The Saudi Dental Journal (2012) 24, 169–174

King Saud University

The Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

ORIGINAL ARTICLE

Comparison between a laser fluorescence device and visual

examination in the detection of occlusal caries in children
Chaza Kouchaji

Department of Pediatric Dentistry, College of Dentistry, Damascus University, Syria

Received 1 January 2012; revised 25 May 2012; accepted 20 July 2012

Available online 17 August 2012

KEYWORDS Abstract Occlusal surfaces of molars are especially susceptible to the development of caries due to
Laser fluorescence; the features, such as pits and deep fissures, of their anatomical structure.
Visual detection; Aim: To evaluate the efficiency of DIAGNOdent laser fluorescence measurements in compari-
Occlusal caries son with visual examination for occlusal caries detection for first permanent molars in children.
Methods: The study involved 156 permanent molar teeth in 40 children aged 7–12 years. A rel-
atively new technology, the fluorescence laser DIAGNOdent pen, was used for detecting and diag-
nosing caries on the occlusal surfaces of molars. The visual examination of fissures was based on the
Ekstrand classification system.
Results: The results showed a strong relationship between examination with the DIAGNOdent
and visual inspection. DIAGNOdent’s sensitivity and specificity were 97% and 52%, respectively,
indicating that the laser fluorescence DIAGNOdent pen is a reproducible and accurate diagnostic
tool that may be very helpful in conjunction with visual examination in the detection of occlusal
caries in permanent molars in children.
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1. Introduction on the masticatory surfaces of the first permanent molars, fol-

