Original Paper
Caries Res 2011;45:294–302
DOI: 10.1159/000328673
Clinical Performance of Two Fluorescence-Based
Methods in Detecting Occlusal Caries Lesions in
Primary Teeth
R. Matos a, b T.F. Novaes b M.M. Braga b W.L. Siqueira c D.A. Duarte a
F.M. Mendes b  
a
Universidade Cruzeiro do Sul and b Department of Pediatric Dentistry, School of Dentistry, University of
São Paulo, São Paulo, Brazil; c Department of Dentistry, Schulich School of Medicine and Dentistry, University of
Western Ontario, London, Ont., Canada
Key Words
Dental caries ⴢ Fluorescence ⴢ Occlusal surfaces ⴢ Primary
teeth ⴢ Sensitivity ⴢ Specificity
Abstract
This in vivo study aimed to evaluate the performance of 2
fluorescence-based methods in detecting occlusal caries le-
sions in primary teeth, compared with the performance of
visual inspection and radiographic methods, and to propose
a mathematic correction of the diagnostic parameters due
to the imperfect reference standard method used in the
study. Two examiners assessed the occlusal surfaces of 407
primary teeth (62 children) using visual inspection (ICDAS),
radiographic, DIAGNOdent pen (pen type laser fluores-
cence; LFpen), and fluorescence camera (FC) methods. At
the noncavitated threshold (NC) the reference standard
method was the results of ICDAS, and at the dentine caries
threshold (D3) teeth diagnosed with dentine caries by ICDAS
or radiographic methods were subjected to operative treat-
ment to confirm the presence of lesion. Reproducibility, sen-
sitivity, specificity, accuracy, and the area under the ROC
curve were calculated for the methods at both thresholds. At
the NC threshold, LFpen had a slightly better performance
compared to the FC and radiographic methods. However, at
© 2011 S. Karger AG, Basel
0008–6568/11/0453–0294$38.00/0
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Received: September 28, 2010
Accepted after revision: April 6, 2011
Published online: May 31, 2011
the D3 threshold, both fluorescence-based methods per-
formed similarly. Visual inspection and radiographic meth-
ods presented higher specificities but lower sensitivities
than fluorescence methods. After corrections, there was
a significant decrease in some parameters. In conclusion,
both fluorescence-based methods presented similar per-
formance in detecting occlusal dentine caries lesions in pri-
mary teeth, but they usually gave more false-positive results
than did the visual and radiographic methods. The correc-
tion proposed shows that the performance of the methods
can be overestimated, and the correction should be validat-
ed and considered in further studies that use an imprecise
reference standard method. Copyright © 2011 S. Karger AG, Basel
Occlusal caries detection has been traditionally per-
formed through visual inspection and radiographic
methods but these methods have presented some short-
comings, such as low sensitivity and reliability [Bader et
al., 2002]. Due to these limitations, new technologies, e.g.
fluorescence-based methods, have been proposed to help
dentists detect caries lesions more accurately. Fluores-
cence has been used for caries detection due to its ability
to distinguish sound and carious tissue. An excitation
Fausto Medeiros Mendes
Faculdade de Odontologia da Universidade de São Paulo
Av. Lineu Prestes, 2227
São Paulo, SP 05508-000 (Brazil)
Tel. +55 11 3091 7835, E-Mail fmmendes @ usp.br
source emits a light which is partially absorbed by the
dental substance. The absorbed light is then reemitted by
chromophores within the dental tissue at a longer wave-
length [Lussi et al., 2001; Lussi and Hellwig, 2006; Thoms,
2006].
A pen type laser fluorescence (LFpen) method, named
DIAGNOdent pen (Kavo, Biberach, Germany), was de-
signed to detect proximal and occlusal caries lesions. The
device uses a diode laser emitting a red light (␭ = 655 nm)
and translates the fluorescence reemitted by dental tis-
sue into a numerical scale from 0 to 99 [Lussi and Hell-
wig, 2006]. Higher readings indicate the presence of car-
ies lesions. Despite the fact that some studies have shown
good performance of the device in detecting occlusal
caries in permanent teeth [Huth et al., 2008], no in vivo
studies with the LFpen in primary teeth have been pub-
lished yet. Since significant differences exists between
permanent and primary teeth, such as thinner enamel
[Mortimer, 1970] and faster progression of caries lesions
in primary teeth [Shellis, 1984], the studies performed
with permanent teeth cannot be extrapolated to primary
teeth.
Another fluorescence-based device, a new fluores-
cence camera (FC; Vista Proof, Dürr Dental, Germany),
was recently proposed for caries detection in occlusal
surfaces. The FC emits a light with a 400-nm wavelength
and filters the fluorescence emitted by the tissue. The
specific software then quantifies the caries lesion, pro-
ducing a measure on a numerical scale from 0 to 3. Only
an in vitro study has tested the performance of the FC in
detecting occlusal caries in permanent teeth [Rodrigues
et al., 2008]. No previous study has investigated the clin-
ical performance of the method. Thus, clinical studies
should be performed in primary teeth to investigate the
performance of these recent fluorescence-based meth-
ods in detecting occlusal caries lesions, comparing their
performance with conventional methods of caries detec-
tion.
Another problem usually occurs in clinical studies of
caries detection. Although several in vivo studies have
used checking for the presence of caries lesions after op-
erative intervention as a reference standard [Lussi et al.,
2001; Krause et al., 2007; Huth et al., 2008; Kavvadia and
Lagouvardos, 2008; Abalos et al., 2009], the method is far
from an ideal gold standard. In most studies, operative
treatment can only be performed where disease is thought
to be present. However, this procedure cannot detect
false-negative results [Abalos et al., 2009] and partial ver-
ification can overestimate the performance of diagnostic
tests [Lijmer et al., 1999]. Bur opening of the sample could
Fluorescence Methods in Detecting
Occlusal Caries Lesions
be performed in all teeth that require further treatment
[Abalos et al., 2009], but this procedure significantly lim-
its the sample selection and, consequently, the external
validity. Another alternative is histological validation of
the entire sample after extraction or exfoliation of the
teeth [Ekstrand et al., 1998; Rocha et al., 2003; Reis et al.,
2006], but this procedure also affects the external valid-
ity.
An alternative for the use of an imperfect reference
standard method is mathematical correction of the val-
ues of sensitivity and specificity [Brenner, 1996]. This ad-
justment could approximate the performance obtained in
