diagnostics

Article
In Vivo Performance of Visual Criteria, Laser-Induced
Fluorescence, and Light-Induced Fluorescence for
Early Caries Detection
Antonis Perdiou 1 , Aurora Doris Fratila 2, * , Ruxandra Sava-Rosianu 1,3 , Vlad Tiberiu Alexa 1,3 ,
Dacian Lalescu 4 , Daniela Jumanca 1,3 and Atena Galuscan 1,3

1 Faculty of Dental Medicine, “Victor Babeş” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2,
300041 Timisoara, Romania; antonis.perdiou@umft.ro (A.P.); sava-rosianu.ruxandra@umft.ro (R.S.-R.);
vlad.alexa@umft.ro (V.T.A.); jumanca.daniela@umft.ro (D.J.); galuscan.atena@umft.ro (A.G.)
2 Faculty of Dental Medicine, Ludwig-Maximilian-University Munich, Goethestraße 70,
80336 München, Germany
3 Translational and Experimental Clinical Research Center in Oral Health (TEXC-OH),
14A Tudor Vladimirescu Ave., 300173 Timisoara, Romania
4 Faculty of Food Engineering, Banat’s University of Agricultural Sciences and Veterinary Medicine,
King Michael I of Romania from Timis, oara, Calea Aradului No. 119, 300645 Timis, oara, Romania;
lalescu@usab-tm.ro
* Correspondence: a.fratila@campus.lmu.de; Tel.: +49-1718677932

Abstract: This study aims to compare the diagnostic reliability of ICDAS-II visual criteria, light-
induced fluorescence (using the VistaCam iX, Dürr Dental, Bietigheim-Bissingen, Germany), and
laser-induced fluorescence (using the DIAGNOdent Pen, KaVo, Biberach, Germany) on occlusal
caries. Permanent and temporary molars were selected according to the inclusion criteria. Out of
160 teeth that met the inclusion criteria, 139 were chosen and examined by two previously trained and
calibrated examiners. The kappa value was 0.95 for both VistaCam iX and DIAGNOdent Pen. Results
from visual examination and the readings of the two fluorescence devices were computed, lesions
Citation: Perdiou, A.; Fratila, A.D.; being divided into non-cavitated, enamel lesions, and lesions extended to dentin. All statistical
Sava-Rosianu, R.; Alexa, V.T.; Lalescu, analyses were performed using R (version 4.2.2). Spearman’s rank correlation was computed to
D.; Jumanca, D.; Galuscan, A. In Vivo assess the relationship between the scores of diagnostics reliabilities of the three methods mentioned
Performance of Visual Criteria, above. There was a positive, statistically significant Spearman’s rank correlation coefficient, ρ = 0.25,
Laser-Induced Fluorescence, and between VistaCam iX and ICDAS II, and a positive, not statistically significant Spearman’s rank
Light-Induced Fluorescence for Early
correlation coefficient, ρ = 0.11, between DiagnoDent Pen and ICDAS II. Considering the temporary
Caries Detection. Diagnostics 2023, 13,
teeth, there was a positive, statistically significant Spearman’s rank correlation coefficient, ρ = 0.52,
3170. https://doi.org/10.3390/
between VistaCam iX and DiagnoDent Pen; a positive, statistically significant Spearman’s rank
diagnostics13203170
correlation coefficient, ρ = 0.35, between VistaCam iX and ICDAS II; and the lowest, not statistically
Academic Editor: Sreekanth significant Spearman’s rank correlation coefficient, ρ = 0.16, between DiagnoDent Pen and ICDAS II.
Kumar Mallineni
Conclusions: In conclusion, ICDAS II and light-induced fluorescence are better diagnostic methods
Received: 10 September 2023 than the laser-induced fluorescence devices for detecting occlusal caries. Clinical Significance: This
Revised: 8 October 2023 study may support clinicians in selecting the most efficient tool for diagnosing carious lesion in the
Accepted: 9 October 2023 earliest stages possible. Furthermore, such technologies raise the availability for more preventive
Published: 11 October 2023 approaches, as opposed to invasive procedures.

Keywords: intraoral scanners; oral health; fluorescence; dental caries; digital dentistry; diagnosis

Copyright: © 2023 by the authors.

Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
1. Introduction
conditions of the Creative Commons Although dental caries is a preventable non-communicable disease, reports show
Attribution (CC BY) license (https:// that oral health has not improved in the past 25 years [1]. In 2021, the most recent WHO
creativecommons.org/licenses/by/ resolution underlined the need to improve oral health worldwide [2]. For good oral health,
4.0/). it is necessary, among others, to detect and treat dental caries as early as possible [3]. Oral

Diagnostics 2023, 13, 3170. https://doi.org/10.3390/diagnostics13203170 https://www.mdpi.com/journal/diagnostics

Diagnostics 2023, 13, 3170 2 of 11

health is reckoned to contribute to the general well-being of individuals, thus maintaining

a healthy oral cavity and teeth free of pathological problems such as caries or periodontal
disease is an important objective that needs constant improvement in permanent and
deciduous dentition [4]. Therefore, the role of temporary dentition should not be underesti-
mated. The role of primary dentition in humans is well known: temporary teeth contribute
to the development of the upper and lower jaw; they serve as space maintainers before
the eruption of permanent teeth until they reach their natural exfoliation period. Among
others, mastication is one of the essential functions of temporary teeth [5]. In children,
tooth decay is one of the most common diseases worldwide [6]. Left untreated, it often
results in deciduous teeth’ extraction, compromising the individual’s well-being. Therefore,
early diagnosis and evaluation of white spot lesions and signs of demineralization are
essential for the early treatment and prevention of dental caries in both temporary and
permanent dentition.
In recent years, several methods have been sought to improve the detection of carious
lesions. Until now, most dental healthcare providers focused primarily on clinically visible
lesions while diagnosing. The visual and tactile methods, which include examining the
tooth surface by direct vision or with the help of a probe, are the most used diagnostic
methods for dental caries at the moment [7]. One of the most challenging aspects when
diagnosing dental caries is quantifying clinical observations into an objective numerical
interpretation. One attempt to solve this problem was the development of the DMFT index,
which quantifies the oral health status of an individual by the number of decayed (D),
missing (M), and filled (F) teeth. This index was unsatisfactory and, in many cases, did
not provide information about the severity of the disease or the need for extensive dental
care [7]. Moreover, without radiographs, the DMFT index undervalued the carious lesions
44% of the time [8]. In order to help dentists properly diagnose dental caries, a universal
scoring system called ICDAS II (The International Caries Detection and Assessment System)
was established [9]. The system coding relies strictly on visual inspection of the lesion [10,
11]. ICDAS provides up to 43% more information than the DMFT/dmft index, according to
Coelho (2020) [12]. ICDAS II classifies lesions as active or inactive [10] and helps the dental
professional decide on prognosis and treatment planning [11]. Observing the activity of the
carious lesion can provide a better understanding of whether a preventive or therapeutic
method can be used. An in vivo study conducted by Ferreira et al. (2012) in Puerto Rico
demonstrated that an intervention should be made earlier (sealing the pits and fissures)
for carious lesions that score ICDAS 3 and 4, whereas lesions with scores ICDAS 1 and 2
should be followed in their progress [13]. Alongside visual examination, dentists can use
other methods of evaluating dental decay. Laser fluorescence-based devices measure the
emitted fluorescent infrared light and show the result in whole numbers. It is based on
the principle that chromospheres in the dental enamel and dentin cause auto-fluorescence,
which is reduced by demineralization. Chromophores, like porphyrins, in carious lesions
and bacteria also cause fluorescence, which can be quantified and measured by subtracting
the fluorescence of a sound tooth surface from that of a carious tooth surface [14,15].
The presence of blood or other fluids in the oral cavity influences fluorescence readings.
Therefore, the teeth surfaces must be thoroughly dried beforehand. To enhance patient
compliance, an intraoral camera was designed to save and display clinical pictures of
patients’ teeth. The long-term “monitoring” of incipient lesions can also be improved since
the images can be accessed at any time [16]. To the authors’ knowledge, there are several
in vitro studies in the literature, but very few in vivo studies comparing visual examination,
laser-induced fluorescence, and light-induced fluorescence in detecting occlusal caries in
posterior permanent and temporary teeth. Given the modern approach in cariology, where
initial caries is considered reversible by different infiltration techniques, it is very important
to be able to detect those lesions as early as possible. The study seeks to evaluate the
extent to which laser fluorescence and light-induced fluorescence devices can enhance the
outcomes derived from visual examinations and the identification of early lesions. It aims
Diagnostics 2023, 13, 3170 3 of 11

to assess the diagnostic reliability of both laser-induced fluorescence and light-induced

fluorescence in primary and permanent teeth with occlusal caries.
Diagnostics 2023, 13, x FOR PEER REVIEW 3 of 11

