Detecting Proximal Secondary Caries Lesions

Abstract

When choosing detection methods for secondary caries lesions, dentists need to weigh sensitivity, allowing early initiation of retreatments to avoid lesion progression, against specificity, aiming to reduce risks of false-positive diagnoses and invasive overtreatments. We assessed the cost-effectiveness of different detection methods for proximal secondary lesions using Monte Carlo microsimulations. A vital permanent molar with an occlusal-proximal restoration was simulated over the lifetime of an initially 20-y-old. Three methods were compared: biannual tactile detection, radiographic detection every 2 y, and biannual laser fluorescence detection. Methods were employed either on their own or in pairwise combinations at sensitive and specific thresholds estimated with systematically collected data. A mixed public-private payer perspective in the context of German health care was applied. Effectiveness was calculated as years of tooth retention. Net-benefit analyses were used to evaluate cost-effectiveness acceptability at different willingness-to-pay thresholds. Radiographic detection verified by tactile assessment (both at specific thresholds) was least costly (mean, 1,060 euros) but had limited effectiveness (mean retention time, 50 y). The most effective but also more costly combination was laser fluorescence detection verified by radiography, again at specific thresholds (1157 euros, 53 y, acceptable if willingness to pay >32 euro/y). In the majority of simulations, not combining detection methods or applying them at sensitive thresholds was less effective and more costly. Net benefits were not greatly altered by applying different discounting rates or using different baseline prevalence of secondary lesions. Current detection methods for secondary lesions should best be used in combination, not on their own, at specific thresholds to avoid false-positive diagnoses leading to costly and invasive overtreatment. The relevant characteristics, such as predictive value, of different methods should be assessed in longitudinal clinical studies.

How to intervene in the caries process in adults: proximal and secondary caries? An EFCD-ORCA-DGZ expert Delphi consensus statement

“…These were assessed in a recent review [25], which found that visual, radiographic, and laser fluorescence detection had similar sensitivities and specificities (abilities to detect carious and sound surfaces, respectively), while tactile assessment and light-induced fluorescence are not as useful at present, at least not if used in isolation. There is further data demonstrating that in most low caries risk populations, avoiding false-positive readings and ultimate over-detection and treatment should be prioritized, as secondary lesions progress slowly (see above) and missed lesions may be detected at the next recall consultation [26]. Overall, it seems advisable to combine bitewing radiography (allowing the detection of clinically inaccessible lesions) with visual-tactile assessment (allowing confirmation of findings).…”

Secondary caries: what is it, and how it can be controlled, detected, and managed?

“…In many instances, discolorations or clinically irrelevant imperfections may have been identified as secondary caries [19,30,31]. At present, there is sparse evidence demonstrating what kind of characteristics an identified defect needs to progress into a state where care is undoubtedly needed, or to remain in the status quo in the long term, possibly never progressing and hence never needing care [32].…”

“…Given that secondary caries detection is performed as part of a routine screening appointment and possibly applied repeatedly, there is some evidence indicating that specific measures should be prioritized, as secondary caries progresses only slowly and missed lesions may be detected at the next screening round. Alternatively, a sequential usage of sensitive followed by specific methods seems advisable [32]. Avoiding false-positive diagnoses, which lead to costly and invasive overtreatment, seems especially relevant in most of today's low-risk populations.…”

Performance of 5 different displays in the detection of artificial incipient and recurrent caries-like lesions

“…6 However, the combination of a clinical tactile exam and radiographic evaluation has been shown to be both effective and economical for caries diagnosis. 7 The aim of this study was to assess if the auto calibrating medical grade monitors perform better in comparison to off the shelf and tablet monitors for the identification of artificial incipient caries-like lesions at common primary and secondary caries locations.…”