Community Dent Oral Epidemiol 2012; 40: 257–266  2011 John Wiley & Sons A/S

All rights reserved

Vibeke Baelum1, Hanne Hintze2, Ann

Implications of caries diagnostic Wenzel2, Bo Danielsen3 and
Bente Nyvad4

strategies for clinical

1
School of Dentistry and Institute of Public
Health, Aarhus University Faculty of Health
Sciences, Aarhus, Denmark, 2Department of
Oral Radiology, School of Dentistry, Aarhus
management decisions University Faculty of Health Sciences,
Aarhus, Denmark, 3School of Oral Health
Care, University of Copenhagen Faculty of
Health Sciences, Copenhagen, Denmark,
Baelum V, Hintze H, Wenzel A, Danielsen B, Nyvad B. Implications of caries 4
Department of Dental Pathology, Operative
diagnostic strategies for clinical management decisions. Community Dent Oral Dentistry and Endodontics, School of
Epidemiol 2011.  2011 John Wiley & Sons A ⁄ S Dentistry, Aarhus University Faculty of
Health Sciences, Aarhus, Denmark
Abstract – Objectives: In clinical practice, a visual–tactile caries examination is
frequently supplemented by bitewing radiography. This study evaluated
strategies for combining visual–tactile and radiographic caries detection
methods and determined their implications for clinical management decisions
in a low-caries population. Methods: Each of four examiners independently
examined preselected contacting interproximal surfaces in 53 dental students
aged 20–37 years using a visual–tactile examination and bitewing radiography.
The visual–tactile examination distinguished between noncavitated and
cavitated lesions while the radiographic examination determined lesion depth.
Direct inspection of the surfaces following tooth separation for the presence of
cavitated or noncavitated lesions was the validation method. The true-positive
rate (i.e. the sensitivity) and the false-positive rate (i.e. 1-specificity) were Key words: dental caries; diagnostic errors;
calculated for each diagnostic strategy. Results: Visual–tactile examination oral diagnosis; radiography; routine
provided a true-positive rate of 34.2% and a false-positive rate of 1.5% for the diagnostic tests
detection of a cavity. The combination of a visual–tactile and a radiographic Vibeke Baelum, Department of
examination using the lesion in dentin threshold for assuming cavitation had a Epidemiology, Institute of Public Health,
Faculty of Health Sciences, Aarhus
true-positive rate of 76.3% and a false-positive rate of 8.2%. When diagnostic
University, Bartholins Alle 2, DK-8000
observations were translated into clinical management decisions using the rule Aarhus C, Denmark
that a noncavitated lesion should be treated nonoperatively and a cavitated Tel.: +45 89426097
lesion operatively, our results showed that the visual–tactile method alone was e-mail: baelum@soci.au.dk
the superior strategy, resulting in most correct clinical management decisions Submitted 28 March 2011;
and most correct decisions regarding the choice of treatment. accepted 20 October 2011

Examinations for the purpose of disease detection
in asymptomatic patients should be carefully eval-
uated in terms of both the anticipated health
benefits and the possible risks for the examined
patients (1). In many contemporary populations,
most people undergo regular dental check-up
examinations, commonly initiated by dentists (2)
who send calling cards to their patients reminding
them. In the Nordic countries, 87–90% of the adults
have visited a dentist within the past 2 years (2, 3),
and 64–68% have visited within the past year (4, 5).
While a dental visit does not necessarily mean that
an oral examination has been carried out, there is a
close correlation between the number of dental
visits and the number of oral examinations made
(5).
For decades, it has been customary to supple-
ment the visual–tactile caries detection examina-
tion with bitewing radiography in the anticipation
of an additional diagnostic yield, that is, detection
of lesions remaining undetected by visual–tactile
examination alone (6). Although guidelines com-
monly stress that radiographs should be used only
on specific individualized indication (7), and
although radiographic screening for caries lesions
among children with little caries experience carries
too little benefit (8, 9), the practice of screening
using bitewing radiographs continues to be pro-