the studies to the actual performance of the methods, in-
creasing the external validity of the study. However, this
procedure has never been employed in studies of caries
detection.
Therefore, the present in vivo study aimed to investi-
gate the clinical performance of 2 new fluorescence-
based methods in detecting occlusal caries lesions in pri-
mary teeth compared with the performance of visual in-
spection and radiographic methods. Another aim was to
verify the effect of a mathematic correction on the sensi-
tivity and specificity values based on the imperfect valid-
ity of the reference standard method used in the present
study.
Subjects and Methods
Subject Selection
This study was approved by the local Committee for Ethics in
Research, and signed and informed consent was obtained from
the children’s parents or guardians. Eighty children seeking den-
tal treatment at the School of Dentistry of the University of São
Paulo were selected using the enrolment form of each child. Be-
cause of the random selection of the forms, the researchers were
previously unaware of the subjects’ oral condition.
Of the 80 children initially selected, 10 did not present with
any primary molar fulfilling the inclusion criteria. Two children
refused to participate in the study (positive response rate 97.1%).
Thus, 68 children (30 males and 38 females) aged 4–12 years
(mean 7.3 8 1.6), living in São Paulo, Brazil (0.7 mg/l F– in the
water supply), participated in the study.
The examinations were performed on occlusal surfaces of pri-
mary molars. Exclusion criteria for teeth were presence of restora-
tions, presence of hypoplastic pits, frank occlusal cavitation, and
presence of large carious lesions on smooth or proximal surfaces.
The selection of the teeth was performed during a fast visual as-
sessment, with no previous prophylaxis or air drying and aided
by a plane buccal mirror, at the first session for the child. If the
tooth did not have any obvious cavity when observed at this ses-
sion under these conditions (no prophylaxis and no air-drying),
it was selected for the study. Finally, 407 primary molars were in-
cluded to be evaluated.
Caries Res 2011;45:294–302 295
 Examination Methods
Caries lesions were assessed by LFpen, FC, visual inspection,
and radiographic methods in the selected teeth. Two examiners
(R.M. and T.F.N.) carried out all of the examinations. One bench-
mark examiner (M.M.B.) trained the others with 3 patients for
each method used in the study, but no calibration procedure was
performed. The 2 examiners were PhD students with previous
experience in using the methods in research and clinical practice,
and the benchmark examiner was a senior lecturer with extensive
experience in using these methods in several research projects. A
theoretical explanation about the International Caries Detection
and Assessment System (ICDAS) criteria and the other methods
was given by the benchmark examiner. Afterwards, the examin-
ers were trained in performing the methods on these 3 children.
These patients were not included in the main sample. The exam-
iners were instructed to analyze each tooth independently, and
they were not aware of each other’s results. A total of 21 primary
molars were examined during the training session.
In the children selected for the study, teeth were subjected to
careful cleaning with a rotating bristle brush and a pumice/water
slurry prior to the examinations. One site per tooth was selected on
the basis of visual suspicion of a caries lesion. When 2 appropriate
sites were available, 1 was randomly chosen using computer-gener-
ated random numbers. Since caries lesions can differ at different
sites within a tooth and between teeth within the same mouth, and
since the caries detection methods are performed at the surface
level (not at the subject level), we decided to choose more than 1
tooth per subject, which is different from the methods of other au-
thors [Huth et al., 2008]. Therefore, a drawing of the occlusal sur-
face was made to indicate the selected site for each tooth.
Visual inspection was firstly performed with subjects posi-
tioned in a dental unit with operating light illumination, a 3-in-1
syringe, a plane buccal mirror, and a WHO periodontal probe.
The teeth were initially examined wet and, after that, they were
dried for 5 s with compressed air. The examiners used the ICDAS
to perform a visual inspection [Ismail et al., 2007]. The scores
were: 0 (sound tooth), 1 (first visual change in enamel), 2 (distinct
visual change in enamel), 3 (localized enamel breakdown), 4 (un-
derlying dark shadow from dentine), 5 (distinct cavity with visible
dentine), and 6 (extensive distinct cavity with visible dentine).
For the radiographic examinations, bitewing radiographs
were taken for each side, comprising upper and lower primary
molars (2 radiographs for each child). The X-ray machine (Spec-
tro 70 X; Dabi Atlante, Ribeirão Preto, Brazil) was set to 70 kV and
8 mA, and the exposure time was 0.3 s. The radiographs were
taken with bitewing holders (Jon Han-Shin PF 682; Jon Ind., São
Paulo, Brazil), and the focus-to-film distance was 40 cm. Kodak
Insight radiographic films (22 ! 35 mm; Eastman Kodak, Roch-
ester, N.Y., USA) were used and the films were manually devel-
oped using standard processing times.
The radiographs were examined on a backlit screen with no
magnification. The criteria used to indicate enamel or dentine
caries lesions were proposed in a previous study [Rodrigues et al.,
2008]: no radiolucency visible (0), radiolucency visible in enamel
(1), radiolucency visible in dentine but restricted to the outer half
of dentine (2), and radiolucency extending to the inner half of
dentine (3).
The LFpen method was carried out using a DIAGNOdent pen
device (Kavo). Probe tip 2 (for occlusal surfaces) was used for the
measurements. The laser device was calibrated against the refer-
296 Caries Res 2011;45:294–302
ence object before the examination. On every tooth, the device
was also calibrated on a sound smooth surface. This LF reading
was electronically subtracted from the readings of the site under
examination. After a standardized drying time of 5 s, the tip was
placed on the selected sites and rotated around its vertical axis.
Two measurements of each site were performed and the mean
value was recorded.
Concerning the other fluorescence-based method, an FC (Vis-
ta Proof; Dürr Dental, Bietigheim-Bissingen, Germany) was used
and the image of each surface was recorded by the camera soft-
ware (DBSWIN, Dürr Dental) after the evaluation of each exam-
iner. This software created images of 720 ! 576 pixels which were
quantified from green (approximately 510 nm wavelength) to red