2. Materials and Methods

2.1. Ethicaland the identification of early lesions. It aims to assess the diagnostic reliability of both
Approval
laser-induced fluorescence and light-induced fluorescence in primary and permanent
The proposal of thiscaries.
teeth with occlusal study was approved by the ethics committee of the Victor Babes
University of Medicine and Pharmacy, Timisoara (Nr.08/26.02.2021), and informed consent
2. Materials and Methods
was obtained from all patients before the initiation of the study.
2.1. Ethical Approval
The proposal of this study was approved by the ethics committee of the Victor Babes
2.2. Study Design
University of Medicine and Pharmacy, Timisoara (Nr.08/26.02.2021), and informed con-
This sent
study was was conducted
obtained on patients
from all patients aged 7oftothe17,
before the initiation referred to the department of
study.
Dental Prevention, Community Dentistry, and Oral Health (University of Medicine and
2.2. Study Design
Pharmacy, Victor Babes, Timisoara, Romania). Two calibrated dentists performed the
This study was conducted on patients aged 7 to 17, referred to the department of
clinical examinations.
Dental Prevention,The inter-examiner
Community Dentistry, andreliability
Oral Healthwas testedofusing
(University Medicinetheandkappa value,
a value used to compare
Pharmacy, two
Victor Babes, examiners
Timisoara, Romania).withTwodifferent scoreperformed
calibrated dentists ranges. the Theclin-kappa value
ical examinations.
for this study was 0.95,Theconsidered
inter-examineralmost
reliabilityperfect
was testedagreement
using the kappa value, a value
according to the kappa
used to compare two examiners with different score ranges. The kappa value for this
scores developed by Landis and Koch (1977) [17]. Inclusion criteria
study was 0.95, considered almost perfect agreement according to the kappa scores devel- addressed patients
with signsoped
of pit and fissure caries in at least one permanent or temporary
by Landis and Koch (1977) [17]. Inclusion criteria addressed patients with signs of tooth in the
pit and fissure caries in at least one permanent or temporary tooth
posterior region. A clinical examination of each tooth was carried out under adequate in the posterior region.
A clinical examination of each tooth was carried out under adequate lighting after clean-
lighting after cleaning the tooth surfaces. The samples used in the pilot study were not
ing the tooth surfaces. The samples used in the pilot study were not included in the main
included in theOne-hundred-and-thirty-nine
study. main study. One-hundred-and-thirty-nine
(139) teeth were included in (139) teethninety-seven
the study: were included in the
permanent posterior
study: ninety-seven teeth and
permanent forty-two primary
posterior teeth and posterior teeth. The
forty-two teeth wereposterior
primary intact or teeth. The
teeth werehad incipient and inconspicuous caries with or without color changes. Teeth showing oc-
intact or had incipient and inconspicuous caries with or without
clusal restorations, enamel hypoplasia, hypomineralization or structural defects, and pulp
color changes.
Teeth showing
necrosis were excluded (Figure 1). In comparison, the two calibrated dentists examinedor structural
occlusal restorations, enamel hypoplasia, hypomineralization
defects, and pulpwith
the teeth necrosis were excluded
a laser fluorescent (Figure Kavo,
pen (DIAGNOdent, 1). InBiberach,
comparison,
Germany)theand two
an calibrated
intraoral fluorescent camera using the fluorescent head of a light-induced fluorescence
dentists examined the teeth with a laser fluorescent pen (DIAGNOdent, Kavo, Biberach,
device (Dürr Dental, Germany) (Figure 2).
Germany) and an intraoral fluorescent camera using the fluorescent head of a light-induced
fluorescence device (Dürr Dental, Germany) (Figure 2).

Diagnostics 2023, 13, x FOR PEER REVIEW 4 of 11

Figure 1. Flow diagram of the selection process.
Figure 1. Flow diagram of the selection process.

(a) (b)
Figure 2. Picture of a permanent molar taken by light-induced fluorescence device (a) with magni-
Figure 2. Picture of a lens,
fying permanent molar
(b) using the taken
fluorescent modeby light-induced
of VistaCam fluorescence
iX. (Dürr Dental, Germany). device (a) with magnify-
ing lens, (b) using the fluorescent mode of VistaCam iX. (Dürr Dental, Germany).
2.3. Visual Examination Using the International Caries Detectoin and Assesment System
(ICDAS II)
Visual examination was performed using the ICDAS II caries codes. Occlusal surfaces
of the teeth were cleaned from plaque and debris using water spray and cotton pellets if
necessary. Dental explorers were not used for examination. Occlusal caries was scored
according to the ICDAS-II System:
Code 0: Sound tooth surface: No evidence of caries after 5 s of air drying.
Diagnostics 2023, 13, 3170 4 of 11

2.3. Visual Examination Using the International Caries Detectoin and Assesment System (ICDAS II)
Visual examination was performed using the ICDAS II caries codes. Occlusal surfaces
of the teeth were cleaned from plaque and debris using water spray and cotton pellets if
necessary. Dental explorers were not used for examination. Occlusal caries was scored
according to the ICDAS-II System:
Code 0: Sound tooth surface: No evidence of caries after 5 s of air drying.
Code 1: First visual change in enamel: Opacity or discoloration (white or brown) is
visible at the entrance to the pit, and a fissure is seen after prolonged air drying.
Code 2: Distinct visual change in enamel visible when wet; lesion must be visible
when the tooth is dry.
Code 3: Localized enamel breakdown (without clinical visual signs of dentinal in-
volvement) seen when wet and after prolonged drying.
Code 4: Underlying dark shadow from dentine.
Code 5: Distinct cavity with visible dentine.
Code 6: Extensive (more than half of the tooth surface) distinct cavity with visible
dentine.

