J Clin Exp Dent. 2022;14(2):e177-84.

Detection methods of initial occlusal caries

Journal section: Operative Dentistry doi:10.4317/jced.59185

Publication Types: Research https://doi.org/10.4317/jced.59185

Clinical effectiveness of high definition fluorescence

camera in detection of initial occlusal caries

Mohamed Salama 1, Olfat Hassanein 2, Omar Shaalan 3, Asmaa Yassen 4

1
Doctoral Candidate, Department of Conservative Dentistry, Faculty of Dentistry, Cairo University. Assistant Lecturer, Department
of Conservative and Esthetic Dentistry, Faculty of Dentistry, The British University in Egypt
2
Professor, Department of Conservative Dentistry, Faculty of Dentistry, Cairo University
3
Lecturer, Department of Conservative Dentistry, Faculty of Dentistry ,Cairo University
4
Professor, Department of Conservative Dentistry, Faculty of Dentistry, Cairo University; Department of Conservative and Esthe-
tic Dentistry, Faculty of Dentistry , The British University in Egypt

Correspondence:
Department of Conservative and Esthetic Dentistry
Faculty of Dentistry, The British University in Egypt
El Sherouk City, 11837 Cairo, Egypt
[email protected]

Salama M, Hassanein O, Shaalan O, Yassen A. Clinical effectiveness of

Received: 23/11/2021 high definition fluorescence camera in detection of initial occlusal caries.
Accepted: 24/01/2022 J Clin Exp Dent. 2022;14(2):e177-84.

Article Number: 59185 http://www.medicinaoral.com/odo/indice.htm

© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]
Indexed in:
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Abstract
Background: Although visual inspection is the preferred route in everyday clinical practise for detecting early
caries lesions, novel technologies like light fluorescence-based devices (Vista Proof iX HD smart) have been deve-
loped to enhance early caries detection.
Material and Methods: Occlusal surface of 45 molar and 49 premolar teeth from 34 adult participants who ful-
filled the eligibility criteria were examined by two observers using three diagnostic methods. Examination was
performed visually using the International Caries Detection and Assessment System (ICDAS-II) followed by Vista
Proof. Fissurotomy was applied for histological validation. Intra- and inter-observer agreement were measured for
ICDAS-II and light-induced fluorescence camera using Kappa test. The overall diagnostic accuracy parameters,
area under the receiver operating characteristic curve (AUC-ROC) and 95% confidence interval (95% CI) of the
(AUC) for caries detection by Vista Poof were evaluated.
Results: For ICDAS-II and Vista Proof methods, there was almost perfect intra- and inter-observer agreement. Ba-
sed on ICDAS-II as a reference standard 1, Vista Proof showed a low level of agreement in enamel carious lesion
detection with low sensitivity value of 48%, high specificity of 100%, and AUC was 0.112, while a high level of
agreement in dentin carious lesion detection with high sensitivity value of 100%, low specificity of 48% and AUC
was 0.888. Based on fissurotomy as reference standard 2, Vista Proof showed a high level of agreement in dentin
carious lesion detection with high sensitivity value of 95% and 0% specificity and AUC was 0.814.
Conclusions: Quantitative light-induced fluorescence camera with reference to ICDAS-II is considered as an accu-
rate diagnostic modality for detection of early occlusal caries. Histological findings validate the diagnostic accura-
cy of the camera in dentin.

Key words: Histological validation, Initial caries, ICDAS, Light induced fluorescence, Vista Cam.

