Radiographic Diagnosis of Dental Caries

S. Brent Dove, D.D.S., M.S.

Abstract: The purpose of this report was to respond to aspects of the RTI/UNC systematic review relating to the radiographic
diagnosis of dental caries. The systematic review was commissioned as part of the NIH Consensus Development Conference on
Diagnosis and Management of Dental Caries Throughout Life. The systematic review evaluated the dental literature from 1966 to
1999. Well-defined search criteria along with clear inclusion and exclusion criteria were used to perform the review. Some of the
inclusion and exclusion criteria used in the systematic review may have limited the evidence supporting the use of radiography,
especially for the diagnosis of proximal surface caries. The RTI/UNC review only included studies in which sensitivity and
specificity were reported or could be derived from the data presented. Studies that used the receiver operating characteristic as a
measure of diagnostic accuracy were not included. Although the strength of evidence is considered poor, this does not mean that
the use of radiographic methods is of no diagnostic value. It simply means that, using the criteria established by the systematic
review, the evidence is inadequate to validate the method. Guidelines should be developed for assessing diagnostic methods that
assist researchers in developing study designs that will hold up to critical review.
Dr. Dove is Division Head, Department of Dental Diagnostic Sciences, University of Texas Health Science Center. Direct
correspondence to him at Department of Dental Diagnostic Sciences, University of Texas Health Science Center, 7703 Floyd Curl
Drive, San Antonio, TX 78229 ; 210-567-3332 phone; 210-567-3334 fax; dove@uthscsa.edu.
Key words: dental caries, caries diagnosis, dental radiology, dental radiography, oral diagnosis

A
lmost since the discovery of x-rays by
Wilhelm Conrad Roentgen in 1895, radiog-
raphy has been used to detect the effects of
dental caries on dental hard tissues. Radiography has
been primarily used for the detection of lesions on the
proximal surfaces of teeth, which are not clinically vis-
ible for inspection. Radiographs are also recommended
as a supplement to the clinical examination of occlusal
surfaces for the detection of pit and fissure caries. Over
the years, it has been well established that more dental
caries are detected by radiography than by clinical ex-
amination alone.1-6
Radiographic diagnosis of dental caries is funda-
mentally based on the fact that as the caries process
proceeds, the mineral content of enamel and dentin
decreases with a resultant decrease in the attenuation
of the x-ray beam as it passes through the teeth. This is
recorded on the image receptor as an increase in radio-
graphic density. This increase in radiographic density
must be detected by the clinician as a sign of a carious
lesion. Many different factors can affect the ability to
accurately detect these lesions: exposure parameters,
type of image receptor, image processing, display sys-
tem, viewing conditions, and ultimately, the training
and experience of the human observer.
A systematic review of the existing literature was
performed by the RTI/UNC Evidence-Based Practice
Center to address the question of the validity of six dif-
ferent diagnostic methods for the detection of dental
caries in primary and permanent teeth. The diagnostic
methods assessed were: visual and visual/tactile inspec-
tion, radiography, fiber-optic transillumination (FOTI),
electrical conductance (EC), laser fluorescence (LF),
and combinations of these methods.
Three primary computer indexes used in search-
ing the literature were MEDLINE, EMBASE, and the
Cochrane controlled trials register. The period searched
was from January 1966 to December 1999. Inclusion
and exclusion criteria were clearly defined prior to per-
forming the search. Studies were limited to those with
human subjects and natural carious lesions, publica-
tion language in English, and histological validation of
caries status for each surface studied or visual/tactile
validation of intact surface for cavitation only; outcomes
must be expressed as sensitivity and specificity or pro-
vided data from which these outcomes could be de-
rived. While both in vitro and in vivo studies were in-
cluded in the review, only those methods that are
commercially available to the general practitioner were
assessed.
Thirty-nine studies were selected from among
1,407 diagnostic reports that satisfied all criteria.
These studies reported 126 different assessments of
different diagnostic methods. Of these studies, 65
assessements evaluated the diagnostic performance of
radiographic methods. The studies were critically re-
viewed and a quality rating scale assessed that ap-
praised several elements of internal validity, includ-
ing study design, duration, sample size, blinding of
examiners, baseline assessments, and examiner reli-