The occlusal surfaces of molars are especially susceptible to the
development of caries due to their anatomical structure, which
contains pits and deep fissures (Weerheijm and Gruythuysen,
1992). In industrialized nations, the caries prevalence rate
has decreased and the occlusal surface of the tooth has become
the most affected surface (Newbrun, 1993). The majority of
caries lesions in the school-aged population is concentrated
E-mail address: shazako@yahoo.com
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http://dx.doi.org/10.1016/j.sdentj.2012.07.002
lowed by approximal surfaces on posterior teeth (Batchelor
and Sheiham, 2004).
Caries diagnosis requires a thorough dental examination
and close attention to the clinical evidence. Nevertheless, many
studies have demonstrated that diagnosing occlusal caries
without cavities is difficult, and that both false-positive and
false-negative findings occur frequently (Horowitz, 2004; Bad-
er et al., 2002; Sheehy et al., 2001). Accordingly, as a visual
exam is a subjunctive method, it is difficult to diagnose occlu-
sal caries using only this method (Lussi, 1991; Lussi, 1993).
Complementary tools, such as the laser fluorescence system
DIAGNOdent, may be used in order to avoid the occurrence
of false-positive and false-negative findings. Furthermore, it
is very important to know the degree of carious demineralized
occlusal surfaces susceptible to remineralizing treatment, the
170
demineralized occlusal surfaces requiring restorative treatment
and the surfaces that do not require treatment.
There are a number of relatively new detection technolo-
gies commercially available to help in the early detection of
carious lesions (Young, 2002). One such device is DIAGNO-
dent, which involves fluorescence measurements performed
by a laser device. Development of the DIAGNOdent came
about thanks to the work of Hibst and Gall who showed
in 1998 that exposing a tooth surface to red light (638–
655 nm) helps to differentiate between sound and carious tis-
sues. This is because the fluorescence intensity caused by exci-
tation in caries lesions exceeds that of healthy tissues. Red
emission light, in addition to infrared fluorescence excitation,
is less well absorbed and scattered by enamel than light of
shorter wavelengths. Red light penetrates deeper into the
material of the tooth, enabling fluorescence detection even
from carious dentine under visibly sound enamel (Hibst and
Gall, 1998). Two laser fluorescence-based devices are avail-
able: the DIAGNOdent 2095 and the DIAGNOdent pen
2190 (Rodrigues et al., 2011).
When the laser irradiates the tooth, the light is absorbed by
organic and inorganic substances present in the dental tissues,
as well as by metabolites from oral bacteria (Hibst and Paulus,
2000). These metabolites may be porphyrins that are produced
by several types of oral bacteria. Studies using chromatogra-
phy have found that porphyrins showed some fluorescence
after excitation by red light (Lussi et al., 2004).
Decalcified areas in the enamel and dentin structure stimu-
late fluorescent light of a different wavelength. The resulting
fluorescence is evaluated by the appropriate electronic system
in the DIAGNOdent unit, measured by a photodiode and con-
verted into digits, which appear on a screen. Fluorescence
intensity values, from 0 to 99, are transformed into an acoustic
signal. DIAGNOdent readings between zero and 14 indicate a
healthy occlusal surface, readings between 15 and 20 indicate
the presence of enamel caries, and readings of 21 or more indi-
cate the presence of dentinal caries (DIAGNOdent, KaVo,
Biberac, Germany).
According to a relatively recent systematic review (Bader
and Shugars, 2004), further assessment of the laser device in
clinical applications is needed, especially with regard to ana-
tomical factors that interfere with the laser fluorescence
device’s ability to assess occlusal caries. Accordingly, DIAG-
NOdent readings should not be relied on when making
diagnostic decisions (Markowitz et al., 2012).
Few studies have been performed to compare the results of
clinical exploration with those obtained through the use of the
DIAGNOdent for the diagnosis of children’s permanent mo-
lars. For this reason, the decision was made to study the valid-
ity of this instrument by measuring the fluorescence of occlusal
surfaces and to compare the results with the results of a visual
examination of first permanent molars in children.
1.1. The aim of the study
To evaluate the efficiency of laser fluorescence measurements,
obtained using the DIAGNOdent pen, by comparing with
them with visual examination for the detection of occlusal car-
ies for first permanent molars in a convenience sample of boys
and girls aged 7 through 12 years who sought dental care at the
pediatric clinic of Damascus University.
C. Kouchaji
2. Materials and methods
2.1. Study sample
The study involved 156 first permanent molars from 40 pa-
tients aged 7 to 12 years, who were referred for treatment at
the Pediatric Department of Damascus University. Ethical ap-
proval was given by the Ethics Committee of the Faculty of
Dental Surgery in Damascus University.
The mean patient age was 9.5 ± 1.8 years, with 21 male
and 19 female subjects. The study used first permanent molars
with and without carious lesions. In order to be included in the
study, patients had to have at least one permanent molar that
met the following criteria: be fully erupted (surfaces free from
any gingival tissues) and have no restoration on the occlusal
surface; not be sealed; and have no hypoplastic surfaces, path-
ological abrasions or other structural defects. Excluded from
the sample were the molars of children who had systemic dis-
eases that could interfere with the diagnostic process such as
temporomandibular joint defects that limit the child’s ability
to open his or her mouth and other syndromes that made it
impossible for the child to cooperate. There were 79 upper mo-
lars and 77 lower molars.
Histological validation was not possible in this clinical
study. The gold standards were visual examination and DIAG-
NOdent manufacturer’s criteria.
2.2. Assessment parameters
2.2.1. Visual clinical examination
Visual examination was always carried out first in order to
eliminate the possibility of the laser fluorescence system pro-
ducing bias in the visual scores obtained. One dentist visually
examined all the teeth in the study. Visual clinical examination
was performed without probing with patients positioned in a
dental chair and with the aid of a light reflector, air/water
spray and plane buccal mirror. No prior professional cleaning
was carried out and no magnifying device was used. After dry-
ing the tooth surface for 3 to 5 s, the visual inspection was per-
formed. The criteria used to record the visual appearance of
teeth were based on Ekstrand’s ranked system (Ekstrand
et al., 1997) and are shown in Table 1.
2.2.2. Laser fluorescence examination
Scanning with the laser fluorescence system (DIAGNOdent
LF Pen, KaVo, Biberach, Germany) was performed after the
initial visual dental examination. The examiner was trained
to use the laser equipment following the manufacturer instruc-
tions. No professional cleaning was done. The occlusal surface
was briefly air-dried using a 3-in-1 air syringe for 10 s. Care
was taken to tilt the instrument around the measuring site to
ensure that the tip picked up fluorescence from the slopes of
the fissure walls. The DIAGNOdent device currently available
on the market is equipped with two diagnostic tips: a cone-
shaped ‘‘A’’ tip designed for fissures and a broad ‘‘B’’ tip for
smooth, buccal and lingual surfaces of teeth. Probe tip A (nar-
row) was then tracked across the occlusal fissure and a peak
reading recorded. The probe tip was positioned on this spot
and rotated around its vertical axis until the highest value
was found, which could range from 0 (sound) to 99 (caries).
The peak value (maximum fluorescence) readings were then
Comparison between a laser fluorescence device and visual examination in the detection of occlusal caries in children 171

Table 1 Visual clinical examination according to Ekstrand et al., 1997.

Score Criteria
0 No or slight change in enamel translucency after prolonged air- drying (5 s).
1 Opacity or discoloration hardly visible without drying, but visible after air-drying.
2 Opacity or discoloration visible even without air-drying.
3 Localized enamel breakdown in opaque or discolored enamel and/ or grayish discoloration from the underlying dentin.
4 Cavitation in opaque or discolored enamel exposing to dentin.

Table 2 Criteria used in examination with DIAGNOdent Disease No disease

(Lussi et al, 1999) DIAGNOdent score recommended by Positive test a b
manufacturer. Negative test c d
Score Criteria
0–14 No caries
15–20 Enamel caries Sensitivity = a/(a + c), Specificity = d/(b + d), Positive
21–99 Dentinal caries Predictive Value = a/(a + b), Negative Predictive Va-
lue = d/(c + d).