2.4. Examination Using Laser-Induced Fluorescence

A laser fluorescence device (DIAGNOdent Pen, KaVo, Biberach, German) was used
for the measurements. A sound-appropriate dental surface of a central or lateral incisor
was selected for calibration. This allowed determining a value for each occlusal surface.
The highest laser fluorescence value was recorded after three readings for each occlusal
surface [18,19].

2.5. Examination Using Light-Induced Fluorescence

The examination using light-induced fluorescence (VistaCam iX, Dürr Dental, Bieti-
gheim-Bissingen, Germany) consisted of a camera handpiece with two interchangeable
lenses so that it could be used not only with the fluorescence attachment for detecting
caries but also as a conventional intra-oral camera, and it was connected to a laptop by a
USB cable (Figure 3). The patient was positioned in dorsal decubitus on the chair. Cotton
rolls were placed in the mouth and thoroughly air dried from the unit. A light-induced
fluorescence device was mounted on a calculator, and all the lights were turned off. We
first took pictures of the teeth using the fluorescent head and then the white light head.
The DBSWIN 5.17 evaluation software was also used to store and visualize data. Thus,
communication with the patient and therapy planning was more effective. The light-
induced fluorescence device (Durr Dental, Bietigheim-Bissingen Germany) scoring was
0–1.2 = sound tissue; 1.3–1.5 = enamel caries; and >1.5 = dentine caries [11,20]. In order
to evaluate the diagnostic reliability of the systems mentioned above, the measurements
were coded with 0, 1, and 2 (see Table 1). The Wilcoxon signed-rank test was employed to
identify statistical differences in the diagnostic reliability scores among the three methods.
Spearman’s rank correlation was computed to assess the relationship between the scores of
diagnostics reliability of the three methods mentioned above. All statistical analyses were
performed using R (version 4.2.2).

Table 1. Coding for the statistical tests.

Code ICDAS-II DiagnoDent VistaCam IX

0 0 0–14 0–1.2
1 1, 2, and 3 15–20 1.3–1.5
2 4, 5, and 6 21–99 >1.5
 1.2 = sound tissue; 1.3–1.5 = enamel caries; and >1.5 = dentine caries [11,20]. In order to
evaluate the diagnostic reliability of the systems mentioned above, the measurements
were coded with 0, 1, and 2 (see Table 1). The Wilcoxon signed-rank test was employed to
identify statistical differences in the diagnostic reliability scores among the three methods.
Spearman’s rank correlation was computed to assess the relationship between the scores
Diagnostics 2023, 13, 3170 5 of 11
of diagnostics reliability of the three methods mentioned above. All statistical analyses
were performed using R (version 4.2.2).

(a) (b)
Figure 3. Picture of a permanent premolar taken by light-induced fluorescence device. (a) With mag-
Figure 3. Picture of a permanent premolar taken by light-induced fluorescence device. (a) With
nifying lens, (b) using the fluorescent mode of VistaCam iX. (Dürr Dental, Germany).
magnifying lens, (b) using the fluorescent mode of VistaCam iX. (Dürr Dental, Germany).

The
The objective
objective was
was to
to examine
examine the
the degree
degree ofof association
association between
between these
these diagnostic
diagnostic
methods in the context of evaluating occlusal caries in primary and permanent
methods in the context of evaluating occlusal caries in primary and permanent teeth.teeth.
The
statistical analysis aimed to quantify the relationships and provide insights into the
The statistical analysis aimed to quantify the relationships and provide insights into the inter-
play and consistency
interplay among
and consistency the tools
among in detecting
the tools and diagnosing
in detecting dental
and diagnosing lesions.
dental lesions.

Table 1. Coding for the statistical tests.