doi: 10.1111/j.1600-0528.2011.00655.x 257

Baelum et al.
moted (7, 10, 11). Consequently, the practice of
combining the visual–tactile examination with a
radiographic examination is very common among
Swedish and Norwegian children (12–14) and
moderately common among Danish children (15).
Much less is known about the use of bitewing
radiographs among adults. However, the average
adult Danish dental patient had 0.79 intraoral
radiographs taken in the year 2000, rising to an
average of 0.85 radiographs taken per dental
patient in the year 2002 (16), and this may be taken
as an indication of frequent use of bitewing
radiographs in dental examinations.
All caries diagnostic methods are error-prone,
with less-than-perfect reliability (inter- and intra-
examiner reproducibility) (17, 18) and less-than-
perfect validity (18–20). While this is well known,
the consequences have not been given much
attention (1, 6). Research on the effect of the
combination of caries detection methods is incon-
clusive, with some finding that combining methods
may decrease the reproducibility for both intra-
and inter-examiner comparisons (21), while others
report the opposite effect (22, 23). Although two
studies on extracted teeth indicate that combining
diagnostic tests may increase both sensitivity and
specificity relative to the isolated tests (23, 24), the
case-mix, i.e. the distribution of lesions in the
sample of teeth investigated, greatly influence the
results (22).
A few have studied the implications for clinical
management decisions of combining caries detec-
tion methods in occlusal surfaces (21, 25). One
study (25) demonstrated that the use of additional
methods for caries detection (bitewing radio-
graphs, electric conductance measurement, quanti-
tative light fluorescence, DIAGNOdent) may lead
to a slight reduction from 167 to 159 (5%) in the
total number of correct treatment decisions and a
substantial increase in the number of overtreat-
ments from 46 to 81 (76%) compared with the use
of the visual examination alone. In another study
(21), the combination of methods resulted in a
slight increase in the proportion of correct ‘conser-
vative restoration’ treatment decisions at the
expense of a slight decline in the proportion of
correct ‘follow up or sealant’ treatment decisions.
As far as we are aware, no study has assessed the
implications of combining the visual–tactile and
bitewing examination methods for caries lesion
detection in interproximal surfaces for the resulting
clinical management decisions. The purpose of the
present study was to address this question.
258
Material and methods
This analysis is a secondary analysis of data
originating in a study of the validity and reliability
of three commonly used diagnostic methods for the
detection of cavitated interproximal carious lesions
(19). Each of four examiners independently exam-
ined preselected contacting interproximal surfaces
(for details, see later) in 53 dental and dental
hygienist students aged 20–37 years (mean
24.7 years) using a visual–tactile examination, bite-
wing radiography or fiber-optic transillumination
(FOTI). However, the FOTI data are not further
considered in the present study.
The examiners, who had been trained and
calibrated in the use of the criteria, independently
assessed the interproximal surfaces based on a
visual–tactile and a bitewing examination carried
out on separate days using the criteria described in
Table 1. The visual–tactile criteria used were those
later described by Nyvad et al. (17, 26), but the
lesion activity observations were not used in the
original study, which focused on the detection of
cavitated carious lesions. Thereby, the distinctions
in the visual–tactile diagnoses were between
sound, noncavitated and cavitated carious lesions
(19). For the visual–tactile examination, straight
probes and pigtail explorers were used to examine
the surface contour and surface texture and to
remove any debris present. No attempts were
made to physically penetrate lesions. Debris which
could not be removed completely by the probe was
removed by dental floss, and the surfaces were
kept dry by cotton rolls, compressed air and
suction apparatus. Following each visual–tactile
interproximal diagnosis, the examiners expressed
their confidence in the diagnosis of the absence or
presence of a cavitated lesion in the surface just
examined. The confidence scale used was the five-
point scale outlined in Table 1. The bitewing
examination was based on two bitewing radio-
graphs (one in each side of the mouth) taken using
a dental X-ray unit (GX 1000; Gendex Corporation,
Wilwaukee, WI, USA) operating at 70 kV, 10 mA
and exposure times of 0.22 and 0.26 s. The focus-
film distance was 36 cm, and the collimator was
rectangular with a size of 3.4 · 4.4 cm. The film
used was Kodak Ektaspeed Plus (Eastman Kodak
Company, Rochester, NY, USA) in Kwik-Bite
(Hawe Neos Dental, Bioggio, Switzerland)
film holders. Development was performed in a
Dürr automatic processor model 1330 AC245L
(Dürr, Bietigheim- Bissingen, Germany) with
 Implications of caries diagnostic strategies

Table 1. Caries diagnostic criteria and confidence ratings used in the study
Examination method Code Classification used in original study (19) Classification in present study
Visual–tactile 0 Sound Sound
1 +3 Noncavitated lesion Noncavitated
2 +4 Cavitated lesion Cavitated
Confidence scale 1 Certain cavity is present Certain
2 Almost certain cavity is present Uncertain
3 Uncertain Uncertain
4 Almost certain cavity is not present Uncertain
5 Certain cavity is not present Certain
Radiography 0 Sound Sound
1 Radiolucency in outer half of enamel Enamel
2 Radiolucency in inner half of enamel Enamel
3 Radiolucency in outer third of dentin Outer dentin
4 Radiolucency in inner two-thirds of dentin Inner dentin
Validation 0 Sound Sound
1 +3 Noncavitated lesion Noncavitated
2 +4 Cavitated lesion Cavitated