(approximately 680 nm wavelength), and a numerical value from
0 to 3 corresponding to the lesions severity was shown. The im-
ages were performed after drying the teeth for 5 s.
One week after all of the assessments, 14 children (20.6%) were
randomly selected and they were assessed by 1 examiner (R.M.)
using all of the methods in order to calculate the intraexaminer
reproducibility. A total of 97 teeth (23.8%) were reexamined.
Reference Standard Methods
The analyses of the methods of occlusal caries detection were
performed at 2 different thresholds: noncavitated caries lesions
(NC) and dentine caries lesions (D3).
For the NC threshold, the reference standard method was the
results obtained by visual inspection. This method was chosen
because when visual inspection is performed with extensive dry-
ing of the site early and accurate detection of the initial deminer-
alization can be achieved [Ekstrand et al., 1998]. In order to re-
duce the subjectivity of the method, only agreements between 2
examiners using visual inspection to detect NC caries lesions
were included in the analysis. The appropriate cutoff point for
the presence of noncavitated caries lesions was the score 1 on the
ICDAS. The reproducibility values for interexaminer reproduc-
ibility before the exclusion of these teeth are shown in table  1.
Therefore, 383 primary teeth which reached agreement between
the examiners were considered.
For the D3 threshold, the presence of dentine caries lesions
was evaluated after operative treatment in another clinical ses-
sion. Teeth with the presence of cavitation assessed by visual in-
spection (score of 3 or more on the ICDAS) and/or a radiograph-
ic image reaching the dentine (score of 2 or 3) were submitted for
operative intervention. Only agreements between 2 examiners
were considered to be validated. After opening it with a small bur,
the examiners checked the cavity with an explorer to differentiate
carious from sound dentine. The other teeth were considered
sound in further analyses.
Statistical Analysis
The statistical unit was the tooth. Data were presented and
analyzed separately for each examiner. Firstly, inter- and intraex-
aminer reproducibilities were calculated considering all of the
scores of the visual inspection and radiographic methods or val-
ues of the LFpen and FC readings through the intraclass correla-
tion coefficient (ICC). Second, inter- and intraexaminer reliabili-
ties were calculated using Cohen’s kappa test after collapsing the
results in 2 categories (sound vs. decayed) considering both NC
and D3 thresholds. For visual inspection, the cutoff points for NC
and D3 thresholds were scores of 1 and 3 on the ICDAS, respec-
Matos /Novaes /Braga /Siqueira /Duarte /
Mendes  
tively. For the radiographic method, a score of 1 was the cutoff
point for the NC threshold, and a score of 2 was the cutoff value
for the D3 threshold. For the fluorescence-based methods, the
cutoff points are described below.
The sensitivity, specificity, and accuracy values and the 95%
confidence intervals (95% CI) were calculated for each method at
the NC threshold. The examined teeth are clustered because we
opted to choose more than 1 tooth per subject. Therefore, we em-
ployed an approach previously described [Rao and Scott, 1992;
Durkalski et al., 2003] to calculate sensitivity, specificity, and ac-
curacy values and 95% CI. Receiver operating characteristics
(ROC) analyses were also performed and the area under the ROC
curve (Az) was calculated. The first assessments of the examiners
were used to calculate the parameters. Since visual inspection was
employed as the reference standard method, the performance and
comparisons were carried out only for radiographic and fluores-
cence-based methods. The best cutoff points for the fluorescence-
based methods were obtained through ROC analysis, considering
the sum of specificity and sensitivity. For the LFpen method values
higher than 4 were considered NC lesions, and for the FC the equiv-
alent cutoff point was 1.1. Az values were compared among the
methods using a nonparametric approach, and sensitivity, speci-
ficity and accuracy values were compared using the McNemar test.
At the D3 threshold, the same parameters and comparisons
were performed. The cutoff point for the LFpen method to detect
D3 lesions, obtained by ROC analysis, was 34, and for the FC the
best cutoff point was 1.4. All analyses were carried out using ap-
propriate software (MedCalc 9.3.0.0; Mariakerke, Belgium). For
all statistical analyses, the level of significance was p ! 0.05.
Since imperfect reference standard methods were employed,
adjustment of sensitivity and specificity values was performed us-
ing an approach previously proposed [Brenner, 1996]. The correc-
tions were performed using the formula assuming independence
of classification by diagnostic and reference standard methods.
The formulas are:
[Jablonski-Momeni et al., 2008; Rodrigues et al., 2008; Braga et
al., 2009; Diniz et al., 2009], and the values of the radiographic
method were calculated based on a systematic review [Bader et al.,
2002]. Subsequently, with the estimation of the number of true-
positive, true-negative, false-positive, and false-negative results,
these values were considered in all teeth which were not subjected
to operative intervention. In the teeth which opening with bur
was performed, the actual results were used. As the reference
standard was related to visual inspection and radiographic meth-
ods, the correction at the D3 threshold was performed only for the
fluorescence-based methods.
For the NC threshold, the estimated sensitivity and specificity
values of the reference standard method were 0.796 and 0.799, re-
spectively. For the D3 threshold, the sensitivity of the reference
standard method employed in the present study was 0.786, and
the specificity was 0.995. Then, after estimation of the sensitivity
and specificity of the reference standard methods, the corrections
were performed using the formulas described.
Results
With regard to interexaminer reproducibility, all
methods presented similar ICC values when considering
the entire values of the scores or of the devices. All figures
were around 0.9, showing good interexaminer agree-
ment. Intraexaminer ICC values were higher than inter-
examiner ones, except for the visual inspection method.
However, all values were higher than 0.9 (table 1).
When the collapsed results were considered, both fluo-
rescence-based methods presented similar interexamin-
er kappa values which were higher than those for visual
P q Sers q Sedm  1  P
q 1  Sprs
q 1  Spdm
inspection in detecting NC caries lesions. Nevertheless,
Secor  for intraexaminer agreement, FC presented a higher kap-
P q Sers  1  P
q 1  Sprs