3. Results
Code TableICDAS-II
2 presents the outcomes obtained DiagnoDentthrough the application of three IX
VistaCam diagnostic
0 methods. In the 0 visual examination (ICDAS),0–1438.85% (N = 54) of examined 0–1.2 received a
teeth
score of 0, whereas 55% (N = 80) scored 1, and 3.6% (N = 5) scored 2. The laser-induced
1 1, 2, and 3 15–20 1.3–1.5
fluorescence device examination found 79.78% (N = 97) of the teeth scoring 0, 10.7% (N = 14)
2 4, 5, and 6 21–99 >1.5
scoring 1, and 20.14% (N = 28) scoring a 2. Conversely, the examination using the light-
induced fluorescence device revealed that 37.41% (N = 52) of the teeth scored 0, whereas
3. Results
55.40% (N = 77) scored 1, and 7.19% (N = 10) scored 2. For permanent teeth, the visual
Table 2 presents
examination (ICDAS)the outcomes
results showed obtained through
that 35.02% (N the
= 34) application
of the teeth of scored
three diagnostic
0, 63.92%
methods. In the visual
(N = 62) scored 1, andexamination
1.03% (N = (ICDAS),
1) scored38.85%
2. The(N = 54) of examined
laser-induced teeth received
fluorescence device
aexamination
score of 0, whereas 55% (N(N= =
found 68.04% 80) scored
66) of the1,teeth
and scoring
3.6% (N0,= 12.37%
5) scored (N2.=The laser-induced
12) scoring 1, and
fluorescence
29.59% (N = device examination
19) of the foundthe
teeth 2. Lastly, 79.78% (N = 97) of
light-induced the teeth scoring
fluorescence device0,examination
10.7% (N =
14) scoring
results 1, and
showed 20.14%
that 31.96% (N(N
= 28) scoring
= 31) of thea teeth
2. Conversely, the examination
scored 0, 59.79% (N = 59.79) using the 1,
scored light-
and
8.25% (N = 8) scored 2. In the case of temporary teeth, the visual
induced fluorescence device revealed that 37.41% (N = 52) of the teeth scored 0, whereas examination (ICDAS)
results showed
55.40% (N = 77) that 47.62%
scored (N 7.19%
1, and = 20) of(Nthe teeth
= 10) scored
scored 2. 0,For42.86% (N = 20)
permanent scored
teeth, 1, and
the visual
9.52% (N = 4)(ICDAS)
examination scored 2.results
The laser-induced
showed that 35.02%fluorescence
(N = 34)device
of theexamination
teeth scoredfound 73.81%
0, 63.92% (N
=(N62)
= scored
31) of the teeth
1, and scoring
1.03% (N =0,1)4.76%
scored(N2.=The
2) scoring 1, and 21.43%
laser-induced (N = device
fluorescence 9) of the teeth
exami-
2. Lastly,
nation the 68.04%
found light-induced
(N = 66)fluorescence device examination
of the teeth scoring 0, 12.37% (N results showed
= 12) scoring that 29.59%
1, and 50.00%
(N == 19)
21) of the teeth scored 0, 45.24% (N = 19) scored 1, and 4.76% (N =
teeth 2. Lastly, the light-induced fluorescence device examination results 2) scored 2.
showed Figure
that431.96%
shows (N the=comparison between
31) of the teeth scoredthe 0, three
59.79% methods, taking
(N = 59.79) scoredinto1,account
and 8.25% the
total sample size. The Wilcoxon signed-rank test showed no statistically significant differ-
ences between ICDAS II scores and light-induced fluorescence device scores (p = 0.4) and
marginally significant differences between ICDAS II scores and laser-induced fluorescence
device scores (p = 0.1).
 light-induced fluorescence device examination results showed that 50.00% (N = 21) of the
teeth scored 0, 45.24% (N = 19) scored 1, and 4.76% (N = 2) scored 2.

Table 2. Results of the diagnostic instruments for all teeth.

Diagnostics 2023, 13, 3170 6 of 11
0 1 2
All teeth
ICDAS II 38.85% (N = 54) 57.55%
Table 2. Results of the diagnostic instruments for all teeth.
(N = 80) 3.6% (N = 5)
VistaCam Ix 37.41% (N = 52) 55.40% (N = 77) 7.19% (N = 10)
DIAGNOdent pen 69.78%0(N = 97) 10.07%1 (N = 14) 20.14%2 (N = 28)
Permanent teeth All teeth
ICDAS
ICDAS IIII 35.02% (N =
38.85% (N = 54)34) 63.92%
57.55% (N (N= =80)
62) 1.03%
3.6% (N(N = 1)
= 5)
Vistacam
VistaCam Ix Ix 31.96%
37.41% (N (N==52)
31) 59.79%(N(N= =77)
55.40% 58) 8.25%
7.19% (N(N = 8)
= 10)
DIAGNOdent
DIAGNOdent pen pen 68.04%
69.78% (N (N==97)
66) 12.37%(N(N= =14)
10.07% 12) 19.59%(N(N
20.14% = 19)
= 28)
Temporary Permanent
teeth teeth
ICDAS II 47.62% (N = 20) 42.86% (N = 18) 9.52% (N = 4)
ICDAS II 35.02% (N = 34) 63.92% (N = 62) 1.03% (N = 1)
Vistacam Ix 50.00% (N = 21) 45.24% (N = 19) 4.76% (N = 2)
Vistacam Ix 31.96% (N = 31) 59.79% (N = 58) 8.25% (N = 8)
DIAGNOdent pen 73.81% (N = 31) 4.76% (N = 2) 21.43% (N = 9)
DIAGNOdent pen 68.04% (N = 66) 12.37% (N = 12) 19.59% (N = 19)
Temporary teeth
Figure 4 shows the comparison between the three methods, taking into account the
total sample
ICDASsize.
II The Wilcoxon
47.62%signed-rank
(N = 20) test42.86%
showed(N no statistically9.52%
= 18) significant
(N = 4) differ-
ences Vistacam
betweenIxICDAS II scores and light-induced
50.00% (N = 21) fluorescence
45.24% (N = 19) device scores (p == 2)
4.76% (N 0.4) and
marginally significant differences between ICDAS II scores and laser-induced fluores-
DIAGNOdent pen 73.81% (N = 31) 4.76% (N = 2) 21.43% (N = 9)
cence device scores (p = 0.1).

