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This study aimed to evaluate the in vitro performance in detecting caries around composite restorations in permanent posterior teeth and the impact of treatment decisions of two visual criteria: International Dental Federation (FDI) criteria and the Caries Associated with Restorations and Sealants (CARS) system. The correlation among secondary caries and the presence of gap measured with a three-dimensional (3D) intraoral scanner was also aimed. One hundred sixteen teeth were assessed by a trained and calibrated examiner according to the FDI criteria or CARS system. A second examiner measured the gap on the 3D models using specific software. The reference standard was the histological examination performed by a third examiner blind to the other evaluations. Other 30 extracted permanent teeth were used only to assess the reproducibility of the methods. The same random sample was selected for re-examination by all three methods, and there were seven days between the examinations. Unweighted and weighted kappa tests were conducted to assess intra-examiner reproducibility. Spearman’s correlation coefficient (Rho) and 95% confidence intervals (95%CI) were calculated between the histological examination and scores obtained with FDI criteria, CARS system and treatment decisions. Spearman correlation between the visual and scanner evaluation with the reference standard was performed. Spearman’s rank correlation analyses were conducted independently between the gap evaluated and measured by the visual inspection with the gap assessed using the scanner. The reproducibility of the visual score systems reached high values. Spearman’s correlation coefficients (Rho; 95%CI) between the following variables versus histology were: FDI presence of caries (0.65; 0.53 to 0.74); CARS scores (0.65; 0.52 to 0.74); FDI treatment decision (0.46; 0.31 to 0.59); and CARS treatment decision (0.62; 0.49 to 0.72). Rho (95%CI) between histology and the gap assessment by the visual inspection was 0.59 (0.45 to 0.70), with the gap measurement by the visual inspection was 0.49 (0.33 to 0.62), and the gap measured by the scanner was 0.37 (0.18 to 0.53). Both visual criteria present similar performance in detecting caries. The correlation among treatment decisions is moderate for the FDI and CARS criteria, and both are moderately correlated with lesion depth, with a slight CARS superiority. However, visual examination presents better performance than the 3D intraoral scanner on gap size assessment

To evaluate the performance of visual inspection alone and associated to radiographic and laser fluorescence (LF) methods in detecting non-evident caries lesions at adolescents’ proximal surfaces. Adolescents (12 to 17 years old) were assessed for the presence of caries lesions through visual inspection, radiographic examination, and LF method (DIAGNOdent pen), at non-cavitated (NC) and cavitated lesion (CAV) thresholds. Temporary separation with orthodontic rubbers followed by direct visual inspection was the reference standard method. Two examiners conducted the examinations, and the first examiner reassessed around 20% of the sample, to evaluate inter- and intra-examiner reproducibility, respectively. Sensitivity, specificity, accuracy, and utility values were calculated for the methods alone and combined with visual inspection using two different strategies: simultaneous and sequential combination. A total of 834 proximal surfaces (51 adolescents) were included. Visual inspection presented higher reproducibility values (higher than 0.98). Moreover, visual inspection presented higher sensitivity (around 0.51) than those obtained with other diagnostic strategies (varying from 0.09 to 0.20) at the NC threshold. For CAV, visual inspection presented higher specificity (0.996) than the sequential association with adjunct methods (around 0.97), but with lower sensitivity. Accuracy and utility values for combined strategies were similar or lower than those achieved with the visual inspection performed alone. Visual inspection alone performs better for detecting caries lesions in premolars and molars of adolescents than other diagnostic strategies. The best diagnostic strategy for caries detection of proximal caries lesions in adolescents is the visual inspection alone.

Randomised clinical trial (RCT) is the best study design to evaluate the effect of the treatment and preventive healthcare procedures. The effects of the tested treatments on patient's health are compared in terms of outcomes, which are used to evaluate the participants' health changes. However, these outcomes should be relevant for the target population. In that way, RCTs represent the type of primary study design that provides the most reliable evidence to implement therapies into the clinical practice. In this review, an outline of some aspects related to the choice of RCTs' outcomes was presented, focusing on the conduction of relevant trials in Paediatric Dentistry. The importance and necessity of defining a primary outcome were addressed, preferentially a clinically relevant endpoint. The patients should perceive this outcome, and changes in this variable should reflect directly patient's health improvement or impairment. Moreover, considerations about the objective or subjective variables, use of surrogate outcomes, and the increasing tendency to develop core outcome sets were also presented in this review. The main idea of this manuscript is the RCTs must evaluate outcomes relevant to the children's oral health in order to contribute to the implementation of treatments in the evidence-based health practice.