pa value than did the LFpen and visual inspection meth-

and ods at the same threshold. The radiographic method pre-
P q 1  Sers
q 1  Sedm
 1  P
q Sprs q Spdm sented the highest kappa values at this threshold for both
Spcor  inter- and intraexaminer reproducibility (table 1). The re-
P q 1  Sers
 1  P
q Sprs
where Secor and Spcor = corrected values of sensitivity and speci-
ficity, P = prevalence, Sers and Sprs = sensitivity and specificity of
reference standard methods, and Sedm and Spdm = sensitivity and
specificity of diagnostic methods.
To estimate the sensitivity and specificity values of the refer-
ence standard methods, values of performance from previous
studies were used. For the NC threshold, values of 2 previous
studies using the ICDAS which evaluated the performance of
the method at initial caries lesions threshold were considered
[Jablonski-Momeni et al., 2008; Braga et al., 2009]. A weighted
mean of each value was calculated. Then, using the prevalence of
the present study, positive and negative predictive values were cal-
culated and the number of true-positive, true-negative, false-pos-
itive, and false-negative results were estimated in the examina-
tions performed with visual inspection.
For the D3 threshold, the same values of the visual inspection
were calculated using the results of 4 previous published studies
Fluorescence Methods in Detecting
Occlusal Caries Lesions
liability obtained at the D3 threshold, however, was gen-
erally higher than those obtained for NC lesion detection.
At the D3 threshold, visual inspection obtained the high-
est inter- and intraexaminer values, and both fluores-
cence-based methods presented similar interexaminer
agreement but the FC showed a higher intraexaminer
kappa value than did LFpen method (table 1).
At the NC threshold, 383 teeth were considered for the
analysis. These teeth were classified as sound or with NC
caries lesions by both examiners using visual inspection.
In 25 surfaces, the examiners presented disagreements
through visual inspection and these teeth were excluded
from this analysis. Of 383 teeth, 32 were classified as
sound (8.4%) and 350 (91.6%) were considered to have NC
caries lesions.
Caries Res 2011;45:294–302 297
 Table 1. Intra- and interexaminer reproducibility of visual inspection, the radiographic method, LFpen, and FC
devices in detecting occlusal caries lesions in primary molars

Method ICCa (95% CI) Kappa values (95% CI)

NCb D3c

Interexaminer (n = 407)
LFpen 0.918 (0.901–0.932) 0.759 (0.694–0.825) 0.810 (0.733–0.887)
FC 0.894 (0.872–0.912) 0.786 (0.724–0.847) 0.791 (0.706–0.876)
Visual inspection 0.895 (0.874–0.913) 0.695 (0.576–0.813) 1.000 (1.000–1.000)
Radiographic 0.883 (0.860–0.903) 0.868 (0.778–0.959) 0.892 (0.806–0.978)
Intraexaminer (n = 97)
LFpen 0.986 (0.979–0.990) 0.790 (0.667–0.913) 0.863 (0.709–1.000)
FC 0.948 (0.924–0.965) 0.856 (0.732–0.979) 0.942 (0.828–1.000)
Visual inspection 0.901 (0.856–0.933) 0.795 (0.395–1.000) 1.000 (1.000–1.000)
Radiographic 1.000 (1.000–1.000) 1.000 (1.000–1.000) 1.000 (1.000–1.000)
a
Calculated using the values of the scores or of the devices.
b
Calculated after division into sound vs. NC + D3 according to the described cutoff points (LFpen: sound,
0–4; NC lesions, >4; FC: sound, 0–1.1; NC lesions, >1.1).
c Calculated after division into sound + NC vs. D3 according to the described cutoff points (LFpen: sound,

0–34; dentine caries lesion, >34; FC: sound, 0–1.4; dentine lesions, >1.4).