October 2001 ■ Journal of Dental Education 985

 ability. The overall strength of evidence supporting the
validity of a method was judged in terms of the extent
to which it offered clear, unambiguous assessment of a
particular method for identifying a specific type of le-
sion on a specific type of surface.
Some of the inclusion and exclusion criteria used
in the systematic review may have limited the evidence
supporting the use of radiography, especially for the
diagnosis of proximal surface caries. The RTI/UNC
review only included studies in which sensitivity and
specificity were reported or could be derived from the
data presented. Studies that used the receiver operating
characteristic as a measure of diagnostic accuracy were
not included.
Receiver Operating Characteristic (ROC) analy-
sis is a method to determine the diagnostic accuracy of
a particular method of assessment. ROC is based upon
signal detection theory and provides for an unbiased
measure of discrimination in the paired-comparison or
forced-choice situation.7 This is exactly the type of
choice the dentist faces when determining the presence
or absence of a carious lesion on a radiograph. Using
sensitivity and specificity values for a diagnostic test
or imaging modality can be ambiguous as dentists ex-
hibit a wide variation in their decision criteria.8 The
ROC analysis gives a measure of discrimination that is
independent of the cut-off points of the decision crite-
rion and, therefore, unbiased by them.7 Recently, many
researchers evaluating the diagnostic performance of
radiographic methods have advocated the use of ROC
analysis to evaluate imaging systems for the diagnosis
of dental caries.9 A search of the Medline database from
January 1966 to December 2000 using [exp dental car-
ies/ or dental caries.mp. (21,172)] and [exp radiogra-
phy/ or dental radiology.mp. or exp radiography, den-
tal, digital/ or exp radiographic image enhancement
(101,704)] and [exp ROC curve/ or ROC curve.mp.
(2,167)] as search criteria resulted in sixty-two reports.
Including these studies may have improved the strength
of evidence for radiographic methods for the detection
of dental caries.
Another criteria used for inclusion also had a sig-
nificant effect on the overall outcome of the assess-
ment. Studies included were required to have histologi-
cal validation of caries status for each surface studied.
Some exceptions were made with regard to those stud-
ies where cavitation was the extent of lesions to be de-
tected. Due to the practical and ethical limitations of
obtaining histological confirmation, the majority of
assessments were in vitro (six in vivo and fifty-nine in
vitro). In the determination of a quality rating, the maxi-
mum score for experimental setting was twenty points.
Considering that an in vitro study was given a score of
zero and an in vivo study was given a score of two for
986
experimental setting, 10 percent of the overall quality
score was affected by this criterion. While some of the
methods such as visual inspection, fiber-optic transil-
lumination, and electric conductance can be greatly
affected by the setting in which they were performed,
the basic physics of image formation should not be
greatly affected by difference between a laboratory and
clinical setting, provided extracted human teeth and
natural caries are being studied. A meta-analysis of fac-
tors involved in the validity of radiographic diagnosis
for proximal surface caries indicated that experimental
setting did in fact have an impact on diagnostic perfor-
mance.10 Contrary to the results of this meta-analysis, a
more recent direct experimental examination of the
same question supports the idea that no such relation-
ship exists. Hintze and Wenzel11 directly compared the
diagnostic accuracy of radiographs obtained both in vivo
and in vitro of the same teeth for the detection of oc-
clusal and proximal surface caries. The results of their
study suggest that no difference could be found between
in vivo and in vitro results using ROC analysis.
The RTI/UNC systematic review of the dental
literature indicates that the strength of evidence for ra-
diographic methods for the detection of dental caries is
poor for all types of lesions on posterior proximal and
occlusal surfaces. This was primarily due to the large
amount of variation in the reported sensitivity and speci-
ficity of this method. Little if any evidence exists to
support the use of radiographic methods for primary
teeth, anterior teeth, and root surfaces. The literature is
severely limited by problems associated with both in-
ternal and external validity. These include: incomplete
descriptions of sample selection, diagnostic criteria and
examiner reliability, the use of small numbers of exam-
iners, nonrepresentative teeth, samples with high lesion
prevalence, and the use of reference standards of ques-
tionable reliability.
Although the strength of evidence is considered
poor, this does not mean that the use of radiographic
methods is of no diagnostic value. It simply means that,
using the criteria established to evaluate the existing
evidence, we find the evidence is inadequate to vali-
date the method. Better studies designed to address the
limitations of the current literature could in fact indi-
cate that the method is valid. It does call into question
the relative importance of this method in making treat-
ment decisions.
A review of the RTI/UNC report indicates that
most of the variability in diagnostic performance of
posterior proximal and occlusal surfaces was in fact
associated with the sensitivity of the method and not
the specificity. Table 1 shows the radiographic assess-
ments of the diagnosis of cavitated lesions, lesions in-
volving dentin, and any lesions on proximal surfaces
Journal of Dental Education ■ Volume 65, No. 10
of posterior teeth. For those assessments involving cavi-
tated lesions, the standard deviation of the mean sensi-
tivity was 0.21, whereas the standard deviation of the
mean specificity was only 0.04 (Table 1). This same
trend is consistent for all evaluations of proximal sur-
faces regardless of lesion progression. This trend is not
apparent when considering the diagnosis of occlusal
caries involving dentin (Table 2). However, the vari-
ability in sensitivity is high when compared to that of
specificity when we evaluate the occlusal surfaces of
permanent posterior that had lesions of different depths
(Table 2). On further review, considerable outliers ap-
pear in each dataset. These have been indicated in bold.
Some of the variability may be explained by the detec-
tion task itself and the decision criteria used by differ-
ent evaluators. When radiographic interpretation is per-
formed, the decisions are presented as either the
presence or absence of a lesion. But the decisions are
not always so black-and-white, but in fact lie in a gray
continuum of negative to positive. Therefore, several
different values along this continuum could be selected
as a cutoff to determine if dental caries is present or
absent. Depending upon whether more stringent or more
lenient criteria are used for detection, the sensitivity
and specificity can vary dramatically. If more stringent