Readymatic developer and fixer solutions (Kodak-
Pathé, Paris, France). Radiographs were examined
blind in random order on a view box with ·2
magnification (X-viewer, Lysta, Farum, Denmark)
using the lesion depth scale outlined in Table 1.
Each examiner read the radiographs at least 2 days
after the clinical examinations independently of
the results of these examinations and indepen-
dently of the results obtained by the other
examiners.
The in vivo validation of the diagnostic findings
was carried out by each examiner using the visual–
tactile criteria (Table 1) following tooth separation
by orthodontic rubber rings or separation springs
for 3 days. This validation method precluded the
inclusion of all contacting interproximal sites in the
molar ⁄ premolar areas. Sites were, therefore, pres-
elected for inclusion and represented contacting
interproximal surfaces involving one premolar-
to-premolar contact, one molar-to-molar contact
and two premolar-to-first molar contacts. Applica-
tion of these criteria led to initial inclusion of eight
interproximal surfaces per individual in 48 stu-
dents, six surfaces in three students and four
surfaces in two students. In 20 surface pairs, one
of the surfaces was filled, and these were excluded.
Further, 52 surfaces could not be diagnostically
validated owing to premature loss of the separation
device or no resulting tooth separation and were
also excluded. Thereby, a total of 338 surfaces were
available for evaluation by each examiner.
The order of examiners was haphazard, and the
examiners were unaware of the results obtained by
the previous examiner(s). A slight variation in the
number of diagnostic decisions contributed by each
Table 2. Examiner agreement on the caries validation
recordings of the 338 surfaces. Disagreement
‘sound ⁄ noncavitated’ means that at least one examiner
recorded the surface as ‘sound’ and at least one examiner
recorded the surface as ‘non-cavitated,’ while no exam-
iner recorded the surface as ‘cavitated’
The four Surface Number (%)
examiners diagnosis of surfaces
Agree Sound 134 (39.6)
Noncavitated 46 (13.6)
Cavitated 10 (3.0)
Disagree Sound ⁄ noncavitated 126 (37.3)
Sound ⁄ cavitated 1 (0.3)
Sound ⁄ noncavitated ⁄ cavitated 8 (2.4)
Noncavitated ⁄ cavitated 13 (3.9)
examiner was noted, because the examiners did not
consistently agree whether a given surface was
recordable.
All four examiners agreed in the validation (true
state) of the surface in 190 of the 338 surfaces
evaluated (Table 2). Most of the disagreements
observed (126 of 148) involved a disagreement
whether the surface was sound or had a noncavi-
tated caries lesion; 13 discrepancies concerned
disagreement whether a lesion was cavitated or
not, and eight disagreements involved all three
possible diagnoses: sound, noncavitated or cavi-
tated lesion (Table 2). When the validation exami-
nation results were pooled across examiners, 811
surfaces were deemed sound, 444 surfaces had a
noncavitated caries lesion, and 76 surfaces were
found to be cavitated. No validation by consensus
was attempted, as this does not reflect the real-life
situation.
A number of diagnostic strategies were simu-
lated for the combination of radiographic and

259
Baelum et al.
visual–tactile recordings. As each examiner had
recorded the surfaces using each detection method
separately, the results could be combined to reflect
the use of different diagnostic strategies for the
detection of noncavitated and cavitated caries
lesions. Table 3 shows how recordings made with
each caries detection method were interpreted in
each diagnostic strategy to arrive at the classifica-
tion for each surface as sound, with a noncavitated
caries lesion or with a cavitated caries lesion. The
results of the visual–tactile examination alone
needed no interpretation, whereas the bitewing
radiographic results were subject to two interpre-
tations: In one strategy, called Radiography I, any
lesion extending into dentin was assumed cavi-
tated, while in the Radiography II strategy, only
lesions extending into the inner two-thirds of the
dentin were assumed cavitated. In the diagnostic
strategy combining the visual–tactile results and
the confidence assessment, visual–tactile cavity
diagnoses were changed to noncavitated lesion
diagnoses when uncertainty (Table 1) was ex-
pressed about the diagnosis. The visual–tactile
and both radiographic strategies were further
combined using the additional yield principle, i.e.
the more severe caries lesion found with either
method determined the final classification (Ta-
ble 3).
In the present analysis, the results have been
pooled across the four examiners, which means
that each surface is represented four times (one
for each examiner) in the data. The results of
each diagnostic strategy shown in Table 3 were
cross-tabulated with the results of the validation
method, and sensitivity and specificity values
Table 3. The interpretation of recordings from the different examination methods, alone and in combinations, used in
each diagnostic strategy to arrive at a final classification of the approximal surfaces as either sound, with noncavitated
caries lesion, or with cavitated caries lesion
Final diagnosis after combination of recordings
Diagnostic strategy Sound
Visual–tactile alone Sound
Visual–tactile + confidence Sound
Radiography I alone Sound
Radiography II alone Sound
Visual–tactile + Radiography I Sound
Visual–tactile + Radiography II Sound
Visual–tactile + confidence Sound
+ Radiography I
Visual–tactile + confidence Sound
+ Radiography II
260
were calculated for the diagnosis of a cavitated
lesion, respectively, any caries lesion. The sensi-
tivity of a test (diagnostic strategy) for the
detection of, say, a cavitated caries lesion is the
proportion of truly cavitated caries lesions (as
determined by the validation method) that are
detected by the test. Similarly, the specificity of
the test is the proportion of truly noncavitated
caries lesions that are detected by the test.
The sensitivity is also called the true-positive
rate, while 1-specificity is called the false-positive
rate.
For the purpose of assessing the effect of the
different caries diagnostic strategies on the correct-
ness of the treatment decisions that would have
followed from these strategies, it was assumed
that a cavitated caries lesion needs a restoration
and that a noncavitated caries lesion needs
nonoperative treatment.
Results
The number of visual–tactile diagnoses for which
uncertainty was expressed on the confidence scale
amounted to 108, corresponding to 8% of all visual–
tactile diagnoses. Most of these (55) concerned
surfaces with noncavitated lesions according to the
validation examination, while 24 concerned sound
surfaces and 29 concerned cavitated lesions accord-
ing to the validation examination. Thereby, the
probability of uncertainty regarding a sound surface
was 3% (24 of 811), and 12.4% (55 of 444) and 38.2%
(29 of 76) for noncavitated and cavitated surfaces,
respectively.
Noncavitated Cavitated
Noncavitated Cavitated
Noncavitated or Cavitated, certain
cavitated if uncertain
In enamel In dentin
In enamel or in outer dentin In inner dentin
Noncavitated or in enamel Cavitated or in dentin
Noncavitated or in enamel Cavitated or in inner dentin
or in outer dentin
Noncavitated or in Cavitated, certain or in dentin
enamel if uncertain
Noncavitated or in Cavitated, certain or in
enamel if uncertain or inner dentin
in outer dentin if uncertain
 Implications of caries diagnostic strategies