With regard to the performance of the methods with
no correction, at the NC threshold both fluorescence-
based methods presented higher sensitivities but lower
specificities than the radiographic method. Sensitivity
values were statistically significantly higher for the LFpen
method than for the FC method. Accuracy and Az values
were also significantly higher for the LFpen than for other
methods, and the FC method presented higher accuracy
and Az values than did the radiographic method (table 2).
At the D3 threshold, 25 teeth were considered carious
using visual inspection and/or the radiographic method.
From these teeth, 14 were considered to have dentine car-
ies lesions by both methods (after operative intervention,
1 had only enamel caries lesions, 11 had initial dentine
caries lesions, and 2 had deep dentine caries lesions). Four
teeth were classified as carious only by the radiographic
method (1 had enamel caries lesions and 3 had initial den-
tine caries lesions after operative intervention), and 7
teeth were classified as carious only by visual inspection
(2 with enamel caries lesions and 5 with initial caries le-
sions). Thus, of 407 teeth, 386 were considered sound
(94.8%) and 21 (5.2%) had a dentine caries lesions as-
sessed by operative intervention.
The sensitivities of fluorescence-based methods at the
D3 threshold were similar. Visual inspection and radio-
graphic methods presented lower values of sensitivity but
had no significant differences compared to the fluores-
cence-based methods. The specificities of the fluores-
cence methods were also similar, but visual inspection
and radiographic methods showed significantly higher
specificity values. There were no significant differences
between visual inspection and radiographic methods
concerning sensitivity and specificity. The accuracy val-
ues of both fluorescence-based methods were around 0.9,
with no significant differences, but they were significant-
ly lower than the accuracies of the visual and radiograph-
ic methods (10.95). Concerning the Az, there was no sig-
nificant difference among both fluorescence-based meth-
ods and visual inspection, but the radiograph presented
significantly lower values of Az (table 3). The values ob-
tained by 2 examiners followed the same trends with all
of the methods in both the NC and D3 thresholds.
When correction of the sensitivity and specificity val-
ues was performed considering the imperfect reference
standard method it was observed at the NC threshold that
there were little changes in the sensitivity values for all
methods, but there was a significant decrease in the spec-
ificity values. The decrease in sensitivities for all methods
was around 2%. On the other hand, the specificities of
fluorescence-based methods decreased from 27 to 48%
after correction (FC and LFpen methods, respectively).
Radiographic specificity values decrease by around 7%
(table 4).
At the D3 threshold, on the other hand, the decrease
in the values was more significant in the sensitivities than
in the specificities after the correction. While the sensi-

298 Caries Res 2011;45:294–302 Matos /Novaes /Braga /Siqueira /Duarte /

         

Mendes  
Table 2. Performance of the different methods in detecting NC caries lesions (383 teeth in 68 subjects) on occlusal surfaces of prima-
ry molars

Method Sensitivity (95% CI) Specificity (95% CI) Accuracy (95% CI) Az (95% CI)

Examiner 1
LFpen 0.687a (0.607–0.766) 0.813a (0.640–0.985) 0.697a (0.623–0.771) 0.799a (0.756–0.838)
FC 0.444b (0.362–0.526) 0.906a (0.761–1.000) 0.483b (0.403–0.564) 0.674b (0.624–0.721)
Radiographic 0.088c (0.048–0.129) 1.000b (0.890–1.000) 0.164c (0.106–0.223) 0.544c (0.493–0.595)
Examiner 2
LFpen 0.675a (0.606–0.745) 0.813a (0.636–0.989) 0.687a (0.621–0.753) 0.764a (0.719–0.806)
FC 0.450b (0.369–0.532) 0.875a (0.740–1.000) 0.486b (0.407–0.564) 0.690a (0.641–0.736)
Radiographic 0.094c (0.052–0.136) 0.969a (0.911–1.000) 0.167c (0.106–0.228) 0.533b (0.481–0.584)

LFpen cutoff points: sound, 0–4; NC lesions, >4. FC cutoff points: sound, 0–1.1; NC lesions, >1.1.
Different letters indicate statistically significant differences among values within the same column in the examinations performed
by the same examiner (p < 0.05; McNemar test).

Table 3. Performance of fluorescence-based methods in detecting dentine caries lesions (407 sites in 68 subjects) at occlusal surfaces
of primary molars

Method Sensitivity (95% CI) Specificity (95% CI) Accuracy (95% CI) Az (95% CI)

Examiner 1
LFpen 0.952a (0.864–1.000) 0.883a (0.839–0.927) 0.887a (0.845–0.929) 0.973a (0.952–0.986)
FC 1.000a (0.837–1.000) 0.902a (0.863–0.940) 0.907a (0.871–0.943) 0.970a (0.948–0.984)
Radiographic 0.762a (0.579–0.944) 0.966b (0.944–0.989) 0.956b (0.933–0.978) 0.862b (0.825–0.894)
Visual inspection 0.857a (0.675–1.000) 0.984b (0.970–0.999) 0.978b (0.961–0.995) 0.965a, b (0.942–0.981)
Examiner 2
LFpen 1.000a (0.837–1.000) 0.860a (0.815–0.905) 0.867a (0.826–0.909) 0.958a (0.934–0.975)
FC 0.905a (0.780–1.000) 0.881a (0.836–0.925) 0.882a (0.840–0.924) 0.973a (0.952–0.986)
Radiographic 0.762a (0.579–0.944) 0.961b (0.936–0.986) 0.951b (0.923–0.978) 0.857b (0.819–0.890)
Visual inspection 0.857a (0.675–1.000) 0.984b (0.970–0.999) 0.978b (0.961–0.995) 0.966a, b (0.943–0.981)