Table 1. Permanent posterior teeth—proximal surfaces

Sites
Citation, Method Raters Prevalence Criteria Sensitivity Specificity Type
Rugg-Gunn, 197212 370 9% Lesion in enamel 0.35 1.00 Cavitated
D speed film NR & outer ˚ dentin Lesions
Downer, 197513 185 36% Lesion at DEJ 0.73 0.97 Cavitated
D-speed film NR or beyond Lesions
Mejare, et al., 198514 598 5% Lesion 2/3 0.36 0.98 Cavitated
D-speed film 3 enamel thickness Lesions
Pitts & Rimmer, 199215 1468 1% Lesion into 0.87 0.99 Cavitated
D-speed film 1 dentin Lesions
Hintze, et al., 199816 338 6% Lesion into 0.63 0.93 Cavitated
E-speed film 4 dentin Lesions
Espelid & Tveit, 198617 151 19% Lesion involving 0.69 0.89 Cavitated
D-speed film 7 DEJ Lesions
Mean Performance 0.61 ± 0.21 0.96 ± 0.04

Mileman & van der Weele, 105 43% Lesion into outer 0.54 0.97 Dentin
199018 D-speed film 276 ˚ of dentin Lesions
Verdonschot, et al., 199119 21 NR Lesion reaching 0.50 0.94 Dentin
D-speed film 3 DEJ Lesions
Russell & Pitts, 199320 240 NR Lesion penetrating 0.29 0.92 Dentin
D-speed film 3 DEJ 0.30 0.96 Lesions
E-speed film 0.16 0.96
RVG
Ricketts, et al., 199721 96teeth 13% Lesion into 0.16 0.99 Dentin
D-speed film 5 dentin Lesions
Mean Performance 0.33 ± 0.16 0.96 ± 0.02

Heaven, Firestone, & 16 75% NR 1.0 1.0 All

Feagin, 199222 D-speed 1 Lesions
film with image analysis
Russell & Pitts, 199320 240 NR Lesion 0.26 0.90 All
D-speed film 3 penetrating 0.25 0.90 Lesions
E-speed film DEJ 0.15 0.92
RVG
Ricketts, et al., 199721 96teeth 37% Lesion into 0.27 0.97 All
D-speed film 5 dentin Lesions
Firestone, et al., 199823 102 66% NR 0.61 0.86 All
D-speed film 1 0.78 0.74 Lesions
Film image analysis 0.73 0.82
Sensaray image analysis
Mean Performance 0.51 ± 0.31 0.89 ± 0.08