Table 4 shows the results of cross-tabulating the
validation results with the results of each diagnos-
tic strategy. The highest number of caries lesions
(705 = 544 + 161) was detected when the visual–
tactile examination was combined with radiogra-
phy (Radiography I) for all surfaces, and the
number of lesions detected exceeded the true
number of lesions (520) by 36%. This diagnostic
strategy resulted in the highest true-positive rates
for the detection of cavities and any caries lesion
(76.3% and 97.4%, respectively). However, these
high true-positive rates came at the price of the
highest false-positive rates (8.2% and 34.5%,
respectively) among any of the examination strat-
egies considered. The lowest false-positive rate
(0.6%) for the detection of a cavity was observed
using the visual–tactile examination combined
with the decision to change the diagnosis to ‘non-
cavitated’ if uncertainty was expressed about cav-
itation. The true-positive rate for this diagnostic
strategy was 21.1% for cavity detection.
Table 5 shows that the diagnostic strategy result-
ing in most correct treatment decisions was the
visual–tactile examination, either alone or + confi-
dence (73.6% and 73.3%, respectively), closely
followed by the two diagnostic strategies employ-
ing radiographs only in the case of uncertainty
about the visual–tactile diagnosis (73.3% and

Table 4. Relationship between the diagnoses made following each diagnostic strategy and the validation results. Also
given are the true-positive (TP) and false-positive (FP) rates (TPR and FPR) for the detection of a cavity, respectively, for
the detection of any caries lesion
Validation examination Level of detection
Cavity Any lesion
Sound Noncavitated Cavitated Total TP FP TP FP
Diagnostic strategy N = 811 ⁄ 724a N = 444 ⁄ 410a N = 76 ⁄ 74a N = 1331 ⁄ 1208a rate % rate % rate % rate %
Visual–tactile
Sound 672 150 14 836 34.2 1.5 81.6 17.1
Noncavitated 133 281 36 450
Cavitated 6 13 26 45
Visual–tactile + confidenceb
Sound 672 150 14 836 21.1 0.6 81.6 17.1
Noncavitated 138 288 46 472
Cavitated 1 6 16 23
Radiography Ic
Sound 532 217 13 762 63.5 6.9 80.3 26.5
Lesion in enamel 157 142 14 313
Lesion in dentin 35 51 47 133
Radiography IId
Sound 532 217 13 762 14.9 0.6 80.3 26.5
Lesion in 188 189 50 427
enamel ⁄ or outer dentin
Lesion in inner dentin 4 4 11 19
Visual–tactile + radiography Ic
Sound 531 93 2 626 76.3 8.2 97.4 34.5
Noncavitated 240 288 16 544
Cavitated 40 63 58 161
Visual–tactile + confidenceb + radiography Ic
Sound 672 150 12 834 34.2 1.8 84.2 17.1
Noncavitated 133 278 38 449
Cavitated 6 16 26 48
Visual–tactile + radiography IId
Sound 531 93 2 626 47.4 2.2 97.4 34.5
Noncavitated 270 334 38 642
Cavitated 10 17 36 63
Visual–tactile + confidenceb + radiography IId
Sound 672 150 12 834 15.8 0.8 84.2 17.1
Noncavitated 137 286 52 475
Cavitated 2 8 12 22
a
A number of surfaces could not be read in radiographs.
b
Clinical recordings of cavitated lesions changed to noncavitated lesions, when uncertainty was expressed.
c
Radiographic lesions extending into dentin interpreted as evidence for cavitation.
d
Radiographic lesions extending into the inner two-thirds of dentin interpreted as evidence for cavitation.

261
Baelum et al.

Table 5. Correctness of treatment decisions following different diagnostic strategies assuming that a cavitated lesion
needs a restoration and a noncavitated caries lesion needs nonoperative treatment
Under treatment Overtreatment
Correct
Diagnostic strategy No treatment Nonoperative decisions Nonoperative Operative Total
Visual–tactile 164 (12.3) 36 (2.7) 979 (73.6) 133 (10.0) 19 (1.4) 1331
Visual–tactile + confidenceb 164 (12.3) 46 (3.5) 976 (73.3) 138 (10.4) 7 (0.5) 1331
Radiography Ic 230 (19.0) 14 (1.2) 721 (59.7) 157 (13.0) 86 (7.1) 1208a
Radiography IId 230 (19.0) 50 (4.1) 732 (60.6) 188 (15.6) 8 (0.7) 1208a
Visual–tactile + radiography 95 (7.1) 16 (1.2) 877 (65.9) 240 (18.0) 103 (7.7) 1331
Ic
Visual–tactile + confidenceb 162 (12.2) 38 (2.9) 976 (73.3) 133 (10.0) 22 (1.7) 1331
+ radiography Ic
Visual–tactile + radiography IId 95 (7.1) 38 (2.9) 901 (67.7) 270 (20.3) 27 (2.0) 1331
Visual–tactile + confidenceb 162 (12.2) 52 (3.9) 970 (72.9) 137 (10.3) 10 (0.8) 1331
+ radiography IId
a
A number of surfaces could not be read in radiographs.
b
Clinical recordings of cavitated lesions changed to noncavitated lesions, when uncertainty was expressed.
c
Radiographic lesions extending into dentin were interpreted as evidence for cavitation.
d
Radiographic lesions extending into the inner two-thirds of dentin were interpreted as evidence for cavitation.