LFpen cutoff points: sound, 0–34; dentine caries lesion, >34. FC cutoff points: sound, 0–1.4; dentine lesions, >1.4.
Different letters indicate statistically significant differences among values within the same column in the examinations performed
by the same examiner (p < 0.05; McNemar test).

tivities of both fluorescence methods decreased by around
9%, the specificities decreased only by around 1%. The
methods presented similar performance after the adjust-
ments (table 4).
Discussion
This was the first in vivo study testing the new LFpen
method for detecting occlusal caries in primary teeth,
and it was the first study to evaluate the clinical perfor-
mance of a new FC. With regard to the LFpen, some
in vitro studies were performed using permanent teeth
[Lussi and Hellwig, 2006; Rodrigues et al., 2008] and
they showed similar values of reproducibility compared
to the values obtained in the present study. Concerning
validity, in vitro studies have shown lower specificity
and sensitivity values [Lussi and Hellwig, 2006; Ro-
drigues et al., 2008] compared to the values obtained in
the present study. In vivo studies have also demonstrat-
ed lower values of performance in detecting occlusal
caries lesions in permanent teeth [Krause et al., 2007;
Huth et al., 2008].
These differences could be explained by the different
types of teeth. The enamel of primary teeth has about
half the thickness found in permanent teeth, and some

Fluorescence Methods in Detecting Caries Res 2011;45:294–302 299

Occlusal Caries Lesions
Table 4. Values of sensitivity and specificity of different methods [Lussi et al., 2001; Reis et al., 2006; Abalos et al., 2009].
in detecting NC and dentine caries lesions at occlusal surfaces of Since it works based on the same principles as the new
primary molars corrected for misclassification due to use of im-
perfect reference standard method
LFpen device, the performance in primary teeth should
also be better than in permanent teeth with the first LF
Method Sensitivitya Specificitya device. Therefore, further studies in primary and per-
examiner 1 examiner 2 examiner 1 examiner 2
manent teeth should be performed to clarify this contro-
versy.
NC lesions With regard to the FC, only 1 previous in vitro study
LFpen 0.676 0.664 0.445 0.454 tested the device in detecting occlusal caries lesions in
FC 0.436 0.443 0.648 0.636 permanent teeth [Rodrigues et al., 2008]. In this study,
Radiographic 0.086 0.084 0.935 0.937
the device showed a slightly better performance than the
Dentine lesions
LFpen 0.859 0.907 0.902 0.850 LFpen at the D3 threshold [Rodrigues et al., 2008]. In the
FC 0.903 0.820 0.889 0.872 present study, these methods presented similar perfor-
mances at this threshold. Differences between primary
a
Corrected values considering an imperfect reference stan- and permanent teeth could also explain this divergence.
dard.
The FC device works at a different wavelength than the
LFpen device and is based on different principles. Never-
theless, both devices detect the organic content of caries
lesions and probably the same bacterial metabolites [Lus-
areas present prismless enamel [Mortimer, 1970]. Fur- si and Hellwig, 2006; Thoms, 2006; Rodrigues et al.,
thermore, the mineral content of primary enamel is rel- 2008]. Thus, a similar performance would be expected.
atively lower and caries lesions progress faster in pri- In a previous study carried out in primary teeth, a posi-
mary teeth than in permanent ones [Shellis, 1984]. Be- tive correlation was observed between the devices in as-
cause of these structural, histological, and biochemical sessing occlusal and smooth surfaces, and the FC showed
differences, our hypothesis is that the presence of non- slightly better interexaminer agreement [Benedetto et al.,
evident caries lesions reaching the dentine on occlusal 2010]. Thus, in detecting dentine occlusal caries, both de-
surfaces of primary teeth is rarer than in permanent vices seemed to have similar performances.
teeth. The majority of dentine lesions would have frank Visual inspection and the radiographic method pre-
cavitation and, therefore, these surfaces would be ex- sented a higher specificity than the fluorescence-based
cluded from the studies since they would not fulfill the methods in detecting dentine caries lesions. These find-
inclusion criteria. ings have been observed previously [Bader et al., 2002;
Since the selection of the subjects and teeth in our and Bader and Shugars, 2004]. With regard to the sensitivity
other studies was similar, this hypothesis would also ex- values, there were no significant differences. Therefore,
plain the different prevalence obtained in the present the fluorescence-based methods would not have any ad-
study using primary teeth compared to in vivo studies vantages compared to the conventional methods. How-
which used permanent teeth [Krause et al., 2007; Huth et ever, these results should be interpreted with caution.
al., 2008]. The prevalence of dentine caries lesions ob- Since visual inspection and the radiographic method
tained in the present study (5.2%) was lower than those in were considered to perform the reference standard meth-
other studies which presented prevalences of dentine car- od at the D3 threshold, incorporation bias was intro-
ies of 47.5% [Huth et al., 2008] and 51.1% [Krause et al., duced in the diagnostic parameters of these methods [Lij-
2007], respectively. Thus, our suggestion is that the detec- mer et al., 1999]. The sensitivities of these methods, for
tion of dentine caries lesions in primary teeth is more ac- example, were probably overestimated since false-nega-
curate than in permanent teeth since a lower number of tive results could not be assessed. The overall perfor-
nonevident caries lesions reaching the dentine is expect- mance of the fluorescence-based methods was probably
ed. Further studies should be carried out to confirm this also underestimated.
hypothesis. Considering this possible bias, visual inspection would
Clinical studies performed with the first version of not detect some caries lesions, and these new technolo-
the LF method (DIAGNOdent), however, have shown gies could be used to detect these missed lesions. There-
similar performance in both primary [Rocha et al., 2003; fore, the fluorescence-based methods could be used as
Kavvadia and Lagouvardos, 2008] and permanent teeth adjunct methods to visual inspection in detecting den-

