This paper highlights needs for being clear about definitions and nomenclature; understanding the importance of the
concepts underlying the D1 and D3 diagnostic thresholds used widely within the RTI/UNC Review; and appreciating that the
diagnostic challenge now faced by clinicians is significant and is becoming more complex as the presentation and distribution of
the disease changes over time and the range of preventive and operative treatment options expands. A series of recommendations
informed by the evidence are made, including a rather contentious issue for many clinicians concerning the lack of evidence
supporting the continued use of a sharp explorer as a diagnostic tool for primary caries diagnosis. This practice should be
discontinued as it may cause some harm to the patient and yet fails to provide a significant balancing diagnostic benefit. Finally,
it is suggested that dentistry should learn from the developing evidence base in medicine on how best to disseminate the findings
of reviews and promote appropriate changes in clinical practice.
Dr. Pitts is Director, Dental Health Services Research Unit, University of Dundee. Direct correspondence to him at the University
of Dundee Dental School, Park Place, Dundee, DD1 4HR Scotland, UK; +44-0-1382-635959 phone; +44-0-1382-226550 fax;
[email protected]. The complete version of this paper can be viewed at http://www.nidcr.nih.gov/news/consensus.asp.
Note: The Dental Health Services Research Unit is funded by the Chief Scientist Office of the Scottish Executive Health
Department and is a member of the Medical Research Council’s Health Services Research Collaboration (MRC HSRC). The
views expressed in this paper are those of the author and not necessarily those of the Scottish Executive or the MRC HSRC.
Key words: dental caries diagnosis, evidence-based dentistry, treatment strategies, dental diagnostic systems

I
applaud the organizers for setting out such an based, either through providing information on caries
important and timely agenda for this conference detection (or acting as the benchmark from which other
which is, in a sense, overdue. I would also caution methods must be judged), being part of risk assess-
all participants as to the enormity of the task set out for ments, being used in the assessment of both primary
us. Agreeing where the evidence leads us on the Diag- and secondary preventive strategies, or playing a key
nosis and Management of Dental Caries Throughout role in informing clinical decision making. It is vital
Life is a complex task, but one in which we should be then that the objective findings of the RTI/UNC sys-
able to make significant and valuable progress. The tematic review around which the conference is based,
focus of the conference is rightly on clinical practice as well as those from a number of other reviews from a
and using current knowledge to aid the provision of the variety of countries, are carefully considered by the tar-
best possible appropriate care for individual patients. get group of end users—even if some of the findings
It is important at the outset to realize that much of the seem to contradict the dental “facts of life” taught to
research work in the field of caries diagnosis has been many of us in an earlier era in different dental schools,
conducted and reported in three overlapping applica- and even if some of the more recent findings do not fit
tions of the diagnostic process: clinical practice, clini- with the “classical” findings of research carried out
cal research, and clinical dental epidemiology. The dif- some years ago. Different groups of clinicians in dif-
fering objectives, environments, and priorities of ferent countries will probably find different parts of
research and work in these areas often confuse attempts the recommendations easy or difficult to comply with.
to synthesize the relevant literature, particularly when We should learn from the work done in medicine that
comparing across countries and dental cultures. there is also a developing literature and evidence base
As the aim of this conference is to develop scien- on how to disseminate the findings of reviews effec-
tifically based recommendations that can be applied tively and, having achieved that, how any changes in
by dentists and dental hygienists, it is important that clinical practice that might be indicated can best be
the “everyday” fundamentals of clinical caries diagno- brought about.1 The potential for this conference to
sis are addressed clearly and objectively. Clinical car- contribute to professional behavior change looks favor-
ies diagnosis represents the foundation on which the able, in that initiatives which are professionally led and
answers to most of the consensus questions will be are conducted to a high scientific standard with sys-