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Introduction study signed an informed consent form after describing

First and foremost, dental caries is a disease that affects research procedure in-depth.
60-90 % of the total of school-aged children and adults Based on previous study by Presoto et al. 2017 (7) in
worldwide (1). To adequately manage this globally pre- which Area under ROC curve for diagnostic accuracy of
valent condition, it appears that a thorough understan- fluorescent camera was 0.777 and 0.914 for ICDAS-II, it
ding of dental caries and its associated variables is requi- was estimated that both methods would need a minimum
red (2). The management of dental caries has changed as of 94 teeth. Calculation was performed using MedCalc
our understanding of disease has evolved. Diagnosis of 12.4.0 software.
occlusal caries in initial stage is considered problematic Participants were enrolled according to the following
and challenging for dental professors, due to complica- criteria: All patients were at least 18 years old having
ted anatomy of groove-fossa system, presence of stai- at least one suspected posterior pits and fissure with
ning, and deposition of plaque, calculus, or other subs- occlusal discoloration. Exclusion criteria included tee-
tances that might interfere with accurate diagnosis (3). th with fluorosis, hypoplasia, amelogenesis imperfecta,
Clinically, caries diagnosis is commonly performed by hypomineralization, pit and fissure sealants/restorations,
multiple methods as visual tactile methods, assessments and third molars. (7,8). According to these eligibility cri-
of translucency, color, and dental hardness, as well as by teria, 34 participants were enrolled: 15 females and 19
means of radiographic imaging. International caries de- males. Ninety-four teeth were included in the study: 45
tection and assessment system (ICDAS) based on stan- maxillary and 49 mandibular teeth. Premolars compri-
dard method for visual diagnosis of dental caries had sed 52.1% and molars comprised 47.9% of the examined
been widely used as gold standard for clinical diagnosis teeth.
of dental caries (4). The visual inspection has various Each lesion was evaluated using ICDAS-II, a light-in-
limits in its application. The most evident is that it is re- duced fluorescence camera, and fissurotomy as a con-
lied on practitioner’s subjective evaluations, thus lesions firmatory assessment. Fifteen days before the inquiry,
can go undiagnosed because teeth are often viewed with the two examiners (MS and AY) assessed 60 extracted
naked eye (5). teeth for calibration. Each examiner diagnosed the tee-
As a result, occlusal caries detection technologies should th and recorded their results. They compared the results
not only be capable of detecting and monitoring lesions and returned the discrepancy cases until they reached
at all phases of caries process, but also be very reliable. 100% consistency (7). True blinding was not applica-
Because detecting early occlusal caries is challenging, ble, otherwise, obtained data from each examiner was
novel approaches for detecting early caries have been not exchanged with the other examiner. Each examiner
developed. Some of these technologies use light-based conducted diagnostic procedures in a separate cabin. Vi-
fluorescence devices to utilize fluorescence properties of sual examination was conducted first before assessment
hard tissues (6). The light-induced fluorescence of bac- using light-induced fluorescence method. This minimi-
terial by-products or tooth structure is used to diagnose zed the risk of assessment bias. Furthermore, a sequen-
diseased teeth. Limited data about clinical performance tial clinical examination for all enrolled participants was
of a high-definition quantitative light fluorescence-based conducted as follows: In first visit, teeth were carefu-
camera in detection of initial caries are available. So, lly scaled and polished to remove surface biofilm and
this investigation was carried out to validate its accura- calculus deposits using ultra sonic scaler. Furthermore,
cy. The null hypothesis tested is that there is no differen- teeth were cleaned for 10 seconds with a water powder
ce in the reliability of quantitative light fluorescence-ba- jet cleaner (Prophy Neo Mate, NSK, Japan) using cal-
sed camera (Vista Proof) in comparison with ICDAS-II cium carbonate spherical powder (Flash pearl polishing
and fissurotomy validation in detection of initial occlu- powder, NSK, Japan), followed by another 10 seconds
sal caries. rinsing with an air water spray for thorough cleaning of
fissures from any powder residues. Teeth were exami-
Material and Methods ned by two examiners using two diagnostic modalities
The current study’s protocol was registered in protocol under standardized conditions of lightening from dental
registration and results system (www.clinicaltrials.gov) unit and by using front surface mirror (Zeffiro, Italy),
database under identification number NCT03940170. oil free air syringe and CPITN probe (HAHNENKRA-
All procedures involving human subjects in this study TT, Germany). Teeth were examined visually while they
were carried out in accordance with ethical requirements were wet then after being dry for 5 seconds with a triplex
of Research Ethics Committee of Faculty of Dentistry, syringe. Examiner noted changes in tooth translucency,
Cairo University (Approval number. CREC 19628). The opacity, or color, compared to adjacent healthy teeth,
outpatient clinic of Conservative Dentistry department, and classified their ICDAS scores (9) (Fig. 1). Magnifi-
Faculty of Dentistry, Cairo, Egypt, hosted this diagnos- cation was not used with visual examination as recom-
tic clinical trial and each participant that included in this mended by ICDAS modality. Highest ICDAS score in