300 Caries Res 2011;45:294–302 Matos /Novaes /Braga /Siqueira /Duarte /

         

Mendes  
tine caries lesions. However, the low prevalence of den-
tine caries lesions raises some doubts concerning the util-
ity of additional methods [Baelum, 2010], and this issue
should be addressed in further studies.
On the other hand, in detecting noncavitated caries
lesions, both radiographic and fluorescence methods did
not show good performance. The radiographic method
did not usually perform well in detecting early caries le-
sions [Braga et al., 2010]. Concerning the fluorescence-
based methods, as dentine caries lesions are more infect-
ed than initial lesions [Kidd et al., 2003], a worse perfor-
mance of fluorescence-based methods in detecting initial
lesions would be expected since the methods detect the
presence of bacterial metabolites. Thus, for noncavitated
caries lesions, visual inspection performed with exten-
sive drying of the site on cleaned teeth is the most accu-
rate method for use in clinical practice [Ekstrand, 2004;
Braga et al., 2010].
Additionally, since an imperfect reference method was
used, a suggestion to correct the values of performance
was made. The intention was for these values to be more
realistic than values of tables 2 and 3 or than those values
obtained in previous studies using the same reference
standard method [Krause et al., 2007; Huth et al., 2008].
After the correction, we noticed a significant decrease in
some values. The decrease was more pronounced in the
specificities at the NC threshold and in the sensitivities at
the D3 threshold. This pattern is because of the preva-
lence of the disease. In fact, when using an imperfect ref-
erence standard method in a low-prevalence population
sensitivities are usually overestimated, while in high-
prevalence populations specificities are overestimated
[Irwig et al., 2002].
These results raise some limitations of caries detection
studies. Mainly in the in vivo setting, the reference stan-
dard methods for the presence of caries lesions are far
from ideal. Therefore, the performance of the caries de-
tection methods in studies is usually overestimated. The
correction proposed in the present study corroborates
this issue, and the results after the correction are proba-
bly closer to the actual performance of the methods.
Thus, further studies should take into account the limita-
tions of the reference standard method, and procedures
to correct this performance should be carried out in an
attempt to increase the external validity of the studies. To
the best of our knowledge, this is the first study of caries
detection methods that performs a correction of obtained
results considering the imperfect reference standard
method. Additional studies, however, should be carried
out in order to validate this statistical approach.
Fluorescence Methods in Detecting
Occlusal Caries Lesions
In conclusion, both fluorescence-based methods pre-
sent similar performances in detecting dentine occlusal
caries lesions in primary teeth but they usually yield more
false-positive results than visual and radiographic meth-
ods. Therefore, they could be considered as adjuncts of
visual inspection in order to improve the sensitivity. Fur-
thermore, owing to the use of an imprecise reference
standard method, the correction of values related to the
diagnostic performance shows that they could be overes-
timated. Therefore, adjustment of the values related to
the performance of the methods could be an important
procedure to be performed in studies of caries detection
which use imperfect reference standard methods, but
further studies need to be conducted to validate this ap-
proach.
Acknowledgements
This study was supported by the Conselho Nacional de Des-
envolvimento Científico e Tecnológico (CNPq – process No.
476372/2006-2, 302368/2008-6, and 565061/2008-9), Pró-Reito-
ria de Pesquisa e de Pós-Graduação da USP, and Fundação de
Amparo à Pesquisa do Estado de São Paulo (FAPESP). This study
was also supported by Canadian Institutes of Health Research
(CIHR grant # 106657 and CIHR grant # 97577). Dr. Siqueira is a
recipient of the CIHR New Investigator Salary Award.
Disclosure Statement
The authors certify that they have no affiliation with or finan-
cial involvement in any organization or entity with a direct finan-
cial or personal interest in the subject matter or materials dis-
cussed in this paper.
References Abalos C, Herrera M, Jimenez-Planas A, Llamas
R: Performance of laser fluorescence for de-
tection of occlusal dentinal caries lesions in
permanent molars: an in vivo study with to-
tal validation of the sample. Caries Res 2009;
43:137–141.
Bader JD, Shugars DA: A systematic review of the
performance of a laser fluorescence device
for detecting caries. J Am Dent Assoc 2004;
135:1413–1426.
Bader JD, Shugars DA, Bonito AJ: A systematic