972 Journal of Dental Education ■ Volume 65, No. 10

tematic and objective reviews of the international lit- progression of these enamel lesions with macroscopi-
erature have been shown to work well, as long as they cally intact surfaces is extremely slow and such lesions
are then cascaded down to achieve true local owner- on free smooth surfaces do not always progress; they
ship.1 can stop—lesion arrest—or even reverse—lesion re-
A key area, which will need to be addressed to gression.5,6 Part of the confusion is that these enamel
build and achieve consensus, is clarity about the defi- lesions are often referred to as D1 lesions, as opposed
nitions and nomenclature used. Many apparently simi- to the D1 diagnostic threshold that includes both D1 and
lar terms are used interchangeably in the literature, but D3 lesions (Figure 1). An example of the type of clini-
are taken by different groups of researchers and clini- cal visual diagnostic criteria used often in European
cians to mean very different things. In the conference studies, which can be reported at either or both the D1
title (and hence the mission) there will have to be clar- and D3 diagnostic thresholds, is the recently reported
ity with regard to defining the terms: diagnosis (not Dundee Selectable Threshold System, or DSTM.7,8 Note
just detection); clinical management (encompassing that traditional diagnostic aids (such as bitewing radi-
preventive care of reversible lesions as well as surgical ography and fiber-optic transillumination, FOTI) de-
excision of tooth substance); what constitutes dental tect more lesions still. The newer and more sensitive
caries (the current research view, held for many years research methods of caries diagnosis are now able to
in Europe and now increasingly in the United States, is detect even more subclinical initial lesions, which are
that caries is a continuum, rather than just the macro- in a state of dynamic progression and regression at the
scopic cavitation, which merely represents the late stage early stage of the disease process, before they are dis-
of the disease process); throughout life (here we need cernible by conventional clinical methods. With this,
to differentiate early childhood caries from lesions in lesions be detected and the impact of preventive care
children, adolescents, adults, and seniors, to plan mini- can be assessed to ensure that cavitation is avoided.
mally invasive care for the long-term benefit of the The same iceberg can be used to link the diag-
patient, and to appreciate the possibility of changes nostic divisions of the continuum of dental caries with
between risk groups over time). the type of clinical caries management option that of-
fers the patient the best long-term benefit (Figure 1b).
This choice of the most appropriate care option involves
balancing the risk of continuing tooth destruction if
The Parts of the RTI preventive care fails, against restorations placed and
Systematic Review Relating then replaced repeatedly over time with the imperfect
restorative methods currently available. The approach
to Clinical Caries Diagnosis used in Europe for some years is summarized by the
acronyms NCA for No (active) Care Advised above
To make best use of the review, it is very impor- normal prevention, PCA for Preventive Care Advised
tant to understand the concepts of the D1 and D3 diag- when stable and/or noncavitated lesions are diagnosed
nostic thresholds used widely within the RTI/UNC re- and PCA + OCA when both Preventive and Operative
view because this is an area that causes confusion to Care are Advised for progressive dentinal lesions and
many. Figure 1a shows an updated version of the ice- lesions with significant cavitation.9,10 There is a con-
berg metaphor for conceptualizing dental caries and the tinuing debate in Europe as to exactly when restorative
impact that the changing diagnostic threshold has on intervention is indicated, including a movement to rec-
what is considered by dentists and researchers to con- ognize the need to tailor the decision to individual pa-
stitute sound and diseased tooth tissue.2 The term “car- tients and their needs, wants, and circumstances, and
ies free” is frequently used when referring to data re- with a focus on cavitation (surface discontinuity) rather
ported at the D3 (caries into dentin only) diagnostic than dentin involvement (lesion depth) per se. It should
threshold. This term conveys the mistaken impression be noted that progressive dentinal hidden dentine le-
that no disease is present in an individual or popula- sions can sometimes be found in sites that are clini-
tion, even though large numbers of carious lesions have cally sound and that these lesions are scheduled for
been recognized and scored by dentists and research- operative care (Figure 1b). It also must be emphasized
ers as dental caries in the enamel.3 The diagnosis of so- and re-emphasized that clinical caries diagnosed at the
called white spot and brown spot caries has been ac- enamel lesion threshold with intact surfaces are not
cepted for many years in Europe, so that monitoring scheduled for restoration, but are typically managed
the behavior of these lesions over time using clinical preventively in Europe.
caries assessments is routine following the classic work A number of technical aspects of the review are
of Backer-Dirks and others.4 It has been shown that the worthy of comment. First, the reviewers are to be con-