Item does not contain fulltext This is a delayed-type cross-sectional prospective accuracy study nested in a randomized clinical trial. The aim was to investigate the diagnostic accuracy of two visual criteria for caries lesions detection around restorations in primary teeth: the International Dental Federation (FDI) criteria, considering adaptation, staining, and the presence of caries, and the Caries Associated with Restorations and Sealants (CARS) system. For this, one examiner made the diagnosis and subsequent treatment decision using visual assessment in 163 children (3-10 years old) with both FDI and CARS criteria. The order of criteria used was defined by randomization. The reference standard was composed of two approaches: (1) the presence of carious tissue after restoration removal and (2) the presence of caries lesions after 6 and 12 months of follow-up. Sensitivity, specificity, and accuracy parameters were calculated at the dentin threshold. Poisson multilevel regression analyses were performed to evaluate the association of the diagnostic methods and other explanatory variables with the outcomes. Of the 651 restorations included, 480 were evaluated by the reference standard methods and were analyzed. The CARS system presented higher accuracy (0.721) than those obtained with FDI recurrence of caries (0.702), FDI marginal adaptation (0.700), and FDI marginal staining criteria (0.681). The FDI marginal staining showed the study's lowest sensitivity (0.280) and accuracy (0.681) values. The specificity values of FDI recurrence of caries and FDI marginal adaptation were lower than the CARS system. Restorations assessed after the follow-up period resulted in lower sensitivity but higher specificity than those replaced after initial evaluation. In conclusion, the CARS system is more accurate in detecting caries around restorations in primary teeth than the FDI system, in general. However, the FDI recurrence of caries and FDI marginal adaptation present similar performance to the CARS system when the dentin threshold is considered. On the other hand, marginal staining is not an accurate parameter to evaluate caries around restorations.

