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    Brazilian Journal of Oral Sciences

      ISSN 1677-3225

    Braz. J. Oral Sci. vol.11 no.1 Piracicaba ene./mar. 2012

     

    ORIGINAL ARTICLE

     

    Reproducibility of caries diagnosis in permanent teeth according to WHO, ICDAS-II and Nyvad criteria

     

     

    Priscila Florentino SilvaI; Franklin Delano Soares ForteII; Ana Maria Barros Pereira ChavesIII; Isabela Albuquerque Passos FariasIV; Kaline Silva CastroV

     

    IGraduate Program in Dentistry, Master's Degree Program in Preventive and Pediatric Dentistry, Federal University of Paraíba, João Pessoa, Brazil
    IIPhD, Graduate Program in Dentistry, Master's Degree Program in Preventive and Pediatric Dentistry, Federal University of Paraíba, João Pessoa, Brazil
    IIIPhD, Graduate Program in Dentistry, Master's Degree Program in Preventive and Pediatric Dentistry, Federal University of Paraíba, João Pessoa, Brazil
    IVProfessor, Department of Restorative Dentistry, Federal University of Paraiba, João Pessoa, Brazil
    VGraduate Program in Dentistry, Master's Degree Program in Preventive and Pediatric Dentistry, Federal University of Paraíba, João Pessoa, Brazil

    Correspondence

     

     


    ABSTRACT

    AIM: To assess inter-examiner reproducibility in the detection of 20 occlusal caries in permanent teeth using three diagnostic codes and criteria: WHO (1997), Nyvad and ICDAS-II.
    METHODS: Three graduate students (G) and two undergraduate dental students (UG) without previous experience in the use of Nyvad and ICDAS-II were trained by a reference examiner. Examiner validity was assessed by consensus agreement between the investigators. Two cutoff points were used for ICDAS-II and Nyvad to represent reproducibility values: the A- lesion, B- cavity lesion.
    RESULTS: According to the examiners consensus, the kappa values ranged from 0.71 to 0.85 for G group and from 0.85 to 0.95 for UG group (ICDAS-II). For the Nyvad index values varied from of 0.77 to 1.00 (G) and from 0.65 to 0.74 (UG), for the WHO index, values obtained ranged from 0.66 to 1.00 (UG) and 1.00 (G). Using a cutoff A, interexaminers reproducibility (ICDAS-II) ranged from 0.73 to 0.87 (G) and 1.00 (UG). According to Nyvad criteria, the kappa value ranged from 0.78 to 1.00 (G) and from 0.70 and 0.90 (UG) when compared to the consensus. The kappa values using the cutoff point B ranged from 0.66 to 1.00 (G), 0.76-0.89 (UG) in ICDAS-II and the in Nyvad criteria varied from 0.87 to 1.00 (G) and from 0.65 to 0.88 (UG).
    CONCLUSIONS: Reproducibility values ranged from good to perfect. The reproducibility revealed precise answers in the occlusal caries lesions diagnosis according to the criteria used. The best use of reliability tools for examiner training was important regardless of the examiners being undergraduate or graduate students.

    Keywords: dental diagnosis, tooth decay, reproducibility.


     

     

    Introduction

    In recent years, the prevalence of dental caries in children and adults has declined and changed both in industrialized and in developing countries like Brazil1-2. The international epidemiological criteria used in Brazil, the WHO standard, do not register lesions caries in pre cavitations stages, such as white spotlesions3. Thus, the progress of non cavitated caries lesions in populations it is an important evidence of using new indices in a public with new dental profile.

    Treatments that emphasize prevention need diagnostics that reveal the real stage of carious process, from the subtle demineralization changes to the cavitations itself, monitoring the individual routine4. The development of new criteria for detecting initial carious lesions process are followed by studies5-6. Among the new caries detection systems are Nyvad et al. (1999)7 and International Caries Detection and Assessment System II (ICDAS-II) created in 20028.