72.9%, respectively). The incorrect treatment deci-
sions were fairly balanced with respect to their
distribution among under- and overtreatment
except for the two diagnostic strategies involving
the combination of visual–tactile bitewing exami-
nation of all surfaces. When these strategies were
used, most of the incorrect treatment decisions
represented overtreatment (Table 5).
Table 6 summarizes the results in terms of the
number of correct treatment decisions under each
diagnostic strategy. Overall, the visual–tactile
method alone was better than any other diagnostic
strategy in terms of the total number of correct
clinical decisions (74%) and the number of correct
decisions to treat (62%). When the visual–tactile
method was used in such a way that ‘uncertain’
cavity diagnoses were considered noncavitated
and subsequently treated nonoperatively, 73% of
all decisions were correct, and 61% of the treatment
decisions were correct. The main distinction be-

Table 6. Summary of the correctness of the clinical management decisions made following different combinations of the
visual–tactile and the radiographic method for caries lesion detection. Underlying assumptions are that cavitated carious
lesions need operative treatment, while that noncavitated carious lesions need nonoperative treatment
Clinical management decision based on diagnostic findings

Operative Nonoperative Any treatment No treatment All

N correct N correct N correct N correct N correct
Diagnostic strategy N (%) N (%) N (%) N (%) (%)
Visual–tactile 45 26 (58) 450 281 (62) 495 307 (62) 836 672 (80) 979 (74)
Visual–tactile + confidencea 23 16 (70) 472 288 (61) 495 304 (61) 836 672 (80) 976 (73)
Radiography Ib 133 47 (35) 313 142 (45) 446 189 (42) 762 532 (70) 721 (54)
Radiography IIc 19 11 (58) 427 189 (44) 446 200 (45) 762 532 (70) 732 (55)
Visual–tactile + radiography Ib 161 58 (36) 544 288 (53) 705 346 (49) 626 531 (85) 877 (66)
Visual–tactile + confidencea 48 26 (54) 449 278 (62) 497 304 (61) 834 672 (81) 976 (73)
+ radiography Ib
Visual–tactile + radiography IIc 63 36 (57) 642 334 (52) 705 370 (52) 626 531 (85) 901 (68)
Visual–tactile + confidencea 22 12 (55) 475 286 (60) 497 298 (60) 834 672 (81) 970 (73)
+ radiography IIc
a
Clinical recordings of cavitated lesions changed to noncavitated lesions, when uncertainty was expressed.
b
Radiographic lesions extending into dentin were interpreted as evidence for cavitation.
c
Radiographic lesions extending into the inner two-thirds of dentin were interpreted as evidence for cavitation.