October 2001 ■ Journal of Dental Education 973

 Figure 1a. Conceptualizing the caries process

gratulated for their diligence, endurance, and thorough- gue that this method captures more of the diagnostic
ness in completing such a major task. The key finding information obtained, whilst others are less convinced.11
that the quality of studies in the areas reviewed was Differences in the approach to histological validation
often found to be poor may be seen as contentious by employed represent a further challenge in this area. On
some in dentistry. It is frustrating that, when measured the one hand in vitro studies are commended as they
against contemporary methodological standards, there can provide a true gold standard; on the other hand, the
are so few useable studies. However, it is important for differences between the diagnostic performance
these findings to be judged in the context of similar achieved in vitro and in vivo casts some doubt on the
reviews in many fields of medical care where similar generalizibility of the in vitro findings. Although very
findings are common. This represents a major challenge demanding in terms of logistics, the ideal study design
to the dental research community for the future. would be to assess diagnosis in vivo first and then re-
Some areas of the review might have been im- assess the same surfaces in vitro following extraction
proved if more time and resources were available. A of the tooth (for some ethically acceptable reason). A
key concern in this complex area of reviewing diag- further difficulty occurs when the gold standard classi-
nostic literature in evidence- based healthcare is that cally employed is potentially less sensitive than some
the quality standards imposed on grading the papers of the methods being tested against it.
included are pertinent to the objective(s) of the study.
In this review, as data from some papers were employed
for a number of different analyses, not always those
intended by the authors of the primary research, it might
Additional Studies Not
be argued that some of the quality scores were there-
fore inappropriate for some evidence tables. The pre-
Included in the RTI/UNC
sentation of the data also was complex. Other areas for Review
technical debate include the possible use of Receiver
Operating Characteristic (ROC) analyses rather than The papers cited in this section provide a Euro-
relying solely on sensitivity and specificity. Some ar- pean perspective on many of the challenges to clinical

974 Journal of Dental Education ■ Volume 65, No. 10

Figure 1b. Linking diagnosis to clinical management

caries diagnosis raised in the review. The diagnostic genic damage can readily be produced, particularly on
challenge now faced by clinicians should not be under- initial caries within occlusal fissures, and this action
estimated or regarded as a basic or undemanding skill. will favor continued lesion development.14 Similar find-
The presentation of the disease has changed at a time ings were shown by Ekstrand and colleagues nearly
when the prevalence and incidence have slowed in some twenty years later15 when it was also shown experimen-
cases, but also when the disease has become more po- tally that the effect of probing with an explorer had a
larized between risk groups and the range of preven- deleterious effect in terms of subsequent enamel dem-
tive and operative treatment options has expanded.12,13 ineralization.16 Apart from any risk of conveying cari-
Although the clinical examination is the bedrock of ogenic organisms from one fissure system to another,
daily dental practice, it is clear from many studies that it is argued that a practice likely to cause harm to the
clinical examination used alone in vivo will miss many patient cannot be justified if it fails to provide a sig-
lesions until they become so advanced that preventive nificant balancing benefit. In this case, work showing
intervention to avoid cavitation is compromised. The the absence of any diagnostic benefit from the visual +
occlusal surface presents particular difficulties as gross tactile method over the visual only method means that
cavitation seems to occur less frequently and the limi- the use of the sharp explorer to sense “stickiness” in
tations of the clinical visual method have led to a fear occlusal fissures for primary caries diagnosis should
of underdetecting hidden (or occult) lesions involving be discontinued. A further complication with interpret-
dentin.12 ing this literature is the difficulty of comparing studies
A contentious issue for many clinicians concerns that include established, open cavities in the assessment
the lack of evidence supporting the continued use of a of occlusal caries diagnosis, along with those confined
sharp explorer as a diagnostic tool. Although its use as to equivocal lesions.17
part of a visuo-tactile clinical method is widespread A significant extension of the well-used clinical
and has been widely taught for many years in many visual method of caries diagnosis on accessible free
countries, many European centers now teach that it is smooth surfaces can be made by temporarily separat-
unethical to use an explorer in this way. This is because ing adjacent teeth with elastomeric tooth separators
it has been shown many years ago in Sweden that iatro- commonly used in orthodontic practice.18,19 This allows