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Fig. 1: A-E: ICDAS-II scoring system representing score from 0 – 4 with intraoral images: (A) Code 0; (B)
Code 1; (C) Code 2; (D) Code3; (E) Code 4.

each occlusal surface was recorded at investigation site. tooth drying with a triplex air syringe for 15 seconds. By
Regarding quantitative analysis of lesion activity using pressing focus button, the camera focused sharply on the
Vista Proof Camera, teeth were examined using fluo- tooth followed by pressing the trigger button for captu-
rescence-induced interchangeable head of the camera ring the image. Image was analyzed by special software
(Vista Proof) following manufacturer’s instructions. The (DBSWIN) version 5.15.1. The software produced a di-
head of the camera was positioned perpendicular to the gital image that showed lesions in different colors with
occlusal surface of teeth. This scenario was conducted numerical values between 0 and 3 predicting depth and
under isolation with cotton rolls and suction tip and after extent of the lesion Figure (2) (10).

Fig. 2: A-E: Vista Cam scoring system according to manufacturer with intraoral representative fluorescence
images: (A) score 0≤ x<1 ;(B) score1≤x<1.5; (C) score1.5≤x<2; (D) score2≤x<2.5; (E) score x ≥2.5.

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The true histological extent of carious lesions was de- of caries compared with traditional ICDAS-II and detec-
termined by fissurotomy which was considered as a tion of enamel and dentin lesions compared with fissu-
confirmatory test. Clinical fissure evaluation was deci- rotomy and ICDAS-II.
ded according to the reading obtained from Vista Cam,
ICDAS-II, in addition to lesion activity and caries risk Results
assessment. When Vista Cam reading ≥ 2 and ICDAS-II There was nearly perfect intra-observer agreement for
as score 3, fissurotomy was carried out. In case of IC- ICDAS-II (Kappa= 0.943 for observer 1 and Kappa=
DAS-II score 2, fissurotomy was only carried out when 0.891 for observer 2), and Vista Proof methods (Kappa
Vista Cam reading was ≥2, and the lesion appeared to = 0.841 for observer 1 and Kappa= 0.810 for observer
be active on visual (matt appearance) and tactile (soft) 2). Inter-observer agreement was nearly perfect for both
examination and the participant was categorized as high ICDAS-II and Vista Proof methods (Kappa= 0.854 and
caries risk (11). It is worth mentioning that current lite- Kappa= 0.872, respectively). Vista Proof showed a low
rature regarding ICDAS-II score 2 reported that dentin level of agreement with ICDAS-II in enamel carious le-
involvement was evident upon histological validation in sion detection with low sensitivity value of 48%, high
several teeth within this score (12). The procedure was specificity of 100% to achieve an overall accuracy of
done using fissurotomy kit (SS WHITE USA). Suita- 67% (Table 2). Positive and negative predictive values
ble sixed bur gently went over the fissure and then it were 100% and 53% respectively showing a slightly be-
was visually inspected under magnification loupes (4x tter predictive value for carious teeth than sound teeth.
custom made Univet loupes, Italy). Extent of the lesion ROC curve analysis revealed that AUC was 0.112 with
was examined with the tip of exploratory probe to as- 95% confidence interval (0.037-0.187), which indicates
sess hardness of the bottom of the fissure. Final depth a poor association between ICDAS-II and Vista Proof
of the lesion was taken to represent the ‘true lesion ex- methods. While Vista Proof showed a high level of agree-
tent’ (code1: enamel and code2: dentin).For subsequent ment with ICDAS-II in dentin carious lesion detection
evaluation of both examiner’s scores, ICDASII scores, with high sensitivity value of 100%, low specificity of
corresponding Vista Proof reading and fissurotomy were 48% to achieve an overall accuracy of 67%. Positive and
represented in Table 1. Management of dental condition negative predictive values were 53% and 100% respecti-
was done for patient’s satisfaction and health care (13). vely showing a slightly better predictive value for sound
Statistical analysis was performed using IBM SPSS teeth than carious teeth. ROC curve analysis revealed that
Statistics Version 20 for Windows. Significance level AUC was 0.888 with 95% confidence interval (0.813-
was set at P ≤ 0.05. Intra- and inter-observer agreement 0.963), which indicates a good association between IC-
regarding ICDAS-II and Vista Proof modalities were DAS-II and Vista Proof methods (Table 2, Fig. 3). Vista
evaluated using Cohen’s Kappa test. Diagnostic validity Proof showed a high level of agreement with fissurotomy
of Vista Proof device was determined, including sensiti- in dentin carious lesion detection with high sensitivity va-
vity, specificity, overall accuracy, positive and negative lue of 95% and 0% specificity to achieve an overall accu-
predictive values, and ROC curve analysis, in detection racy of 95% (Table 3). Positive and negative predictive