Comparison graph
Figure 4. Comparison graph of
of all
allteeth
teethusing
usingthe
thethree
threediagnostic
diagnosticmethods.
methods.

In the
In the context
contextof
ofpermanent
permanentdentition,
dentition,statistical
statisticalanalysis
analysis revealed
revealed a lack
a lack of signif-
of significant
icant differences between ICDAS II scores and scores obtained through light-induced
differences between ICDAS II scores and scores obtained through light-induced fluores-
fluorescence devices (p = 0.18). However, marginal significance was observed in the com-
cence devices (p = 0.18). However, marginal significance was observed in the comparison
parison between ICDAS II scores and those generated by laser-induced fluorescence devices
between ICDAS II scores and those generated by laser-induced fluorescence devices (p =
(p = 0.15), as depicted in Figure 5.
0.15), as depicted in Figure 5.
Considering only primary teeth, there were no statistically significant differences
between ICDAS-II scores and light-induced fluorescence device scores (p = 0.7) and between
ICDAS-II scores and laser-induced fluorescence device scores with (p = 0.4) (Figure 6).
For all the examined teeth, a Spearman’s rank correlation matrix was computed. A
statistically significant positive Spearman’s rank correlation was found between light-
induced fluorescence and laser-induced fluorescence (ρ = 0.34, p < 0.001, 95% C.I. 0.17
to 0.48). A smaller but statistically significant positive Spearman’s rank correlation was
observed between the light-induced fluorescence device and ICDAS II (ρ = 0.25, p = 0.007,
95% C.I. 0.08 to 0.40). In contrast, the positive Spearman’s rank correlation between the
laser-induced fluorescence device and ICDAS was 0.11 (p = 0.215), with a 95% C.I. from
−0.07 to 0.27, indicating a lack of statistical significance (Figure 7).
 Diagnostics2023,
Diagnostics 2023,13,
13,3170
x FOR PEER REVIEW 7 of 117 of 11

Figure 5. Comparison graph of permanent teeth using the three diagnostic methods.

Considering only primary teeth, there were no statistically significant differences be-
tween ICDAS-II scores and light-induced fluorescence device scores (p = 0.7) and between
ICDAS-II
Figure scores and
Comparison
Figure5.5.Comparison laser-induced
graph
graph ofof
permanent fluorescence
permanent teeth
teeth using
using device
thethe three
three scores with
diagnostic
diagnostic (p = 0.4) (Figure 6).
methods.
methods.

Considering only primary teeth, there were no statistically significant differences be-
tween ICDAS-II scores and light-induced fluorescence device scores (p = 0.7) and between
ICDAS-II scores and laser-induced fluorescence device scores with (p = 0.4) (Figure 6).

Diagnostics 2023, 13, x FOR PEER REVIEW 8 of 11

Figure 6. Comparison
Comparison graph
graphof
oftemporary
temporaryteeth
teethusing
usingthe
thethree
three diagnostic
diagnostic methods.
methods.

For all the examined teeth, a Spearman’s rank correlation matrix was computed. A
Figure 6. Comparison graph of temporary teeth using the three diagnostic methods.
statistically significant positive Spearman’s rank correlation was found between light-in-
duced fluorescence and laser-induced fluorescence (ρ = 0.34, p < 0.001, 95% C.I. 0.17 to
For all the examined teeth, a Spearman’s rank correlation matrix was computed. A
0.48). A smaller
statistically but statistically
significant significant
positive Spearman’s positive
rank Spearman’s
correlation was foundrank correlation
between light-in-was ob-
duced fluorescence and laser-induced fluorescence (ρ = 0.34, p < 0.001, 95% C.I. 0.17 pto= 0.007,
served between the light-induced fluorescence device and ICDAS II (ρ = 0.25,
95% C.I.
0.48). 0.08 tobut
A smaller 0.40). In contrast,
statistically the positive
significant positive Spearman’s rankcorrelation
Spearman’s rank correlation wasbetween
ob- the
laser-induced
served betweenfluorescence device
the light-induced and ICDAS
fluorescence wasand
device 0.11ICDAS
(p = 0.215),
II (ρ = with
0.25, a
p =95% C.I. from
0.007,
−0.07C.I.
95% to 0.27, indicating
0.08 to a lack ofthe
0.40). In contrast, statistical
positivesignificance (Figure
Spearman’s rank 7).
correlation between the
laser-induced fluorescence device and ICDAS was 0.11 (p = 0.215), with a 95% C.I. from
−0.07 to 0.27, indicating a lack of statistical significance (Figure 7).