October 2001 ■ Journal of Dental Education 975

 Table 1. Recommendations in response to the relevant conference questions

Question 1. What are the best methods for detecting early-stage and late-stage dental caries?
1. Recognize that clinical caries diagnosis (with all its flaws) is the current foundation of lesion detection in clinical practice,
clinical research, and clinical epidemiology. The literature evaluating the method is mixed between these three applications,
and care is needed to separate out the objectives of use and the performance of the method in each field.
2. Clinical visual methods of caries diagnosis are universally employed, are rapid, economical, and acceptable for detecting
early-stage disease (enamel lesions such as white and brown spot caries on accessible sites), noncavitated dentinal lesions,
and late-stage cavitated caries. However, although the methods are inherently feasible, their inherent limitations must
always be remembered.
3. Although clinical diagnostic methods are highly specific, the low sensitivity achieved, particularly for non-cavitated occlusal
surfaces in vivo, means that the use of diagnostic aids with superior performance is indicated and that new methods for
caries diagnosis are required.
4. Although the volume of high-quality evidence on new diagnostic methods is lower than desirable, the very limited high-
quality evidence available to support traditional clinical diagnostic methods means that clinicians cannot be complacent
about the status quo.
5. Given the potential for caries-inducing and caries-accelerating iatrogenic damage from the use of a sharp explorer in a
visuo-tactile method, combined with the lack of any evidence of any additional diagnostic benefit, sharp explorers should
no longer be used for the diagnosis of primary coronal caries in fissures.
6. Continuing, effective undergraduate, faculty, and postgraduate educational initiatives will be needed to share the evidence
with teachers and clinicians in order to persuade those still using them to move away from sharp explorers.
7. The continuum of the caries process and the long-term benefits to the patient of preventive caries management should be
more readily appreciated by practicing dentists and should thus be the subject of continuing, effective undergraduate,
faculty, and postgraduate educational initiatives.
8. The state of scientific knowledge regarding caries diagnosis (and related preventive management) in all three fields has
moved forward, ahead of many traditional professional, regulatory, and advisory frameworks, which should be objectively
updated regularly.
9. The concepts of diagnostic thresholds should be more widely understood and the use of the ambiguous term “caries free”
should be avoided.
10. It should be explicitly recognized that the current situation regarding the state of the art of caries diagnosis in clinical
practice, clinical research and clinical dental epidemiology will need to alter with the continuing new developments in
knowledge. Strategies for systematically sifting, grading, and promoting the adoption of worthwhile new caries diagnostic
approaches should be put in place internationally.
11. Attempts should be made to harmonize epidemiological diagnostic methods in order to promote improved comparability
and produce more reliable estimates of contemporary preventive care and restorative treatment needs.

Question 5. How should clinical decisions regarding prevention and/or treatment be affected by detection methods and
risk assessment?
1. There is a need for more reliable diagnostic methods to provide unambiguous indications of the extent, surface status, and
activity of lesions in order to plan appropriate care.
2. There is a need for diagnostic methods that can reliably assess sealed surfaces.
3. There is a need for better tools for the diagnosis and treatment planning of secondary caries, given the proportion of repeat
dentistry currently carried out.
4. Before a decision to restore is made, clear evidence of significant cavitation or progressive dentinal involvement should be
required.
5. Results of clinical diagnosis should able to be fed into preventively-biased clinical decision frameworks compatible with a
NCA, PCA, PCA + OCA style of classification in order to avoid the premature restoration of small noncavitated lesions.
6. There is a need for valid, reliable, automated clinical decision support systems

