Cochrane · DTA · CD014546
Visual or visual‐tactile examination to detect and inform the diagnosis of enamel caries
Macey, R, Walsh, T, Riley, P, et al. · Cochrane Database of Systematic Reviews · 2021 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
30
current version
GRADE rated
2
No studies
1
Included studies
67
as reported
No studies 1 · 3.3%Ungraded 27 · 90%Very low 0 · 0%Low 2 · 6.7%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Participants seemingly asymptomatic for dental caries but who may have undetected early caries; children, adolescents, and adults eligible (primary, mixed, and permanent dentition); those recruited with caries into dentine or frank cavitation, or referred to secondary care for restorative treatment, excluded | 67 studies (71 datasets), 19,590 tooth sites/surfaces, 35% enamel caries prevalence; 42 (59%) datasets permanent dentition and 29 (41%) primary/mixed dentition; 48 in vitro (extracted teeth), 18 clinical, 1 school; studies published 1988 to 2019 |
| Intervention | Visual or visual-tactile examination on intact teeth according to detailed criteria and indices (e.g. Ekstrand/ERK, ICDAS) | ICDAS (n=38 datasets); ERK (n=15 datasets); Other visual (n=18 datasets) |
| Comparison | Reference standard: histology (optimum); excavation/operative exploration; radiographs; tooth separation using orthodontic bands | Histology (n=60 datasets); Excavation (n=4 datasets); Radiographs/microCT (n=4 datasets); Separation (n=3 datasets) |
| Outcomes | Diagnostic test accuracy: sensitivity and specificity with 95% CI at a positivity threshold of enamel caries; diagnostic odds ratio (DOR) | Summary sensitivity 0.86 (0.80 to 0.90); summary specificity 0.77 (0.72 to 0.82); DOR 20.38 (14.33 to 28.98); GRADE certainty Low (n=71 datasets) |
| Study designs | Diagnostic accuracy study designs: cross-sectional studies comparing a diagnostic test with a reference standard; RCTs of diagnostic test accuracy; case-control accuracy studies; in vivo or in vitro; reporting at patient, tooth, or tooth-surface level (tooth surface for the primary analysis) | Diagnostic accuracy studies; 48 in vitro; 18 clinical; 1 school; all avoided case-control and RCT designs |
| Timing | Up to 3 months between index test and reference standard (in vivo) | NR |
Search date: 2020-04. Databases: MEDLINE Ovid; Embase Ovid; US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov); World Health Organization International Clinical Trials Registry Platform
Questions and results
Visual or visual-tactile classification systems (any system: ICDAS, ERK, Nyvad, Downer, Lussi, UniViSS, or unspecified) vs Reference standard (histology, excavation, radiographs/microCT, or tooth separation)
Population: Asymptomatic children or adults presenting for clinical examination (in vivo studies), or extracted teeth of children or adults (in vitro studies); teeth seemingly healthy or with possible early (enamel) caries. Studies intentionally including caries into dentine or frank cavitation were excluded
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Non-histology reference standard (excavation, radiographs, separation) | Specificity 0.86 [0.76, 0.92] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Occlusal surface | Sensitivity 0.87 [0.82, 0.90] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Specificity 0.77 [0.72, 0.82] | 67 studies | Low Downgraded: risk of bias, inconsistency, indirectness |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Occlusal surface | Specificity 0.74 [0.66, 0.81] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Sensitivity 0.86 [0.80, 0.90] | 67 studies | Low Downgraded: risk of bias, inconsistency, indirectness |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Medium prevalence of dentine caries (15% to 34%) | Sensitivity 0.81 [0.72, 0.88] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Primary/mixed dentition | Sensitivity 0.87 [0.80, 0.92] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Histology reference standard | Specificity 0.76 [0.69, 0.81] | NR | Ungraded |
Diagnostic accuracy: in vitro versus in vivo comparison Up to 3 months between index test and reference standard (in vivo studies) · Study setting (in vitro vs in vivo) | Pre-specified in vitro versus in vivo comparison was not completed because 49 of the 60 histology studies were in vitro; a sensitivity analysis removing the in vivo studies confirmed a minimal change to summary… | NR | Ungraded |