O objetivo desta pesquisa foi avaliar o efeito do uso de dois critérios visuais no diagnóstico e decisões de tratamento de lesões de cárie ao redor de restaurações, dando ênfase à realização de estudos clínicos em dentes decíduos. Os critérios utilizados foram o sistema proposto pela Federação Dentária Internacional (FDI), composto pelos parâmetros manchamento marginal, adaptação marginal e recorrência de cárie, e o Caries Associated with Restorations and Sealants (CARS) associado a uma proposta de decisão de tratamento para ser utilizada em associação ao critério. A presente tese contém um compilado de estudos relacionados a esse tópico, sendo (I) o protocolo de um ensaio clínico randomizado (ECR) de avaliação de restaurações em crianças, (II) um estudo transversal comparando decisões de tratamento, (III) um estudo de acurácia diagnóstica com desfecho tardio em dentes decíduos e (IV) um estudo in vitro utilizando os métodos em dentes permanentes. O objetivo do ECR (I), que é o estudo principal, foi avaliar o efeito dos dois critérios visuais na avaliação de 626 restaurações em dentes decíduos, numa amostra de crianças de 3 a 10 anos, considerando desfechos relacionado com a saúde oral de crianças e com os custos relacionado as avaliações após dois anos de acompanhamento. O desfecho primário será a necessidade de uma nova intervenção na restauração avaliada após 2 anos de acompanhamento. Mudanças na qualidade de vida das crianças após dois anos, assim como os custos e efeitos dos tratamentos por criança, serão analisados como desfechos secundários. O estudo transversal (II) teve como objetivo investigar a influência dos critérios FDI e CARS na avaliação de 550 restaurações em dentes decíduos na decisão de substituição das restaurações na mesma amostra de crianças do estudo (I). Outras variáveis que possivelmente poderiam influenciar esta decisão de tratamento também foram consideradas nas análises. No estudo de diagnóstico com desfecho tardio (III) foram avaliadas a sensibilidade, especificidade e acurácia dos critérios FDI e CARS na detecção de lesões de cárie ao redor de 651 restaurações em dentes decíduos, na mesma amostra de crianças do estudo (I). O padrão de referência utilizado foi a avaliação visual-tátil da dentina abaixo da restauração quando indicada a substituição na linha de base ou o exame visual-tátil da restauração após 6 e 12 meses de acompanhamento. Um estudo in vitro (IV) também foi realizado numa amostra de 116 dentes permanentes posteriores restaurados com resina composta, com o objetivo de avaliar a performance dos métodos FDI, CARS e do scanner 3D na detecção de lesões de cárie secundárias e na predição de severidade das lesões. O padrão de referência utilizado neste estudo foi a avaliação histológica. Observou-se que restaurações avaliadas pelo critério FDI receberam maior número de indicações de substituição comparadas as avaliadas pelo critério CARS. Além disso, a experiência de cárie da criança e restaurações multisuperfície influenciaram a decisão de substituição. Em relação a acurácia dos métodos, o CARS apresentou maior acurácia que o critério FDI, mas os parâmetros de avaliação da adaptação marginal e cárie recorrente propostos pelo FDI apresentaram performance similar ao CARS quando o limiar da dentina foi considerado nas análises. No entanto, o manchamento não se mostrou um parâmetro acurado para detectar lesões de cárie ao redor de restaurações em dentes decíduos. Quando avaliados in vitro numa amostra de dentes permanentes, os dois critérios visuais mostram uma correlação moderada com a profundidade das lesões de cárie ao redor de restaurações de dentes permanentes, e o scanner 3D não melhora a avaliação de falhas marginais das restaurações, comparado com o exame visual. Em conclusão, o CARS parece ser um sistema mais acurado e que leva a intervenções operatórias menos invasivas do que o FDI. No entanto, o critério de avaliação de recidiva de cárie do FDI é semelhante ao CARS. A avaliação do manchamento definitivamente não deve ser utilizado como um parâmetro para determinar a presença de lesão de cárie ou para indicar a troca das restaurações. This research aims to evaluate the effect of using two visual criteria on diagnosis and treatment decisions of caries lesions around restorations, focusing on clinical studies in primary teeth. The selected criteria were the International Dental Federation (FDI) criteria and the Caries Associated with Restorations and Sealants (CARS) system. For the FDI criteria, the subcategories marginal staining, marginal adaptation, and recurrence of caries were used. For the CARS system, a proposed treatment decision was used in association with the criteria. This thesis presents a compilation of studies related to this subject, being (I) a study protocol of a randomized clinical trial (RCT) to evaluate restorations in children, (II) a cross-sectional study to compare treatment decisions, (III) a delayed type cross-sectional prospective accuracy study in primary teeth, and (IV) an in vitro study using the criteria in permanent teeth. The RCT (I) objective, which is the main study, was to evaluate the effect of two visual criteria in the assessment of 626 restorations in primary teeth in a sample of children from three to 10 years old. The primary outcome will be the need for a new intervention in the evaluated restorations after two years of follow-up. The changes in children\'s oral health-related quality of life and the restorative dental treatment cost will also be analyzed as secondary outcomes. The cross-sectional study (II) aimed to investigate the influence of the FDI and CARS system on the decision to replace 550 restorations in primary posterior teeth in the same sample of children of the study (I). Variables that might influence this decision were also considered. The delayed type cross-sectional prospective accuracy study evaluated the sensibility, specificity, and accuracy of the FDI and CARS system in detecting caries lesions around 651 restorations in primary teeth in the same sample of children of the study (I). The reference standard methods were the restoration removal and visual-tactile examination of dentin beneath the margin interface when the replacement was indicated or visual-tactile detection and assessment of the restoration after six and 12 months of follow-up. An in vitro study (IV) was also carried out in a sample of 116 composite restorations of permanent posterior teeth. This study aimed to evaluate the FDI, CARS, and three-dimensional (3D) intraoral scanner\'s performance in detecting secondary caries lesions and predicting their severity. The reference standard was the histological examination. It was observed that restorations evaluated according to the FDI criteria were more frequently indicated for replacement than those assessed with the CARS system. Besides that, children\'s caries experience and multisurface restorations influenced the decision to replace restorations. Regarding the accuracy of the methods, the CARS system was more accurate than the FDI criteria. However, the FDI criteria for evaluating recurrence of caries and marginal adaptation presented similar performance to the CARS system when the dentin threshold is considered. On the other hand, marginal staining was not an accurate parameter to evaluate caries around restorations in primary teeth. In a sample of permanent teeth, both visual criteria are moderately correlated with lesion depth. The 3D intraoral scanner does not add further information to gap size assessment than visual inspection. In conclusion, the CARS system seems to be the most accurate diagnostic visual method and suggests less invasive treatment decisions than FDI criteria. However, the FDI recurrence of caries is similar to the CARS system. The marginal staining definitely should not be used to evaluate caries lesion around restorations or to indicate restoration replacement.