262

tween the two strategies was that abstention from
operative treatment decisions for cavitated lesions
for which doubt was expressed increased the
proportion of correct operative treatment decisions
from 58% to 70% (Table 6). The combinations of the
visual–tactile method with radiography when clin-
ically uncertain came close to the performance of
the visual–tactile method alone, yielding 73%
correct decisions, and 61%, respectively, 60% cor-
rect treatment decisions. The combination of the
visual–tactile and radiographic methods for all
surfaces resulted in fewer correct decisions (66%
and 68%, respectively) and fewer correct decisions
to treat (49% and 52%, respectively).
Discussion
Countless studies have reported estimates of the
sensitivity (the true-positive rate) and the specific-
ity (the true negative rate) for the diagnosis of
caries lesions (20, 27). These estimates are typically
obtained by comparing the detection results with a
histological reference, the caries lesion ‘gold stan-
dard’ (27). However, this approach is based on a
traditional notion of caries-related treatment deci-
sions, which holds that a caries diagnosis precedes
and is separated from the treatment decision.
However, this notion does not hold, and dentists
base their caries-related treatment decisions on
caries scripts (28). Caries scripts consist of salient
features describing the distinguishing characteris-
tics of a particular expression of caries (28), and the
caries lesion detection process is a process of script
matching in which the lesion observed in a
patient’s tooth is matched with a pattern for which
the dentist routinely recommends a specific treat-
ment. Thereby, the decisions made are ‘this kind of
lesion needs this kind of treatment’ decisions, and
the hypothetico-deductive method and differential
diagnosis play no role (6, 28).
The results of the present study are based on the
assumption that the examiners would match their
observation of a cavity with the need for a
restoration and their observation of a noncavitated
caries lesion with the need for nonoperative caries
therapy (29). We have thus assumed that their
treatment prescription strategy is the same, and the
variation, therefore, stems from the examiners’
observations during the caries examinations and
their interpretations of what they observe. Our use
of the validation data to estimate the ‘correctness’
of the caries lesion observations and the ensuing
Implications of caries diagnostic strategies
treatment consequences is not an attempt to state
that the results of the validation examination
represent a diagnostic ‘truth.’ We are indeed aware
of the between-examiner disagreements in the
results of the validation examination following
tooth separation, which implies limited utility of
this method as a validation method (19). Instead,
we use the validation method results as the best
representation of the observations upon which the
examiner would have liked to act when matching
caries lesion presentations with caries scripts. In
their daily clinical practice, dentists have no key to
the caries diagnostic ‘truth’ if such exists (6), and
they practice on the basis of their own observations
and their interpretations thereof.
Dentists place more focus on the detection of
caries lesions than on the exoneration of sound
surfaces. This strategy is understandable because
the error of overlooking a lesion, particularly a
deep lesion, is perceived as a very serious error. It
is therefore not surprising that dental practitioners
have a propensity to use additional caries detection
methods to reduce the risk of overlooking caries
lesions. The most common combination consists of
a visual–tactile examination supplemented by bite-
wing radiography, and most guidelines on the use
of radiographs endorse ‘routine’ or ‘screening’
examinations (7) using this combination, either
for specific age cohorts (10) or for the population at
large at intervals not exceeding 24 months (7, 11).
However, the results of the present study indicate
that if the finding of a radiographic demineraliza-
tion extending into dentin is considered evidence
of cavitation and hence of operative treatment, the
use of radiography as an ancillary caries diagnostic
method does not lead to better treatment of the
patients than a diligently exercised visual–tactile
examination would do. The ancillary use of radi-
ography resulted in a 40% increase in the number
of treatment decisions made (from 497 to 705), but
the proportion of correct treatment decisions
decreased from 62% for the visual–tactile method
alone to 49% and 52%, respectively, for the com-
bination of the visual–tactile and the radiographic
methods.
The diagnostic strategy combining a visual–
tactile examination and bitewing radiography only
in case of clinical doubt did not appear superior to
the use of the visual–tactile method alone. This is
remarkable because one might have expected such
discretionary use of bitewings to result in im-
proved clinical decisions. If anything, discretionary
use of bitewing radiography as an ancillary diag-
263
Baelum et al.
nostic method results in slightly inferior clinical
decision making, compared with the visual–tactile
method alone. However, relatively few clinical
diagnoses were perceived as uncertain, as doubts
were expressed in only 8% of the clinical diagnoses,
and it is clear that even if bitewings in such cases
would lead to more correct clinical decisions, the
impact on the overall proportion of correct clinical
decisions would be limited. Importantly, the
results clearly indicate that bitewing radiography
should not be considered a means of correcting
errors made with the visual–tactile method, as it
results in the addition of errors to an already less-
than-perfect visual–tactile caries diagnostic meth-
od.
Clearly, the conclusion regarding the additional
value of bitewing radiography hinges on the
diagnostic criteria used with the visual–tactile
method. The number of caries lesions found by
means of a visual–tactile examination depends on
the diagnostic criteria and methods used, and a
review (30) has shown that these criteria may vary
considerably in terms of the stages of lesion
formation considered, use of probes for tactile
assessment and intensity of drying for disclosure of
the early stages of lesion formation. The studies
suggesting an additional value of radiographs for
the detection of caries lesions have typically
employed rather crude visual–tactile criteria, con-
sidering only cavitated or rather late stages of the
caries process (31–37). When more refined clinical
criteria are used, such as the Nyvad criteria (17),
which aim to detect the early stages of caries lesion
formation by means of a diligently exercised
visual–tactile examination, the additional benefit
of bitewing radiography is not clear (38, 39).
Regular dental check-ups were generally imple-
mented at a time when the caries prevalence and
experience were substantially higher than seen
today. However, the caries decline has now been
evident for almost half a century (40, 41) and
continues. The percentage of Danish 15 year olds
who have experienced one or more cavitated caries
lesions has decreased from 88% in 1988 to 50% in
2010, and the mean DcavMFS has dropped from 6.7
in 1988 to 2.1 in 2010 (42). Obviously, the proba-
bility that new caries lesions will develop within
the next few years in 15 year olds, who so far have
not developed caries lesions, is rather low, and this
may call for a reassessment of both the recall
intervals and the contents of the caries examina-
tions. The low caries occurrence in many contem-
porary populations means that the a priori
264
probability of caries in a surface is quite low, and
from a clinical management point of view, the
desire would be for caries detection methods that
correctly rule out the presence of caries, rather than
for methods that focus on identification of lesions.
It is thus of utmost importance to avoid false-
positive diagnoses, and in particular those false-
positive diagnoses that may lead to unnecessary
restoration of intact teeth. Unfortunately, the sen-
sitivity and specificity values reported for the
methods available for caries lesion detection leave
much to be desired (20), and the less-than-perfect
specificity of the methods is particularly problem-
atic in the context of the regular check-up examin-
ations carried out among asymptomatic and
possibly caries-free patients.
The participants in this study were dental or
dental hygienist students from a Danish population
with a rather low caries experience, and one may,
therefore, expect the results to apply in low-caries
populations. Caries diagnosis among the middle-
aged and elderly may be compounded by their
often much greater restorative experience, and the
results of the present study may not necessarily be
extrapolated to those populations. Other caveats
include the somewhat artificial diagnostic situa-
tion, which was created for the purpose of ensuring
independence of the recordings made using the
visual–tactile and radiographic methods. Securing
independence has the advantage that the contribu-
tion of each method can be assessed, but this
deviates from the typical clinical circumstances
where the clinician would have both sources of
diagnostic information available simultaneously
when assessing the salient features of a lesion.
However, the use of a more typical clinical
approach would preclude us from disentangling
the contribution of each diagnostic information
source as these are not processed independently
during the clinical decision-making process (28).
The results presented here are based on the
pooled observations of four examiners represent-
ing considerable experience in both visual–tactile
and radiographic methods for caries diagnosis.
While some variation was observed between exam-
iners in terms of their observations using each of
the examination methods as well as using the
validation method (19), the data material is too
small to allow firm conclusions whether different
caries diagnostic combinations might work better
in the hands of some than others. Each examiner
assessed 319–338 interproximal surfaces, of which,
only 16–25 were found to be cavitated, and this is