Question 6. What are the promising new research directions for the prevention, diagnosis and treatment of dental caries?
1. There is a need for more effective primary preventive products.
2. There is a need for specific secondary preventive products that can deliver reliable lesion reversal prior to the cavitation
stage ever being reached.
3. There is an urgent need for more high-quality studies that are well conducted and well reported using an internationally
agreed common minimum data set for reporting.
4. There is a need for more studies evaluating the same lesions both in vivo and in vitro.
5. There is a need for more studies evaluating caries diagnosis in primary teeth.
6. There is a need for more studies evaluating diagnostic performance at the caries into enamel and dentin D1 threshold.
7. There is a need for more studies on combinations of diagnostic methods, with adjunctive and supplemental analyses.
8. There is a need for more sensitive, specific, reliable, objective diagnostic methods to indicate sites vulnerable to lesion
progression prior to too much damage being done, i.e., tools to specifically cater to early stage caries.
9. There is a need for diagnostic tools to cater for lesions around the size/extent at which restorative intervention is indicated,
in order to monitor the outcome of aggressive preventive care.
10. There is a need for diagnostic tools tailored for rapid, reliable, and accurate use in epidemiological settings.
11. There is a need for diagnostic tools to specifically detect hidden dentine caries.
12. There is a need for better dental materials with physical properties that more closely match tooth tissue and the
13. There is also a need to develop the evidence base on how to disseminate effectively the findings of systematic reviews in
dentistry and, having achieved that, to establish how any changes in clinical practice that might be indicated can best be
brought about.

976 Journal of Dental Education ■ Volume 65, No. 10

a direct assessment of the presence or absence of sur- dence base for effective care and the needs of an indi-
face cavitation to be made without exposing the patient vidual patient.32-34 More work is needed to understand
to ionizing radiation to obtain a bitewing radiograph better the interplay between the diagnostic and treat-
which cannot give a definite indication of the integrity ment decisions made by general dentists, particularly
of the approximal surface. Although the technique does as they relate to more preventive modes of care, such
require some practice and, in some cases, a further visit, as fissure sealants,35 and how dentists value features of
it has been shown to be feasible in a general practice new technology in ways different from their patients.36
setting.20 The clinical visual elective temporary tooth This should lead to clearer evidence-based clinical
separation method can also be used in diagnostic re- guidelines for caries management37 in different patient
search where the lack of clinical cavitation in groups, including the socioeconomically deprived with
approximal sites with dentinal radiolucencies on bitew- most disease.38 Taken together and building on a syn-
ing radiographs has been striking.21,22 The probability thesis of the information taken from the reviews pre-
of approximal cavitation has also been linked to caries sented at the conference, this process should help cli-
activity.23 nicians to practice sound, effective, and up-to-date caries
Comparing of the relative merits of clinical vi- prevention and management based on more accurate
sual and radiographic diagnoses represents an impor- and reliable caries diagnosis.
tant area of changing practice as new evidence unfolds A Perspective on Recommendations for Clinical
and evidence- based guidelines are produced to inform Practice, Education, and Research
clinical decisions.24,25 There is perceived to be an ur- Using the information presented in the RTI re-
gent need, given the deficiencies of clinical and other view, combined with the additional evidence cited in
traditional caries diagnostic methods, for new methods this contribution, a number of recommendations can
that avoid the use of ionizing radiation.26 The compara- be made to address the questions set out for the
tive research of clinical and other diagnostic methods Concensus Development Conference. These are set out
brings with it methodological difficulties in combin- in Table 1.
ing the data in the most effective and useable way.
Longbottom advocated two different strategies for this,
contrasting using adjunctive additional methods—when Acknowledgments
the additional method(s) are used/counted only in those The author would like to acknowledge the invalu-
cases where the clinical diagnosis is sound—with able contributions made to the work outlined in this
supplemental additional methods, when the highest- paper by very many colleagues and collaborators. Par-
severest score from the clinical or additional method(s) ticular thanks are due to those contributing to the
are used/counted as the final diagnosis.27 These ap- DHSRU Dental Service, Dental Caries, and Dental
proaches merit further consideration as new research Practice Programmes, to our international collabora-
unfolds. One neglected area of study is the diagnostic tors, to all who assisted with the “Eurocaries” project,
use of magnification in caries diagnosis.28 (Further con- and to the members of the Guideline Development
sideration of this topic can be found in the full version Groups of the Faculty of General Dental Practitioners
of this paper found at http://www.nidcr.nih.gov.) and SIGN.
Traditionally, it has been claimed that recording
caries at the D1 threshold is associated with very poor
examiner reproducibility. However, there is a growing REFERENCES
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October 2001 ■ Journal of Dental Education 977

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978 Journal of Dental Education ■ Volume 65, No. 10

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