Background To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs. Methods This is a secondary analysis of a two-arm randomized clinical trial with parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3–6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up. Results 4383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias. Conclusions Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice. Trial registration Clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014.

Background: To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs.Methods: This is a secondary analysis of a two-arm randomized clinical trial with two parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3 to 6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up. Results: 4,383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias.Conclusions: Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice.Trial registration: clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014

We aimed to evaluate whether children’s caries experience exerts an influence on the performance of visual and radiographic methods in detecting nonevident proximal caries lesions in primary molars. Eighty children (3–6 years old) were selected and classified as having a lower (≤3 decayed, missing, or filled surfaces; dmf-s) or higher (> 3 dmf-s) caries experience. Two calibrated examiners then assessed 526 proximal surfaces for caries lesions using visual and radiographic methods. As a reference standard, 2 other examiners checked the surfaces after temporary separation. Noncavitated and cavitated lesion thresholds were considered and Poisson multilevel regression analyses were conducted to evaluate the influence of caries experience on the performance of diagnostic strategies. Accuracy parameters stratified by caries experience were also derived. A statistically significant influence of caries experience was observed only for visual inspection, with more false-positive results in children with a higher caries experience at the noncavitated lesion threshold, and more false results at the cavitated threshold. The detection of noncavitated caries lesions in children with a higher caries experience was overestimated (specificity = 0.696), compared to children with a lower caries experience (specificity = 0.918), probably due to confirmation bias. However, the examiners underestimated the detection of cavitated lesions in children with a higher caries experience (sensitivity = 0.143) compared to lower-caries-experience children (sensitivity = 0.222), possibly because of representativeness bias. The radiographic method was not influenced by children’s caries experience. In conclusion, children’s caries experience influences the performance of visual inspection in detecting proximal caries lesions in primary teeth, evidencing the occurrence of cognitive biases.

Background Visual inspection (VIS) with radiographic examination (RAD) is the recommended diagnostic strategy for detecting caries in children; however, this recommendation is based on accuracy studies. The authors conducted a clinical trial to compare the detection and subsequent treatment of carious lesions in primary molars performed with VIS alone and with RAD. Methods Children (3-6 years old) were randomly assigned to 2 groups according to the diagnostic strategy used for caries detection on primary molars: VIS or RAD. Participants were diagnosed and treated according to the management plan related to the allocated group. The primary outcome was the number of new operative interventions during the 2-year follow-up period. Other secondary outcomes were also compared. Comparisons were performed with Mann-Whitney test using an intention-to-treat approach. Results Of the 252 children included and randomized, 216 were followed-up after 2 years (14.3% attrition rate). There was no difference between the groups for the primary outcome (P = .476). For the secondary outcomes, the RAD group had more restoration replacements (P = .038) and more restorations performed since the beginning of the study (P = .038) compared with the VIS group. In addition, the RAD group had a higher number of false-positive results than the VIS group (P Conclusions Simultaneous use of VIS and RAD for caries diagnosis in primary molars of children who seek dental treatment does not provide additional benefits compared with VIS alone. Practical Implications Dentists should perform VIS only, not RAD, for detecting carious lesions in preschool-aged children. ClinicalTrials.gov: NCT02078453 .