insufficient for valid inference regarding the per-
formance of different examiners using different
methods.
So far, most studies of clinical decision making
following the use of different diagnostic methods
and strategies have been based on extracted teeth
(21, 25). In this situation, the proportion of lesions
for detection is typically much higher than would
be the norm in any real-life setting (20), and
conclusions may, therefore, be distorted by the
artificial case-mix. Such distortion is amply illus-
trated by the results of two apparently similar
studies of the effect of combining a visual and a
radiographic method for the detection of dentin
caries in occlusal surfaces (23, 24). In one study
(24), visual detection of occlusal dentin caries had
sensitivity and specificity values of 0.72 and 0.41,
while the other study (23) reported sensitivity and
specificity values of 0.12 and 0.93 for the visual
detection of occlusal dentin caries. However, when
cavitated teeth were allowed in the latter case-mix
(22), the sensitivity value for the visual diagnosis of
occlusal dentin caries increased from 0.12 to 0.62. It
is, therefore, a great advantage of the present study
that it is based on a real-life study group. The
results of the present study are less prone to bias
from case-mix issues, and the study design is more
relevant for the daily clinical practice situation than
is an in vitro study of extracted teeth.
Imperfect caries diagnostic methods are used on
a regular basis for the detection of dental caries
lesions in a substantial number of asymptomatic
individuals who visit their dentist for routine
check-ups, and the implications of the inevitable
diagnostic errors, therefore, become of great con-
cern. The present results show that the observation
of a radiographic lesion into dentin should not in
and of itself lead to the decision of operative
treatment. This conclusion is consistent with obser-
vations that lesion depth (43) and density of the
radiographic dentinal demineralization (44) are
inaccurate in distinguishing cavitated and noncav-
itated lesions in interproximal surfaces. If radio-
graphic dentinal lesions are interpreted as evidence
for cavitation, a substantial number of errors may
occur when bitewing radiography is added to the
visual–tactile examination, and this problem will
be particularly severe in low-caries prevalence
populations. In this perspective, it may, therefore,
be unfortunate that detecting more caries lesions
for treatment is deeply ingrained in the practitio-
ners mind as doing good and that contemporary
international guidelines (7, 11) continue to recom-
Implications of caries diagnostic strategies
mend frequent screening for caries by bitewing
radiography.
References
1. Baelum V. What is an appropriate caries diagnosis?
Acta Odontol Scand 2010;68:65–79.
2. Holst D, Grytten J, Skau I. Demand for dental
services and expenditures for dental treatment in
the Norwegian adult population. Nor Tannlaegefo-
ren Tid 2005;115:212–6.
3. Hjern A, Grindefjord M, Sundberg H, Rosén M.
Social inequality in oral health and use of dental care
in Sweden. Community Dent Oral Epidemiol
2001;29:167–74.
4. Suominen-Taipale AL, Widstrom E, Alanen P, Uutela
A. Trends in self-reported use of dental services
among Finnish adults during two decades. Commu-
nity Dent Health 2000;17:31–7.
5. Christensen LB, Petersen PE, Steding-Jessen M.
Consumption of dental services among adults
in Denmark 1994–2003. Eur J Oral Sci 2007;
115:174–9.
6. Baelum V, Heidmann J, Nyvad B. Dental caries
paradigms in diagnosis and diagnostic research. Eur
J Oral Sci 2006;114:263–77.
7. European Commission. Radiation protection. Euro-
pean guidelines on radiation protection in dental
radiology. Luxembourg: Office for Official Publica-
tions of the European Communities; 2004; 1–115.
8. Hintze H. Screening with conventional and digital
bite-wing radiography compared to clinical exami-
nation alone for caries detection in low-risk children.
Caries Res 1993;27:499–504.
9. Hintze H, Wenzel A. Clinically undetected dental
caries assessed by bitewing screening in children
with little caries experience. Dentomaxillofac Radiol
1994;23:19–23.
10. Espelid I, Mejare I, Weerheim K. EAPD guidelines
for use of radiographs in children. Eur J Paediatr
Dent 2003;4:40–8.
11. American Dental Association. The selection of
patients for dental radiographic examinations. Rock-
ville, MD: U.S. Department of Health and Human
Services; 2004; 1–23.
12. Gröndahl H-G, Lith A, Jönsson G, Persson Y.
Approximal caries and frequency of bitewing exam-
inations in Swedish children and adolescents. Com-
munity Dent Oral Epidemiol 1992;20:20–4.
13. Lith A. Frequency of radiographic caries examina-
tions and development of dental caries. Swed Dent J
2004;147(Suppl):1–72.
14. Mejare I, Axelsson S, Dahlén G, Espelid I, Norlund A,
Svensson Å et al. Karies – diagnostik, riskbedömning
och icke-invasiv behandling. En systematisk litter-
aturöversikt. Stockholm: The Swedish Council on
Technology Assessment in Health Care; 2007; 1–403.
15. Ekstrand K. Faglig viden om caries: Kan den
kommunale tandpleje gøre det endnu bedre?