    Proposed by Nyvad et al. (1999)7, the Nyvad criteria includes initial manifestation of caries in the pre-cavitary stages differencing active and inactive caries in both levels cavitated and non-cavitated. Three stages of severity related to the depth of penetration are considered in Nyvad index: intact surface, descontinuous surface and cavity in enamel or dentin, avoiding use of an explorer unless the visual examination is not sufficient to choose lesion as active or inactive.

    The ICDAS-II is another set of criteria for non-cavitated caries diagnosis. It recommends the direct visual examination on clean teeth, followed by careful drying of the of the lesion surface preceding the exam, identifying the state of teeth using an ordinal scale from the health surface to cavitated caries. According to studies, epidemiological surveys using these new indices are possible with acceptable reliability in Brazil9-10 and other countries11-13.

    Reproducibility is recognized as the ability to obtain similar results on several examination and has been considered of great importance when evaluating a particular method of validation, ensuring uniformity of caries criteria interpretation14-15.

    The aim of this study was to assess the reproducibility of visual examination of occlusal caries lesions in human permanent teeth using the WHO diagnostic criteria (1997), Nyvad and ICDAS-II. Graduate and undergraduate students of Dentistry course at the Federal University of Paraíba were selected as examiners for this study.

     

    Material and methods

    This research was approved by the Ethics Committee of Lauro Wanderley Hospital, Federal University of Paraíba, under protocol #458/10. The procedures for this research complied with the guidelines and regulations involving human subjects, approved by Resolution No. 196 of 10 October, 1996 - National Council of Health16.

    Three graduate students (G) and two undergraduate students (UG) concluding the Dentistry course were selected as examiners and were trained in WHO (1997), ICDAS-II and Nyvad indexes.

    The examinations were performed in a clinical setting with access to triple syringe and artificial light. Approach to other tests performed previously with other codes and criteria was not allowed, also tests performed by another examiner. The dental mirror and WHO periodontal probe were used without pressure on tooth surface, only to precise questions arising from the visual diagnosis. The teeth were kept immersed in 10% neutral formaldehyde preventing changes in their appearance. Drying the tooth was permitted.

    The examiners were trained with SB Brasil 201015 methodology using the consensus method. According to this method, the prevailing consensus of the examiners was used as gold standard. Initially, the activities consisted of a lecture of codes and criteria to be used in the subsequent examination, digital pictures of the teeth with occlusal caries lesions were presented and theoretical exercises were performed. The examiners also practiced on ICDAS elearning17 electronic program with images of dental caries according to the scores and theoretical exercises.

    Clinical Training

    The training phase consisted of clinical examination of 10 teeth with several situations, from healthy teeth, white spot, enamel fracture, cavitation in dentin to teeth with extensive destruction. The examiners reviewed the examination register in their files and discussed disagreements to reach a consensus.

    Following the training methodology, 20 teeth were examined. All examiners completed the tests, recorded the results in their files, discussed to obtain consensus and a common consent filled was used to calculate the kappa coefficient of sample. Tests with other criteria were conducted after 1 week to reduce the influence of one system in subsequent examination. The last criteria assessment was OMS (1997)3.

    Cutoff

    Two criteria cutoff points were used to analyze the Nyvad and ICDAS-II results. Thus, the cutoff A (lesion) for Nyvad and ICDAS-II criteria considered caries lesion all present demineralization at enamel or dentin, excluding score "0" (without demineralization). The cutoff B (cavity lesion) classified carious lesions those with discontinuous surface (ICDAS-II scores 3, 4, 5 and 6, and Nyvad scores 2, 3, 5 and 6), the other scores 0, 1W, 1B, and 2B, 2W (ICDAS-II) and 0, 1 and 4 (Nyvad) were considered as "not decayed". Interexaminer agreement was expressed by weighted Kappa coefficient. The recommended values for agreement were superior to 0.65 (the same adopted in SB 201015 Brazil methodology).