October 2001 ■ Journal of Dental Education 987

 Table 2. Permanent posterior teeth—occlusal surfaces
Sites
Citation, Method Raters Prevalence Criteria Sensitivity Specificity Type
Wenzel, et al., 199024 46 72% caries into 0.63 0.94 Dentin
D-speed film 6 dentin 0.68 0.98 Lesions
Digitized film enhanced
Wenzel, et al., 199125 81 67% caries into 0.63 0.85 Dentin
E-speed film 4 dentin 0.72 0.83 Lesions
Digitized film 0.62 0.83
Digitized film enhanced 0.69 0.84
RVG contrast enhanced 0.64 0.82
RVG density saturation
Wenzel & Fejerskov, 199226 78 67% caries reaching 0.48 0.81 Dentin
E-speed film 1 dentin 0.71 0.85 Lesions
Digitized film 0.54 0.77
Digitized film enhanced
Nytun, Raadal, & 30 77% radiolucency 0.66 0.50 Dentin
Espelid, 199227 10 involving Lesions
Film dentin
Keltey & Holt, 199328 100 51% radiolucency 0.67 0.92 Dentin
D-speed film 1 into dentin Lesions
Russell & Pitts, 199320 120 28% radiolucency 0.18 0.98 Dentin
D-speed film 3 penetrating 0.21 0.99 Lesions
E-speed film beyond DEJ 0.21 0.97
RVG
Lussi, 199329 63 44% caries into 0.45 0.83 Dentin
D-speed film 24 dentin Lesions
Verdonschot, et al., 199330 81 67% dentinal 0.61 0.79 Dentin
E-speed film 4 caries Lesions
Lussi, et al., 199531 26 42% caries beyond 0.62 0.77 Dentin
D-speed film 6 the DEJ Lesions
Ricketts, et al., 199432 48 67% dentine 0.62 0.76 Dentin
D-speed film 12 caries Lesions
Ekstrand, Ricketts, 100 39% radiolucency 0.54 1.00 Dentin
& Kidd, 199733 3 to middle 1/3 Lesions
D-speed film of dentin
Huysmans, Hitze, 189 55% caries into 0.60 0.94 Dentin
& Wenzel, 199734 3 dentin Lesions
Digora
Ricketts, et al., 199721 96 39% radiolucency 0.14 0.95 Dentin
5 into dentin Lesions
Ashley, Blinkhorn, 103 36% radiolucency 0.24 0.89 Dentin
& Davies, 199835 1 into dentin 0.19 0.89 Lesions
E-speed film
Digora
Huysmans, Longbottom, 107 41% radiolucency 0.58 0.87 Dentin
& Pitts, 199836 2 into dentin Lesions
E-speed film
Mean Performance 0.51 ± 0.19 0.86 ± 0.11

Wenzel, et al., 199024 46 89% caries into 0.73 0.80 All

D-speed film 2 enamel 0.79 0.90 Lesions
Digitized film enhanced
Russell & Pitts, 199320 120 NR radiolucency 0.12 0.95 All
D-speed film 3 penetration 0.12 0.96 Lesions
E-speed film beyond DEJ 0.15 0.97
RVG
Lazarchik, et al., 199537 100 79% caries 0.58 0.79 All
D-speed film 15 present Lesions
Ricketts, et al., 199721 96 70% radiolucency 0.27 0.97 All
D-speed film 5 into dentin Lesions
Mean Performance 0.39 ± 0.30 0.91 ± 0.08

988 Journal of Dental Education ■ Volume 65, No. 10

criteria are applied, fewer false-positives will occur,
resulting in higher specificity at the expense of sensi-
tivity and the associated increase in false-negative de-
cisions. If, however, more lenient criteria are used, the
inverse is typically true.
All of the evidence suggests that radiographic
methods have a higher degree of specificity than sensi-
tivity, which means that false-negative diagnoses are
proportionally more apt to occur in the presence of dis-
ease than are false-positive diagnoses in the absence of
disease. This outcome may be beneficial if the nega-
tive consequences of a false-positive diagnosis outweigh
that of a false-negative diagnosis. Currently the most
common type of intervention is surgical removal of the
lesion, so a false-positive diagnosis results in a perfectly
normal tooth being irreversibly damaged. A false-nega-
tive results in further progression of the lesion and po-
tentially further loss of tooth tissue. This outcome is
somewhat mitigated by the fact that the lesion may be
detected at a later time. Nonsurgical interventions are
gaining in popularity as alternatives to mechanical re-
placement of damaged tooth tissue with artificial ma-
terials. These nonsurgical methods are only effective if
the lesion is detected prior to cavitation. This means
that the lesion must be detected early. To detect the le-
sion earlier, a diagnostic method must provide for higher
sensitivity, which may result in more false-positive di-
agnoses. If early interventions consist of nonsurgical
management, which does not result in any permanent
damage to the tooth, then the negative consequences of
a false-negative diagnosis outweigh those of a false-
positive diagnosis. Every attempt should be made to
increase the sensitivity of currently available methods
of radiographic diagnosis to coincide with this change
in intervention strategy.
New digital radiographic techniques that elimi-
nate the use of silver halide emulsion x-ray film by cap-
turing radiographic images on photostimulable phos-
phor imaging plates or charge-coupled devices may
improve detection of dental caries. The images acquired
with these technologies are digital and can be processed
or analyzed to enhance diagnostic performance. The
weight of available evidence suggests that the use of
some digital methods offers small gains in sensitivity
without reduction in specificity and that image analy-
sis techniques may offer more substantial gains.
Renewed effort should be made to ensure that
future studies address the question of diagnostic valid-
ity adequately. Guidelines should be developed for as-
sessing diagnostic methods that assist researchers in
developing study designs that will hold up to critical
review.
October 2001 ■ Journal of Dental Education
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Journal of Dental Education ■ Volume 65, No. 10