[Knowledge about caries: is it possible for The
Danish Public Dental Health Service for Children to
achieve even better results?]. Tandlaegebladet
2006;110:788–99.
265
Baelum et al.
16. Sundhedsstyrelsen. Tandlægeydelser under Den Off-
entlige Sygesikring 2000–2002. Nye tal fra Sundh-
edsstyrelsen 2003;7:1–14.
17. Nyvad B, Machiulskiene V, Baelum V. Reliability of a
new caries diagnostic system differentiating between
active and inactive caries lesions. Caries Res
1999;33:252–60.
18. Espelid I, Tveit AB. A comparison of radiographic
occlusal and approximal caries diagnoses made by
240 dentists. Acta Odontol Scand 2001;59:285–9.
19. Hintze H, Wenzel A, Danielsen B, Nyvad B. Reli-
ability of visual examination, fibre-optic transillumi-
nation, and bite-wing radiography, and
reproducibility of direct visual examination follow-
ing tooth separation for the identification of cavitated
carious lesions in contacting approximal surfaces.
Caries Res 1998;32:204–9.
20. Bader JD, Shugars DA, Bonito AJ. Systematic reviews
of selected caries diagnostic and management meth-
ods. J Dent Educ 2001;65:960–8.
21. Valera FB, Pessan JP, Valera RC, Mondelli J, Perci-
noto C. Comparison of visual inspection, radio-
graphic examination, laser fluorescence and their
combinations on treatment decisions for occlusal
surfaces. Am J Dent 2008;21:25–9.
22. Lussi A. Impact of including or excluding cavitated
lesions when evaluating methods for the diagnosis of
occlusal caries. Caries Res 1996;30:389–93.
23. Lussi A. Comparison of different methods for the
diagnosis of fissure caries without cavitation. Caries
Res 1993;27:409–16.
24. Nytun RB, Raadal M, Espelid I. Diagnosis of dentin
involvement in occlusal caries based on visual and
radiographic examination of the teeth. Scand J Dent
Res 1992;100:144–8.
25. Pereira AC, Eggertsson H, Martinez-Mier EA, Mialhe
FL, Eckert GJ, Zero DT. Validity of caries detection
on occlusal surfaces and treatment decisions based
on results from multiple caries-detection methods.
Eur J Oral Sci 2009;117:51–7.
26. Nyvad B, Fejerskov O, Baelum V. Visual-tactile caries
diagnosis. In: Fejerskov O, Kidd E, editors. Dental
caries. The disease and its clinical management, 2nd
edn. Oxford: Blackwell Munksgaard, 2008; 49–68.
27. Bader JD, Shugars DA, Bonito AJ. A systematic
review of the performance of methods for identifying
carious lesions. Public Health Dent 2002;62:201–13.
28. Bader JD, Shugars DA. What do we know about how
dentists make caries-related treatment decisions?
Community Dent Oral Epidemiol 1997;25:97–103.
29. Kidd EAM, Fejerskov O. What constitutes dental
caries? Histopathology of carious enamel and dentin
related to the action of cariogenic biofilms. J Dent Res
2004;83:C35–8.
266
30. Ismail AI. Visual and visuo-tactile detection of dental
caries. J Dent Res 2004;83:C56–66.
31. Hopcraft MS, Morgan MV. Comparison of radio-
graphic and clinical diagnosis of approximal and
occlusal dental caries in a young adult population.
Community Dent Oral Epidemiol 2005;33:212–8.
32. Lillehagen M, Grindefjord M, Mejàre I. Detection of
approximal caries by clinical and radiographic
examination in 9-year-old Swedish children. Caries
Res 2007;41:177–85.
33. Kidd EAM, Pitts NB. A reappraisal of the value of
the bitewing radiograph in the diagnosis of posterior
approximal caries. Br Dent J 1990;169:195–200.
34. de Vries HCB, Ruiken HMHM, König KG, Van’t Hof
MA. Radiographic versus clinical diagnosis of ap-
proximal carious lesions. Caries Res 1990;24:364–70.
35. Bloemendal E, de Wet HCW, Bouter LM. The value
of bitewing radiographs in epidemiological caries
research: a systematic review of the literature. J Dent
2004;32:255–64.
36. Llena-Puy C, Forner L. A clinical and radiographic
comparison of caries diagnosed in approximal
surfaces of posterior teeth in a low-risk population
of 14-year-old children. Oral Health Prev Dent
2005;3:47–52.
37. Poorterman JHG, Aartman IH, Kalsbeek H. Under-
estimation of the prevalence of approximal caries
and inadequate restorations in a clinical epidemio-
logical study. Community Dent Oral Epidemiol
1999;27:331–7.
38. Machiulskiene V, Nyvad B, Baelum V. A comparison
of clinical and radiographic caries diagnoses in
posterior teeth of 12-year-old Lithuanian children.
Caries Res 1999;33:340–8.
39. Machiulskiene V, Nyvad B, Baelum V. Comparison
of diagnostic yields of clinical and radiographic
caries examinations in children of different age. Eur
J Paediatr Dent 2004;5:157–62.
40. Marthaler TM. Changes in dental caries 1953–2003.
Caries Res 2004;38:173–81.
41. Glass RL. The first international conference on the
declining prevalence of dental caries. J Dent Res
1982;61:1304–60.
42. Sundhedsstyrelsen. Sundhedsstyrelsens Centrale Od-
ontologiske Register (SCOR). Available from: http://
www.sst.dk/~/media/6FBEA5D48FDF428585CA051
FC1B29B73.ashx
43. Lunder N, von der Fehr FR. Approximal cavitation
related to bite-wing image and caries activity in
adolescents. Caries Res 1996;30:143–7.
44. Mariath AAS, Casagrande L, de Araujo FB. Grey
levels and radiolucent lesion depth as cavity predic-
tors for approximal dentin caries lesions in primary
teeth. Caries Res 2007;36:377–81.