     

    Results

    The Kappa results of inter-examiner reproducibility tests obtained from the Cohen's Kappa index and classified according to Landis and Koch18 are presented (Table 1). The interexaminer reproducibility verified according to the consensus ICDAS-II ranged from 0.71 to 0.85 for G and 0.85 to 0.95 for UG, Nyvad from 0.77 to 1.00 (G) and 0.65-0.74 (UG), OMS value 1.00 was obtained for G group and from 0.66 to 1.00 for UG group.

     

     

     

     

     

     

     

     

     


    For a cutoff A, the reproducibility according to consensus (ICDAS-II) ranged from 0.73 to 0.87 for G and 1.00 for UG.For Nyvad criteria, the kappa value ranged from 0.78 to 1.00 (G) and for G group was 0.70 and 0.90 (Table 2).

    Data obtained from the cutoff point B are presented in Table 3. In ICDAS-II, the kappa value calculated from consensus ranged from 0.66 to 1.00 (G) and from 0.76 to 0.89 (UG), For Nyvad criteria cut off B was 0.87 to 1.00 (G) and from 0.65 to 0.88 (UG). The reproducibility values ranged from good to very good agreement, according Landis and Koch18.

    Table 4 shows the distribution of discordant diagnoses between the graduate and undergraduate examiners. Graduate students disagreed at 15% of examinations and 20% of undergraduate examiners tests was discordant. Among the disagreements, 33.6% involved cavitated lesions and 66.6% involved non-cavitated lesions (41.6% were inactive lesions and 58.3% active lesions). The graduate examiners obtained 68.75% of discordant diagnoses represented by cavitated lesions and 31.25% non-cavitated lesions (40% active and 60% inactive). Disagreement between sound surfaces and non-cavitated lesions was 40% of undergraduate discordant diagnoses and 36% of graduate discordant diagnoses.

     

    Discussion

    An accurate and reliable exam of dental caries is an essential stage of epidemiological surveys, which will contribute to the overall quality and reliability of research, as well as support appropriate interventions19,20. The occlusal surface is the most affected by caries among children, adolescents and young adults, due to its complex anatomy, making the detection of non-cavited lesions a difficult task21-22. Examiners presented different experience levels as different values of reproducibility has been observed20-21.

    Studies that investigate the relationship between examiner calibration and the reproducibility achieved in the use of new methods for caries detection are necessary in order to validate and refine these systems and epidemiological assessment22-23.

    During data collection, examiner training was important to minimize both the random and systematic error15,24 mainly because an early stage of caries diagnosis was assessed, increasing the reproducibility and validity problems12,25. A substantial decrease of scores values (ICDAS-II) after training sessions was observed either enhance of reproducibility before (0.72) and after (0.78) examination17. Careful reading of the codes and criteria combined with images of characteristic lesions in training session17,25 emphasize learning effectiveness.

    The enamel caries percentage according to consensus found in the present study confirms the ability of the ICDASII and Nyvad criteria to detect early changes in the enamel similar to other studies5,21. Several studies have shown examination outcomes related to examiners experience20, and previous training17,26. Detection of early lesions and detailed features is necessary in new indices which monitor the changes in teeth surface related to patient's attitudes.

    In the present study, higher reproducibility values were observed while cutoff point A (lesion) was chosen unlike studies in which examiners with little experience achieved high reproducibility in D3 cut off (cavity lesion)20. Braga et al. (2009)22 reported the use of cutoff points for diagnostic reproducibility not altering the sensitivity, specificity and accuracy. Differentiating active lesions from inactive induced some classification doubt as reported by examiners7,24, although in this study values ranged from good to perfect when cutoff was not used.

    The sensitivity can vary significantly (0.18 to 0.52) between unexperienced and experienced examiners20, with an increased inter-examiner agreement similar to presented in our study. The sensitivity of graduates emerged in the WHO (1997) index application. The majority of discordant diagnoses between the undergraduate examiners and among the graduate examiners were represented by pre-cavitated active lesions and sound surfaces codes7,22.