Diagnostic accuracy in previously restored teeth (secondary caries) Up to 3 months between index test and reference standard (in vivo studies) · Previously restored teeth (secondary caries) | Only one study (Kim 2017) intentionally included restored teeth in its sample; the pre-specified secondary-caries subgroup analysis could not be performed, no summary estimate reported. | 1 study | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · High prevalence of dentine caries (>= 35%) | Specificity 0.75 [0.66, 0.82] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Approximal surface | Sensitivity 0.80 [0.60, 0.92] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Primary/mixed dentition | Specificity 0.79 [0.70, 0.85] | NR | Ungraded |
Diagnostic accuracy (sensitivity/specificity) for enamel caries, not meta-analyzed Up to 3 months between index test and reference standard (in vivo studies) · Smooth surface | Smooth surfaces reported by 2 datasets (Nakagawa 2013; Shi 2000) but excluded from the surface meta-analysis owing to sparsity; no summary sensitivity or specificity estimated. | 2 studies | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Permanent dentition | Sensitivity 0.85 [0.77, 0.90] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Approximal surface | Specificity 0.83 [0.74, 0.89] | NR | Ungraded |
Diagnostic accuracy on surfaces with pit and fissure sealants Up to 3 months between index test and reference standard (in vivo studies) · Pit and fissure sealants | Pre-specified heterogeneity investigation of surfaces with previously applied pit and fissure sealants: no studies reported the inclusion of sealants. | 0 studies | No studies |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Non-histology reference standard (excavation, radiographs, separation) | Sensitivity 0.78 [0.48, 0.93] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Medium prevalence of dentine caries (15% to 34%) | Specificity 0.80 [0.71, 0.86] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Low prevalence of dentine caries (0% to 14%) | Specificity 0.73 [0.51, 0.88] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Histology reference standard | Sensitivity 0.87 [0.82, 0.90] | NR | Ungraded |
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Permanent dentition | Specificity 0.76 [0.69, 0.83] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · High prevalence of dentine caries (>= 35%) | Sensitivity 0.91 [0.86, 0.95] | NR | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) · Low prevalence of dentine caries (0% to 14%) | Sensitivity 0.76 [0.50, 0.91] | NR | Ungraded |
Visual classification: ICDAS (International Caries Detection and Assessment System) vs Reference standard (histology, excavation, radiographs/microCT, or tooth separation)
Population: Asymptomatic children or adults presenting for clinical examination (in vivo studies), or extracted teeth of children or adults (in vitro studies); teeth seemingly healthy or with possible early (enamel) caries. Studies intentionally including caries into dentine or frank cavitation were excluded
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Specificity 0.76 [0.67, 0.83] | 36 studies | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Sensitivity 0.88 [0.81, 0.92] | 36 studies | Ungraded |
Visual classification: ERK (Ekstrand-Ricketts-Kidd system) vs Reference standard (histology, excavation, radiographs/microCT, or tooth separation)
Population: Asymptomatic children or adults presenting for clinical examination (in vivo studies), or extracted teeth of children or adults (in vitro studies); teeth seemingly healthy or with possible early (enamel) caries. Studies intentionally including caries into dentine or frank cavitation were excluded
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Specificity 0.72 [0.61, 0.81] | 15 studies | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Sensitivity 0.85 [0.74, 0.92] | 15 studies | Ungraded |
Other visual classification systems (unspecified or unique systems, e.g. Nyvad, Downer, Lussi, UniViSS) vs Reference standard (histology, excavation, radiographs/microCT, or tooth separation)
Population: Asymptomatic children or adults presenting for clinical examination (in vivo studies), or extracted teeth of children or adults (in vitro studies); teeth seemingly healthy or with possible early (enamel) caries. Studies intentionally including caries into dentine or frank cavitation were excluded
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Specificity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Specificity 0.84 [0.73, 0.91] | 16 studies | Ungraded |
Sensitivity for detection of enamel caries Up to 3 months between index test and reference standard (in vivo studies) | Sensitivity 0.81 [0.65, 0.91] | 16 studies | Ungraded |