To evaluate the impact of radiographic examination on changes of treatment decision related to dental caries compared to decisions guided by visual inspection alone in primary molars. A total of 126 children aged 3–6 years who had sought dental assistance were randomly selected and examined by two calibrated examiners using visual inspection. A treatment plan regarding dental caries was generated based on this assessment. The same examiners then evaluated two bitewing radiographs, creating an additional treatment plan guided by concurrent assessment of both visual and radiographic methods. Occlusal and proximal surfaces of primary molars received a treatment decision as follows: (i) no treatment, (ii) non-operative treatment, and (iii) operative treatment. The frequency of changes in the treatment decision after radiographic examination was calculated, with subsequent Poisson multilevel regression analysis to evaluate variables influencing such changes. Changes from “no treatment” decided with visual inspection to “non-operative treatment” after radiographic evaluation occurred in 52 surfaces (3.2%), and changes to “operative treatment” were observed in 46 dental surfaces (2.8%). Furthermore, 50 surfaces (6.2%) had their treatment decision changed from non-operative to operative treatment after radiographic assessment. In addition, changes were significantly more frequent in children with higher caries experience, on proximal surfaces and in 1st primary molars. The impact of radiographic examination on changes in the treatment decision of primary molars made with visual inspection is modest. Changes are more frequent in children with higher caries experience and in proximal surfaces. The benefits of the radiographic method for detecting caries in children, as a protocol in the diagnostic process, seem to be overestimated; the impact of this method on changes in treatment decision made by visual examination alone is low. Radiographs could be, however, useful in particular conditions, such as in children with high caries experience.

Apesar de muitos estudos terem sido realizados para avaliar a acurácia dos métodos de detecção de cárie, poucos avaliam possíveis fatores capazes de influenciar o desempenho dos examinadores, como por exemplo, a experiência de cárie da criança. Dessa forma, este estudo teve como objetivo avaliar se a experiência de cárie da criança influencia o desempenho do exame visual e radiográfico na detecção de lesões de cárie proximais em molares decíduos. A amostra foi composta por 80 crianças de 3 a 6 anos de idade, as quais foram classificadas de acordo com a experiência passada de cárie, considerando lesões cavitadas. Dois examinadores calibrados avaliaram 526 superfícies proximais. Inicialmente foi realizado o exame visual, e em seguida, o exame radiográfico. Como padrão de referência, outros dois examinadores realizaram o exame visual direto das superfícies após separação temporária com elástico ortodôntico. A sensibilidade, especificidade e acurácia dos métodos visual e radiográfico, isolados e em associação, foram calculadas e comparadas entre si considerando os limiares de lesões não cavitadas e de lesões cavitadas. Análises de regressão de multinível de Poisson foram utilizadas para avaliar a influência da experiência de cárie e de outras variáveis na performance das estratégias de diagnóstico. Análises estratificadas pela experiência de cárie da criança também foram conduzidas. A associação do exame radiográfico ao exame visual não melhorou a acurácia na detecção de lesões proximais de cárie em dentes decíduos nos dois limiares de um modo geral. No entanto, foi observada uma influência da experiência de cárie apenas no exame visual. A detecção de lesões não cavitadas em crianças com maior experiência de cárie foi superestimada, provavelmente devido a um viés de confirmação. Já para lesões cavitadas, a detecção pelo exame visual foi subestimada, indicando um possível viés de representatividade. Já o exame radiográfico não sofreu influência de vieses cognitivos, e a performance desse método isolado ou associado ao visual de forma simultânea foi melhor nas crianças com maior experiência de cárie. Portanto, conclui-se que a experiência de cárie da criança influencia o desempenho dos examinadores ao utilizar o exame visual na detecção de lesões proximais de cárie em dentes decíduos. Despite many studies have already been conducted to investigate the accuracy of caries detection methods, few investigations have evaluated the influence of some factors on the examiners\' performance, such as child\'s caries experience. Thus, this study aimed to evaluate if the child\'s caries experience exerts some influence on the performance of visual and radiographic methods for the detection of approximal caries lesions in primary molars. Eighty children aged from 3 to 6 years were selected and classified according to the past caries experience considering cavitated lesions. Two calibrated examiners evaluated 526 approximal surfaces for the presence of caries lesions using visual inspection and radiographic methods. As reference standard, two other examiners checked the surfaces by direct visual inspection after the temporary separation with orthodontic rubbers. Sensitivity, specificity, and accuracy obtained with visual inspection and radiographic method, alone or associated, were calculated and compared considering non-cavitated and cavitated lesions thresholds. Poisson multilevel regression analyses were conducted to evaluate the influence of the caries experience on the performance of diagnostic strategies. Radiographic examination and visual inspection performed associated did not improve the accuracy in detecting approximal caries lesions in both thresholds. However, an influence of child\'s caries experience was observe only on the visual inspection. The detection of non-cavitated caries lesions in children with higher caries experience was overestimated, probably due to confirmation bias. On the other hand, considering cavitated caries lesions, the performance of visual inspection was underestimated, indicating the occurrence of representativeness bias. Nevertheless, the radiographic method did not suffer influence of any type of cognitive bias, and the performance of this method, alone or simultaneously associated with visual inspection, was better in children with higher caries experience. In conclusion, the child\'s caries experience exerts influence on visual inspection in detecting approximal caries lesions in primary teeth.