Figure
Figure 7.
7. Correlation
Correlation Matrix
Matrix of
of all
all the
the examined
examined teeth.
teeth. Two
Two stars
stars (‘**’),
(‘**’), Three
Three stars
stars (‘***’)
(‘***’) denote
denote that
that
the corresponding variable is significant at 5%, 1% level, respectively. Absence of of
the corresponding variable is significant at 5%, 1% level, respectively. Absence star
star denotes
denotes no
no significant variable.
significant variable.

The same correlation matrix was calculated, taking into account only temporary
teeth. Light-induced fluorescence and laser-induced fluorescence had a moderate positive
correlation with ρ = 0.52, confidence level 95% (0.24, 0.71), and p = 0.001, being statistically
significant. Light-induced fluorescence and ICDAS experienced a moderate positive cor-
relation with ρ = 0.35, confidence level 95% (0.04, 0.60), and p = 0.045 being statistically
 Figure 7. Correlation Matrix of all the examined teeth. Two stars (‘**’), Three stars (‘***’) denote
Diagnostics 2023, 13, 3170 8 of 11
that the corresponding variable is significant at 5%, 1% level, respectively. Absence of star denotes
no significant variable.

The same correlation

The same correlationmatrix
matrixwas
was calculated,
calculated, taking
taking intointo account
account only only temporary
temporary teeth.
teeth. Light-induced fluorescence and laser-induced fluorescence had
Light-induced fluorescence and laser-induced fluorescence had a moderate positive a moderate positive
cor-
correlation
relation withwith
ρ =ρ 0.52,
= 0.52, confidencelevel
confidence level95%
95%(0.24,
(0.24,0.71),
0.71),and
andpp== 0.001,
0.001, being
being statistically
statistically
significant.
significant. Light-induced
Light-inducedfluorescence
fluorescenceand andICDAS
ICDASexperienced
experiencedaamoderate
moderatepositive
positivecor-cor-
relation
relation with
with ρρ == 0.35,
0.35, confidence
confidence level
level 95%
95% (0.04,
(0.04, 0.60),
0.60), and
and pp == 0.045
0.045 being
being statistically
statistically
significant.
significant. Laser-induced
Laser-induced fluorescence
fluorescence and ICDAS II had had the
the lowest
lowest correlation
correlation (ρ
(ρ ==0.16),
0.16),
and there was no statistical significance (p = 0.296) (Figure
and there was no statistical significance = 0.296) (Figure 8). 8).

Figure
Figure 8.
8.Correlation
Correlationmatrix
matrixonon
temporary
temporaryteeth. OneOne
teeth. star star
(‘*’),(‘*’),
Two Two
starsstars
(‘**’) (‘**’)
denote that the
denote cor-
that the
responding
correspondingvariable is significant
variable at 10%,
is significant 5% level,
at 10%, respectively.
5% level, Absence
respectively. of star denotes
Absence no signifi-
of star denotes no
cant variable.
significant variable.
Diagnostics 2023, 13, x FOR PEER REVIEW 9 of 11

For
For permanent
permanent teeth,
teeth, correlation
correlation showed
showed that
that light-induced
light-induced fluorescence
fluorescence devices
devices and
and
laser-induced
laser-induced fluorescence
fluorescencedevices
devicesexhibited
exhibitedaamild
mildcorrelation
correlation(ρ(ρ == 0.26)
0.26) and
andpp == 0.034,
0.034,
had a mild
which
which made correlation butsignificant.
it statistically
statistically were statistically
significant. insignificant,
Light-induced
Light-induced p = 0.115.
fluorescence
fluorescence Laser-in
devices
devices duce
andand dII flu-
ICDAS
ICDAS hadII
orescence and ICDAS
a mild correlation but II hadstatistically
were almost no correlation (ρ =p 0.07)
insignificant, andLaser-induced
= 0.115. p = 0.487, as shown in Fig-
fluorescence
ure
and9.ICDAS II had almost no correlation (ρ = 0.07) and p = 0.487, as shown in Figure 9.