Table 1: Description of visual, fluorescence-based diagnostic criteria and fis-

surotomy.
ICDAS-II Scores Visa Proof Reading Fissurotomy
Score 1, 2 <2 Enamel
Score 3 2-2.5
Dentin
Score 4 >2.5

Table 2: Diagnostic accuracy of Vista Proof method in detection of enamel and dentin carious lesions based on ICDAS-II as reference standard.
Overall diagnostic
Sensitivity % Specificity % +PV % -PV % AUC 95% CI
accuracy %
Enamel lesions 48% 100% 100% 53% 67% 0.112 0.037-0.187
Dentin lesions 100% 48% 53% 100% 67% 0.888 0.813-0.963
+PV: Positive Predictive Value, -PV: Negative Predictive Value

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Fig. 3: A,B: ROC curve between Vista Proof and ICDAS-II (A)enamel carious lesions; (B) dentin carious
lesions.

Table 3: Diagnostic accuracy of Vista Proof method in detection of dentin carious lesions based on fissurotomy as reference standard.

Overall diagnostic
Sensitivity % Specificity % +PV % -PV % AUC 95% CI
accuracy %

Dentin lesions 100% 0% 95% 0% 95% 0.814 0.689-0.939

+PV: Positive Predictive Value, -PV: Negative Predictive Value

values were 95% and 0% respectively showing a slightly 95% confidence interval (0.689-0.939), which indicates
better predictive value for carious teeth than sound teeth. a good association between fissurotomy and Vista Proof
ROC curve analysis revealed that AUC was 0.814 with method (Table 3, Fig. 4).

Fig. 4: ROC curve between Vista Proof and fissurotomy in detection of dentin carious lesions.

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Discussion effect of storage media such as chloramine, formalin, or