    These findings show effectiveness of new criteria to differentiate active lesions from inactive lesions whether cavitated or not cavitated. According to Nyvad et al. (1999)7 the agreement between examiners for non-cavitated active lesions and inactive non-cavitated lesions were 68.7% and 72.5%. According to Ismail et al. (1992)27, trained examiners confuse incipient caries 17 times more than cavitated caries surfaces.

    The ICDAS-II and Nyvad-II criteria have several scores to demonstrate pre-cavited lesions with respect to depth, and its relation to the activity, allowing the caries development analysis by examiners22. This is a positive feature in surveys using these indices where the additional objective is treatment decision planning instead of reporting the prevalence of caries only.

    Visual inspection of incipient caries lesions should be performed by trained examiners with new methods and criteria in clean and dry teeth surfaces, increasing sensitivity and specificity apply to epidemiologic surveys.

    In conclusion, examiner training according to the methodology proposed in this study, with theoretical discussion, discussion and exercise for proper calibration, makes possible the use of different criteria for caries diagnosis, considering active and inactive, pre-cavitated or cavitated caries lesions.

     

    Acknowledgments

    This study was financial support by CAPES.

     

    References

    1. Brazil. Ministry of Health Care/Health surveillance. Departament of primmary care. Coordination of Oral Health. Project SB Brazil 2010– main results. Brasilia; 2011. 92 p.

    2. Bernabé E, Sheiham A, Sabbah W. Income, income inequality, dental caries and dental care levels: an ecological study in rich countries. Caries Res. 2009; 43: 294-301.         [ Links ]

    3. World Health Organization. Oral health surveys. Basic methods. 4th ed. Geneva: WHO; 1997.         [ Links ]

    4. Assaf AV, Zanin L, Meneghim MC, Pereira AC, Ambrosano GMB. Comparison of reproducibility measurements for calibration in epidemiological surveys of dental caries. Cad Saude Publica. 2006; 22: 1901-7.         [ Links ]

    5. Ismail AI. Clinical diagnosis of carious lesions precavitated. Community Dent Oral Epidemiol. 1997; 25: 13-23.         [ Links ]

    6. Ekstrand KR, Ricketts DNJ, Kidd EAM. Reproducibility and accuracy of three methods for assessment of demineralization depth on the occlusal surface: an in vitro examination. Caries Res. 1997; 31: 224-31.         [ Links ]

    7. Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res. 1999; 33: 252-60.         [ Links ]

    8. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, Pitts NB. The international caries detection and assessment system (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007; 35: 170-8.         [ Links ]

    9. Braga MM, Oliveira LB, Bonini GAVC, Bonecker M, Mendes FM. Feasibility of the International Caries and Assessment System (ICDASII) in epidemiological surveys and comparability with standard World Health Organization Criteria. Caries Res. 2009; 43: 245-9.         [ Links ]

    10. Mendes FM, Braga MM, Oliveira LB, Antunes JL, Ardenghi TM, Bönecker M. Discriminant validity of the International Caries Detection and Assessment System (ICDAS) and comparability with World Health Organization criteria in a cross-sectional study. Community Dent Oral Epidemiol. 2010; 38: 398-407.         [ Links ]

    11. Cadavid AS, Lince CMA, Jaramillo MC. Dental caries in the primary dentition of a Colombian population according to the ICDAS criteria. Braz Oral Res. 2010; 24: 211-6.         [ Links ]

    12. Kuhnisch J, Bererger S, Goddon I, Senkel H, Pitts N, Heinrich-Weltzien R. Occlusal caries detection in permanent molars according to WHO basic methods, ICDAS II and laser ûuorescence measurements. Community Dent Oral Epidemiol. 2008; 36: 475-84.         [ Links ]