review of the performance of methods for
identifying carious lesions. J Public Health
Dent 2002;62:201–213.
Baelum V: What is an appropriate caries diagno-
sis? Acta Odontol Scand 2010;68:65–79.
Braga MM, Mendes FM, Ekstrand KR: Detec-
tion activity assessment and diagnosis of
dental caries lesions. Dent Clin North Am
2010;54:479–493.
Caries Res 2011;45:294–302 301
Braga MM, Mendes FM, Martignon S, Ricketts
DN, Ekstrand KR: In vitro comparison of
Nyvad’s system and ICDAS-II with Lesion
Activity Assessment for evaluation of sever-
ity and activity of occlusal caries lesions in
primary teeth. Caries Res 2009;43:405–412.
Brenner H: Correcting for exposure misclassifi-
cation using an alloyed gold standard. Epide-
miology 1996;7:406–410.
De Benedetto MS, Morais CC, Novaes TF, de Al-
meida Rodrigues J, Braga MM, Mendes FM:
Comparing the reliability of a new fluores-
cence camera with conventional laser fluo-
rescence devices in detecting caries lesions
in occlusal and smooth surfaces of primary
teeth. Lasers Med Sci 2011;26:157–162.
Diniz MB, Rodrigues JA, Hug I, Cordeiro Rde C,
Lussi A: Reproducibility and accuracy of the
ICDAS-II for occlusal caries detection.
Community Dent Oral Epidemiol 2009; 37:
399–404.
Durkalski VL, Palesch YY, Lipsitz SR, Rust PF:
Analysis of clustered matched-pair data. Stat
Med 2003;22:2417–2428.
Ekstrand KR: Improving clinical visual detec-
tion – potential for caries clinical trials. J
Dent Res 2004;83:C67–C71.
Ekstrand KR, Ricketts DN, Kidd EA, Qvist V,
Schou S: Detection, diagnosing, monitoring
and logical treatment of occlusal caries in re-
lation to lesion activity and severity: an in
vivo examination with histological valida-
tion. Caries Res 1998;32:247–254.
Huth KC, Neuhaus KW, Gygax M, Bucher K,
Crispin A, Paschos E, Hickel R, Lussi A:
Clinical performance of a new laser fluores-
cence device for detection of occlusal caries
lesions in permanent molars. J Dent 2008;36:
1033–1040.
302 Caries Res 2011;45:294–302
Irwig LM, Bossuyt PM, Glasziou PP, Gatsonis C,
Knottnerus JA: Designing studies to ensure
that estimates of test accuracy will travel; in
Knottnerus JA (ed): The Evidence Base of
Clinical Diagnosis. London, BMJ Books,
2002, pp 95–116.
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 measur-
ing dental caries. Community Dent Oral Ep-
idemiol 2007;35:170–178.
Jablonski-Momeni A, Stachniss V, Ricketts DN,
Heinzel-Gutenbrunner M, Pieper K: Repro-
ducibility and accuracy of the ICDAS-II for
detection of occlusal caries in vitro. Caries
Res 2008;42:79–87.
Kavvadia K, Lagouvardos P: Clinical perfor-
mance of a diode laser fluorescence device
for the detection of occlusal caries in prima-
ry teeth. Int J Paediatr Dent 2008; 18: 197–
204.
Kidd EA, Banerjee A, Ferrier S, Longbottom C,
Nugent Z: Relationships between a clinical-
visual scoring system and two histological
techniques: a laboratory study on occlusal
and approximal carious lesions. Caries Res
2003;37:125–129.
Krause F, Jepsen S, Braun A: Comparison of two
laser fluorescence devices for the detection
of occlusal caries in vivo. Eur J Oral Sci 2007;
115:252–256.
Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ,
Prins MH, van der Meulen JH, Bossuyt PM:
Empirical evidence of design-related bias in
studies of diagnostic tests. JAMA 1999; 282:
1061–1066.
Lussi A, Hellwig E: Performance of a new laser
fluorescence device for the detection of oc-
clusal caries in vitro. J Dent 2006; 34: 467–
471.
Lussi A, Megert B, Longbottom C, Reich E, Fran-
cescut P: Clinical performance of a laser
fluorescence device for detection of occlusal
caries lesions. Eur J Oral Sci 2001;109:14–19.
Mortimer KV: The relationship of deciduous
enamel structure to dental disease. Caries
Res 1970;4:206–223.
Rao JN, Scott AJ: A simple method for the analy-
sis of clustered binary data. Biometrics 1992;
48:577–585.
Reis A, Mendes FM, Angnes V, Angnes G,
Grande RH, Loguercio AD: Performance of
methods of occlusal caries detection in per-
manent teeth under clinical and laboratory
conditions. J Dent 2006;34:89–96.
Rocha RO, Ardenghi TM, Oliveira LB, Rodri-
gues CRMD, Ciamponi AL: In vivo effec-
tiveness of laser fluorescence compared to
visual inspection and radiography for the
detection of occlusal caries in primary teeth.
Caries Res 2003;37:437–441.
Rodrigues JA, Hug I, Diniz MB, Lussi A: Per-
formance of fluorescence methods, radio-
graphic examination and ICDAS II on occlu-
sal surfaces in vitro. Caries Res 2008;42:297–
304.
Shellis RP: Relationship between human enamel
structure and the formation of caries-like le-
sions in vitro. Arch Oral Biol 1984; 29: 975–
981.
Thoms M: Detection of intraoral lesions using a
fluorescence camera. Proc SPIE Lasers Den-
tistry XII 2006;6137:613705.
Matos /Novaes /Braga /Siqueira /Duarte /
Mendes  
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