Figure
Figure9. 9.Correlation
Correlation matrix
matrix of permanent teeth.
teeth. One
One star
star (‘*’)
(‘*’)denote
denotethat
thatthe
thecorresponding
correspondingvariable
varia-
ble is significant
is significant at 10%
at 10% level.
level. Absence
Absence of star
of star denotes
denotes no no significant
significant variable.
variable.

4. Discussion
As the medical community has moved from an invasive to a minimally invasive phi-
losophy of accomplishing treatments, detecting early dental caries and demineralization
have become essential [21]. The visual examination of dental caries has proven effective,
Diagnostics 2023, 13, 3170 9 of 11

4. Discussion
As the medical community has moved from an invasive to a minimally invasive
philosophy of accomplishing treatments, detecting early dental caries and demineralization
have become essential [21]. The visual examination of dental caries has proven effective,
mainly in the more advanced stages of caries. For this reason, more studies are evaluating
innovative methods of caries identification and quantification, so that dental practitioners
can diagnose dental caries and demineralization in the early stages, thus contributing to
preventive dental care and oral health [22]. When all the examined teeth were accounted for,
a strong correlation was observed between light-induced fluorescence and laser-induced
fluorescence as well as between light-induced fluorescence and visual examination. The
correlation between laser-induced fluorescence and visual examination was not statistically
significant. All of those mentioned above were calculated at a confidence level of 95%.
Akarsu et al. found in their study between visual examination and a combined examination
(visual examination and examination with laser fluorescence) on extracted teeth with non-
cavitated lesions that combined examination yielded better results than visual examination
alone [23]. Shi et al. concluded in another study using laser-induced fluorescence devices
and standard radiographs on extracted posterior teeth that laser-induced fluorescence
devices better identified occlusal caries than a standard radiograph. They also noted that
one of the disadvantages of the laser-induced fluorescence device was that the occlusal
surface to be examined had to be thoroughly dried before using the light fluorescence
device [24]. However, Rodriguez et al. found out that the combination between ICDAS
and BW had the best results with the only problem being the reproducibility of the BW
outcome between ICDAS, laser fluorescence, and bitewing X-ray (BW). According to
Landis and Koch, the k value of the inter-examiner evaluation was 0.5, which is a moderate
value [25]. In another in vitro study, Jablonski et al. compared light-induced fluorescence
devices, laser-induced fluorescence devices, and ICDAS in occlusal caries, with the highest
correlation (r = 0.84) being between light-induced fluorescence device and ICDAS as it
is in this study as well [26]. The null hypothesis was that all three methods would have
the same results. However, this hypothesis held true solely for light-induced fluorescence
devices. Occlusal caries is the most common form of caries in children, adolescents, and
young adults, presenting 75% of the total caries detection, as shown by a study of Lussi
et al. [27]. Also, the occlusal surface is the most challenging surface to examine reliably
for caries detection [18,28]. To the authors’ knowledge, very few studies on the clinical
validity of light-induced fluorescence device on temporary dentition. A study from Ahrani
et al. on extracted temporary teeth showed that light-induced fluorescence device was
statistically significant, with the golden standard being the histological examination for
caries in the approximal surfaces [29]. ICDAS-II can be a difficult task for beginners and
can cause over-treatment. A recent study by Qudeimant et al. showed that there were
evident inconsistencies between examiners for initial caries (ICDAS < 2) and accordance for
extensive carious lesions with ICDAS > 3 [30]. Mazur et al. [31] observed poor agreement.

5. Conclusions
Based on the study’s objectives, it was established that incorporating light-induced flu-
orescence as a supplementary method alongside visual examination enhanced the precision
of caries detection. However, the study revealed a tendency for laser-induced fluorescence
to underestimate non-cavitated lesions, inaccurately categorizing them as healthy tissue.
The limitations of relying solely on visual examination were also highlighted due to the
subjective nature among professionals. Notably, ICDAS and light-induced fluorescence
emerged as superior diagnostic methods compared to laser-induced fluorescence in iden-
tifying occlusal caries. Future investigations should focus on evaluating the impact of
intervals in laser-induced fluorescence devices on the outcomes of visual examinations.
Diagnostics 2023, 13, 3170 10 of 11

Author Contributions: Conceptualization: V.T.A., A.D.F., D.J. and A.P.; Methodology: A.G., A.P.,
R.S.-R., A.P. and D.L.; Formal analysis: V.T.A., D.L., A.P., A.G., D.J., A.D.F. and R.S.-R.; Original Draft
Preparation, V.T.A. and A.P.; Writing—Review and Editing, A.P., A.G. and D.L.; Visualization, V.T.A.,
A.D.F., D.L., A.G., A.D.F., A.P., R.S.-R. and D.J. Supervision: A.G. and D.J. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Ethics Committee of Victor Babes University of Medicine
and Pharmacy Timisoara (Nr.08/26.02.2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to patient privacy.
Conflicts of Interest: The authors declare no conflict of interest.

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