Early detection of caries is the corner stone in deciding thymol solution in vitro studies resulted in a decrease in
whether to perform preventive rather than surgical treat- porphyrin-based fluorescence (20).
ment strategies. Delay in caries treatment may occur Florescence camera (Vista proof HD smart) showed a
if caries is not recognized or underestimated, thus re- low level of agreement with ICDAS-II in enamel carious
sulting in deep carious lesions extending to dentin. In lesion detection with low sensitivity high specificity, an
this study, international caries detection and assessment overall accuracy of 67% with a very poor AUC .The-
system (ICDAS-II) was taken as reference standard for se results could be justified by the fact that the device
detection of diagnostic accuracy of fluorescence camera is very sensitive to any changes in the carious lesion
(Vista Proof iX HD Smart) in addition to use of fissuro- with great sensitivity to any bacterial biproducts which
tomy technique not histopathological cross section for made its scores exceeding the scores of ICDAS II. On
a histological validation of results. The main challenge the other hand, other studies revealed the inability of the
for using histopathology as reference standard is that it device to quantify the scattered fluorescence light in the
is limited to the ex-vivo studies or can only be perfor- early demineralized enamel areas as it could not measu-
med in clinical studies with a relatively small number re the intrinsic changes in enamel structure, so it has a
of teeth that can be extracted and having laboratory exa- lower performance for early enamel lesions. In addition,
mination (14). In addition, it has been recently shown the type of enamel affects the ways of scattering of the
that stereomicroscopic examination for histopathologi- device (21). Moreover, porphyrins, which are a product
cal examination had low accuracy in detecting dentin of bacterial metabolism was found to be less on the ena-
demineralization and underestimated the real depth of mel surface(22). This was in agreement with (12,19,21)
dentin involvement (15). Kappa values for intra- and which mentioned that Vista Proof might have certain
inter-observer agreement level in current visual exami- difficulties in detecting caries at this level showing low
nation using ICDAS-II system showed that there was sensitivity. While this finding disagreed with the findings
almost perfect agreement between measurements. This of (8,23,24) and which reported that VistaCam iX was
outcome may be related to the examiners’ prior training characterized by a high sensitivity and low specificity.
in utilizing the ICDAS-II scoring system. Inter-observer This might be referred to the changes in the cutoff points
agreement results agreed with Jablonski-Momeni et al. that were used in the methodology of these studies in
(2008) (16). While Rodrigues et al. (2008) (17) disco- addition to using an older version of the device. These
vered that inter-examiner values for ICDAS-II scoring cutoffs should be interpreted with caution, as a 0.1 diffe-
system were slightly lower than current findings. Such rence can cause the score to shift from sound to carious
results could be attributed to various clinical experiences enamel or from carious enamel to dentin (17,25).
among examiners and short calibration periods prior to Florescence camera (Vista Proof HD smart) showed a
testing. high level of agreement with ICDAS-II in dentin carious
The results of intra-observer agreement and inter-ob- lesion detection with high sensitivity, low specificity ,
server agreement for Vista Proof iX HD Smart as pre- an overall accuracy of 67% and a very good AUC. This
sented by kappa values showed that there was almost high sensitivity can be explained as the red fluorescen-
perfect agreement between measurements. This could ce monitored by the device as caries, was related to the
be attributed to examiner’s training on how to use the microbial metabolic products which were expected to be
new diagnostic fluorescence camera, as well as taking present in larger amounts in such dentin lesions (21) .
a reading of exact examination site on occlusal surface Also, higher Fluorescence occurred in dentin due to the
for each tooth every time the tooth was examined. In higher concentration of organic molecules was brighter
addition to using the spacer, which allowed the image than that of enamel (26). This finding was in agreement
position and distance to be reproduced and reduced the with (17,27) that obtained high sensitivity at the dentin
penetration of external light. Inter-observer agreement level. Low specificity might be referred to the effect of
results agreed with Jablonski-Momeni et al. (2012) (18). stain inclusion especially the dark satins in the lesions
This finding disagreed with the findings of Novaes et and improper cleaning of the fissures resulting in higher
al. (2012) (19), who discovered that inter-examiner va- measurement values and consequently in higher rates of
lues for Vista Proof iX were slightly lower than current false positives (28). This finding was in disagreement
findings. This could be attributed to examiners’ lack of with (24) that showed low sensitivity and high speci-
experience with the device, as well as an issue with ac- ficity in dentin lesion that might be related to that most
quiring focus during image capture by the device, which of the scores were in deep dentin and using of storage
was solved in the latest released version of the device media which lead to the decrease of porphyrin-based
(Vista Proof iX HD Smart) by integrating autofocus bo- fluorescence (20), in addition to it was claimed that the
ttom. In addition to difference in methodology between carious area of the highest ICDAS score might appear
studies, especially between vivo and vitro studies, the dark due to implied extensive scattering and absorption

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Conflicts of interest
The authors declare that there are no conflicts of interest regarding the
publication of this paper.

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