Can we trust visual methods alone for detecting caries in teeth?

Data sourcesElectronic Databases searched in PubMed, Embase and Scopus. Unpublished literature was traced through OpenSIGLE, annals of IADR/AADR (International and American Associations for Dental Research) and ORCA (European Organisation for Caries Research) from 2003-2014. Studies were limited to English.Study selectionStudies involving visual inspection for detection of primary coronal caries lesions in primary or permanent human teeth were considered. All papers needed to include a clearly defined reference standard and the reporting of absolute numbers of true positives, false positives, true negatives and false negatives or a presentation of sufficient data to calculate these figures. Reference methods considered appropriate were histologic evaluation, operative intervention, direct visual inspection after temporary tooth separation and radiography. For studies with the same data set only the most complete study was included. Articles that reported caries detection using artificial caries, root caries or recurrent decay adjacent to restorations were excluded.Data extraction and synthesisStudy selection for inclusion was performed independently by two reviewers and disagreements were resolved by discussion with a third reviewer. Data were collected by two reviewers on structured tables. Discrepancies were resolved by consensus. A meta-analysis was performed. The following information was extracted; reference standard method, setting (clinical or laboratory), type of teeth (primary or permanent), surface evaluated (smooth, proximal or occlusal), sample size, examiner's experience. Also recorded were visual scoring systems. Studies that did not report any criteria were classified as 'with no criteria'. If authors used criteria with no reference to previously published studies they were classified as 'own criteria'. The PRISMA guideline was followed to report the review and the QUADAS-2 checklist (Quality assessment of studies of diagnostic performance included in systematic reviews) was used to assess the risk of bias of the included studies.ResultsData were used to calculate the pooled sensitivity, specificity, diagnostic odds ratio and summary receiver operating characteristics curve. Heterogeneity of the studies was also assessed. A total of 102 manuscripts and one abstract were included. The analysis demonstrated that the visual method had good accuracy for detecting carious lesions. Clinically obtained specificity was higher. Also observed was moderate to high heterogeneity and evidence of publication bias. Studies employing well known visual scoring systems were significantly more accurate than those that used their own criteria. The results were grouped and differentiate the type of dentition (permanent or primary), type of lesion (initial or advanced), proximal or occlusal surface and clinical settings from laboratory settings.The pooled specificity calculated was high in most of the groups and ranged from 0.573 to 0.992 mostly > 0.90; the lowest was in the occlusal initial caries lesions in primary teeth.The sensitivity ranged from 0.274 to 0.77; the lowest from clinical studies in proximal surfaces in permanent teeth, the highest from three studies evaluating the occlusal initial caries lesions in permanent teeth. Most of the pooled sensitivities were around a low level.ConclusionsVisual caries detection method has good overall performance. Although the studies together had high heterogeneity and risk of bias, the use of detailed and validated indices seems to improve the accuracy of the method.