We aimed to investigate the performance of fluorescence-based methods (FBMs), compared to visual inspection after histological validation, in detecting and assessing the activity status of occlusal carious lesions in primary teeth. One examiner evaluated 50 primary molars close to exfoliation in 24 children. Teeth were assessed using quantitative light-induced fluorescence (QLF) and pen-type laser fluorescence (LFpen). After exfoliation, histological validation was performed. Teeth were cut and sections were evaluated for lesion depth and activity status (after utilization of a pH indicator) under a stereomicroscope. Parameters related to the performance of the methods in detecting caries lesions at two thresholds (initial and dentin lesions) were calculated. Regarding the activity status, lesions were classified into sound+inactive or active, and the area under the ROC curve and the diagnostic odds ratio values of the methods were calculated and compared. Evaluation of red fluorescence using QLF presented higher sensitivity but lower specificity than visual inspection in detecting dentin caries lesions. However, QLF considering different parameters and LFpen had similar performance to that obtained with visual inspection. Regarding activity assessment, all FBMs and visual inspection also presented similar performance. In conclusion, FBMs did not prove advantageous for the detection and activity assessment of occlusal caries lesions in primary molars when compared to visual inspection.

Background In epidemiological surveys, a good reliability among the examiners regarding the caries detection method is essential. However, training and calibrating those examiners is an arduous task because it involves several patients who are examined many times. To facilitate this step, we aimed to propose a laboratory methodology to simulate the examinations performed to detect caries lesions using the International Caries Detection and Assessment System (ICDAS) in epidemiological surveys. Methods A benchmark examiner conducted all training sessions. A total of 67 exfoliated primary teeth, varying from sound to extensive cavitated, were set in seven arch models to simulate complete mouths in primary dentition. Sixteen examiners (graduate students) evaluated all surfaces of the teeth under illumination using buccal mirrors and ball-ended probe in two occasions, using only coronal primary caries scores of the ICDAS. As reference standard, two different examiners assessed the proximal surfaces by direct visual inspection, classifying them in sound, with non-cavitated or with cavitated lesions. After, teeth were sectioned in the bucco-lingual direction, and the examiners assessed the sections in stereomicroscope, classifying the occlusal and smooth surfaces according to lesion depth. Inter-examiner reproducibility was evaluated using weighted kappa. Sensitivities and specificities were calculated at two thresholds: all lesions and advanced lesions (cavitated lesions in proximal surfaces and lesions reaching the dentine in occlusal and smooth surfaces). Results Regarding the reproducibility, the mean (range) of kappa values was 0.781 (0.529–0.927) for occlusal surfaces, 0.568 (0.191–0.881) for smooth surfaces, and 0.844 (0.698–0.971) for proximal surfaces. Considering all lesions, sensitivity and specificity mean values were respectively 0.724 and 0.844 for occlusal, 0.635 and 0.943 for smooth and 0.658 and 0.927 for proximal surfaces. For detecting advanced lesions, sensitivities and specificities were 0.563 and 0.920 for occlusal, 0.670 and 0.985 for smooth, and 0.838 and 0.985 for proximal surfaces. Conclusion The methodology purposed for training and calibration of several examiners designated for epidemiological surveys of dental caries in preschool children using the ICDAS is feasible, permitting the assessment of reliability and accuracy of the examiners previously to the survey´s development.