    13. Ismail AI, Sohn W, Tellez M, Willem JM, Betz J, Lepkowski J. Risk indicators for dental caries using the International Caries Detection and Assessment System (ICDAS). Community Dent Oral Epidemiol. 2008; 36: 55-68.         [ Links ]

    14. Begston AL, Gomes AC, Mendes FM, Cichello LR, Begston NG, Pinheiro SL. Influence of examiner's clinical experience in detecting occlusal caries lesions in primary teeth. Pediatr Dent. 2005; 27: 238-43.         [ Links ]

    15. Brazil. Ministry of Health. Department of Primary Care. SB Brazil 2010 Project: Manual Calibration of Examiners. Brasilia; 2009.         [ Links ]

    16. National Board of Health guidelines and regulating norms for research involving humans. Brasília; 1997.         [ Links ]

    17. Diniz MB, Lima LM, Santos-Pinto L, Eckert GJ, Zandoná AG, Cássia Loiola Cordeiro R. Influence of the ICDAS e-learning program for occlusal caries detection on dental students. J Dent Educ. 2010; 74: 862-8.         [ Links ]

    18. Landis RJ, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977; 33: 159-74.         [ Links ]

    19. Assaf AV, Meneghim MC, Zanin L, Mialhe FL, Pereira AC, Ambrosano GMB. Assessment of different methods for diagnosing dental caries in epidemiologic surveys. Community Dent Oral Epidemiolol. 2004; 32: 418-25        [ Links ]

    20. Fyffe HE, Deery C, Nugent ZJ, Nuttall NM, Pitts NB. Effect of diagnostic threshold on the validity and reliability of epidemiological caries diagnosis using the Dundee Selectable Threshold Method for caries diagnosis (DSTM). Community Dent Oral Epidemiol. 2000; 28: 42-51.         [ Links ]

    21. Diniz MB, Rodrigues JA, Hug I, Cordeiro RCL, Lussi A. Reproducibility and accuracy of the ICDAS II for occlusal caries detection. Community Dent Oral Epidemiol. 2009; 37: 399-404.         [ Links ]

    22. Braga MM, Mendes FM, Martignon, S, Ricketts DNJ, Ekstrand, DKR. In vitro comparison of Nyvad's ICDAS-II system and with lesion activity assessment for evaluation of severity and activity of occlusal caries lesions in primary teeth. Caries Res. 2009; 43: 405-12.         [ Links ]

    23. Ekstrand KR, Martingnon S, Ricketts DJN, Qvist V. Detection and activity assessment of primary coronal caries lesions: a methodologic study. Oper Dent. 2007; 32: 225-35.         [ Links ]

    24. Rodrigues JA, Hug I, Diniz MB, Lussi A. Performance of fluorescence methods, examination and radiographics examination and ICDAS II on occlusal surfaces in vitro. Caries Res. 2008; 42: 297-304.         [ Links ]

    25. Zandoná AGF, Al-Shih S, H Eggertsson, G. Eckert. Student versus faculty performance using a new visual criteria for the detection of caries on occlusal surfaces: an in vitro examination with histological validation. Oper Dent. 2009; 34: 598-604.         [ Links ]

    26. Jablonski-Momeni A, Stachiss V, Ricketts DN, Heinzel-Gutenbrunner M, Pieper K. Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro. Caries Res. 2008; 42: 79-87.         [ Links ]

    27. Ismail AI, Brodeur JM, Gagnon P, Payette M, Picard D, Hamalian T et al. Prevalence of non-cavitated and cavitated carious lesions in a random sample of seven to nine-year-old schoolchildren in Montreal, Quebec. Community Dent Oral Epidemiol. 1992; 20: 250-5.         [ Links ]

     

     

    Correspondence:
    Priscila Florentino Silva
    Pedro Ferreira de Freitas St, 48, CEP: 58052-755
    Jardim Cidade Universitária, João Pessoa - PB - Brazil
    E-mail: priscilafsilva2007@yahoo.com.br

    Received for publication: October 15, 2011
    Accepted: December 12, 2011