Why is it important to improve root caries detection?
Root caries (tooth decay on the root of a tooth) is a well-recognised disease, that is on the increase as populations grow older and keep more of their natural teeth into later life. Like coronal caries (tooth decay on the crown of the tooth), root caries can be associated with pain, discomfort, and tooth loss, which can contribute to poorer oral health-related quality of life in the elderly. Detecting caries earlier can mean less invasive treatment is needed, where more tooth tissue can be preserved. It could also mean less cost to the patient and to healthcare services.
What is the aim of this review?
The aim of this Cochrane Review was to find out whether any diagnostic tools could be used to support the general dentist to correctly identify root caries in adults.
Researchers in Cochrane included four studies to answer this question.
What was studied in the review?
Four studies including 4997 root surfaces were included in the review. The studies took place in Switzerland and Hong Kong, and were published between 2009 and 2016. The accuracy of laser tests was examined in four studies, two studies examined radiographs (x-rays), one study examined comprehensive visual examination, and one study examined a combined test of radiographs and visual examination.
What are the main results of the review?
All studies reported case finding (detection) rather than diagnosis that included the consideration of patient risk and history. Two studies evaluated the use of devices within the mouth, and two studies evaluated the use of devices on extracted teeth (in vitro studies). Due to the small number of studies and important differences in the setting of included studies we were unable to combine the results of the studies.
How reliable are the results of the studies in this review?
We found important study limitations in all included studies, particularly with participant enrolment which was often poorly reported. Applicability of patient selection was also of concern for two in vitro studies. For these reasons, we judged the certainty of the evidence to be very low.
Who do the results of this review apply to?
Studies included in the review were carried out in Hong Kong and Switzerland and aimed at the general dental practitioner conducting a clinical examination on adults attending a dental setting.
What are the implications of this review?
Due to the small number of studies and the very low certainty of the evidence we were unable to establish any additional benefit of diagnostic tools for the detection and diagnosis of root caries.
How up-to-date is this review?
The review authors searched for and used studies published up to 31 December 2018.
Visual-tactile examination is the mainstay of root caries detection and diagnosis; however, due to the paucity of the evidence base and the very low certainty of the evidence we were unable to determine the additional benefit of adjunctive diagnostic tests for the detection and diagnosis of root caries.
Root caries is a well-recognised disease, with increasing prevalence as populations age and retain more of their natural teeth into later life. Like coronal caries, root caries can be associated with pain, discomfort, tooth loss, and contribute significantly to poorer oral health-related quality of life in the elderly. Supplementing the visual-tactile examination could prove beneficial in improving the accuracy of early detection and diagnosis. The detection of root caries lesions at an early stage in the disease continuum can inform diagnosis and lead to targeted preventive therapies and lesion arrest.
To assess the diagnostic test accuracy of index tests for the detection and diagnosis of root caries in adults, used alone or in combination with other tests.
Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles.
We included diagnostic accuracy study designs that compared one or more index tests (laser fluorescence, radiographs, visual examination, electronic caries monitor (ECM), transillumination), either independently or in combination, with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. In vitro and in vivo studies were eligible for inclusion but studies that artificially created carious lesions were excluded.
Two review authors extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) specific to the review context. Estimates of diagnostic test accuracy were expressed as sensitivity and specificity with 95% confidence intervals (CI) for each dataset. We planned to use hierarchical models for data synthesis and explore potential sources of heterogeneity through meta-regression.
Four cross-sectional diagnostic test accuracy studies providing eight datasets with data from 4997 root surfaces were analysed. Two in vitro studies evaluated secondary root caries lesions on extracted teeth and two in vivo studies evaluated primary root caries lesions within the oral cavity. Four studies evaluated laser fluorescence and reported estimates of sensitivity ranging from 0.50 to 0.81 and specificity ranging from 0.40 to 0.80. Two studies evaluated radiographs and reported estimates of sensitivity ranging from 0.40 to 0.63 and specificity ranging from 0.31 to 0.80. One study evaluated visual examination and reported sensitivity of 0.75 (95% CI 0.48 to 0.93) and specificity of 0.38 (95% CI 0.14 to 0.68). One study evaluated the accuracy of radiograph and visual examination in combination and reported sensitivity of 0.81 (95% CI 0.54 to 0.96) and specificity of 0.54 (95% CI 0.25 to 0.81). Given the small number of studies and important differences in the clinical and methodological characteristics of the studies we were unable to pool the results. Consequently, we were unable to formally evaluate the comparative accuracy of the different tests considered in this review. Using QUADAS-2 we judged all four studies to be at overall high risk of bias, but only two to have applicability concerns (patient selection domain). Reasons included bias in the selection process, use of post hoc (data driven) positivity thresholds, use of an imperfect reference standard, and use of extracted teeth.
We downgraded the certainty of the evidence due to study limitations and serious imprecision of the results (downgraded two levels), and judged the certainty of the evidence to be very low.