3. Results
recorded according to the DIAGNOdent manufacturer’s crite-
ria: 0–14 = no caries; 15–20 = enamel caries; >21 = dentinal 3.1. Results of visual evaluation
caries (Table 2). Then the preventive or operative treatment
was performed at the Department of Pediatric Dentistry at Table 3 lists the results of the visual evaluation: 23 (14.7%)
the Faculty of Dental Surgery at Damascus University as fol- teeth scored 0, 52 (33.0%) scored 1, 35 (22.4%) scored 2, 36
lows: 0–14 = no caries and no care advised; 15–20 = enamel (23.1%) scored 3, and 10 (6.4%) scored 4.
caries and preventive care advised; >21 = dentinal caries
and preventive or operative treatment advised, depending on 3.2. Results of laser fluorescence evaluation
patient’s caries risk; and >30 = operative treatment required
(Table 7). The laser fluorescence evaluation results are detailed in Table 4.
Briefly, 16 (10.2%) molars had a score of 0, 39 (25.0%) had a
score of 1, and 111 (71.1%) had a score of 2.
2.3. Statistical analysis
3.3. Interpretation of results and statistical analyses
Visual examinations of fissures by Ekstrand’s scoring system
were compared with maximal laser measurements according
3.3.1. The level of concordance in frequencies of caries presence
to the DIAGNOdent manufacturer’s criteria, as shown in Ta-
between clinical examination and the DIAGNOdent pen
ble 5. The obtained results were analyzed statistically using
The results of the definition of the clinical presence of caries in
SSPS Version 13 statistical software. The inter-rater reliability
the laser fluorescence DIAGNOdent pen system in relation to
was tested using kappa values, in addition to determination of
the presence of caries in the visual examination are shown in
the odd ratios, sensitivity, specificity, receiver operating char-
Table 5. There were 16 teeth with a DIAGNOdent score of 0,
acteristic (ROC) curves for the laser fluorescence system, and
corresponding to a visual caries score of: 12 with score 0, 4 with
the value of the area under curve (AUC). The kappa statistic
score 1, and 0 with score 2, 3 and 4. For a DIAGNOdent score
is used for comparing two raters when the raters have a differ-
of 1, there were 39 teeth with the following visual caries scores:
ent range of scores. Sensitivity and specificity are terms used to
10 with score 0, 27 with score 1, 2 with score 2, and 0 with score
describe the value of tests. The subsequent formulae were used
3 and 4. For a DIAGNOdent score of 2, there were 111 teeth
to determine the following values based on true-positives,
with visual caries scores of: 1 with score 0, 21 with score 1, 33
false-positives, true-negatives, and false-negatives.
with score 2, 36 with score 3, and 10 with score 4.

Table 3 Results of visual evaluation of permanent molars, according to classification of visual examination (Ekstrand et al., 1997).
Score Criteria No. molars Percentage
0 No or slight change in enamel translucency after prolonged air-drying (5 s). 23 14.7
1 Opacity or discoloration hardly visible without drying, but distinctly visible after air-drying. 52 33
2 Opacity or discoloration distinctly visible even without air-drying. 35 22.4
3 Localized enamel breakdown in opaque or discolored enamel and/ or grayish discoloration 36 23.1
from the underlying dentin.
4 Cavitation in opaque or discolored enamel exposing to dentin beneath. 10 6.4
Total 156 100
172 C. Kouchaji

Table 4 Results of laser examinations of occlusal surfaces of

permanent molars.
0 (0–14) no caries 16
1 (15–20) enamel caries 39
2 (21–99) dentinal caries 111
Total 156

Table 5 The relationship between the visual and laser

examinations of occlusal surfaces of molars.
DIAGNOdent pen (VE) Visual score of caries
score recommended (Ekstrand et al., 1997)
by manufacturer
0 1 2 3 4 Total
0 (0–14) no caries 12 4 0 0 0 16
1 (15–20) enamel caries 10 27 2 0 0 39
2 (21–99) dentinal caries 1 21 33 36 10 111
Total 23 52 35 36 10 156

Figure 1 Receiver Operating Characteristic curves and Areas

Under the Curves.

Table 6 Interpretation of kappa scores developed by Landis

and Koch (1977) Kappa Strength of agreement.
0.00 Poor
0.01–0.20 Slight
0.21–0.40 Fair
0.41–0.60 Moderate
0.61–0.80 Substantial
0.81–1.00 Almost perfect
3.3.2. Kappa value
The kappa value was 0.94, which as shown in Table 6, lies in
the 0.81–1.00 band and is considered almost perfect (Landis
and Koch, 1977). The results showed a better relationship be-
tween visual inspection and examination with DIAGNOdent,
meaning that DIAGNOdent is a diagnostic modality in the
present study with respect to operative intervention.
3.3.3. Sensitivity and specificity
The positive and negative odds ratios were 82.73 and 7.7,
respectively. The positive and negative predictive values were
7.1 and 2.6, respectively. The limitation was that the sensitivity
and specificity of the laser fluorescence system were 0.97 and
0.52, respectively.
3.3.4. ROC curves and the value of the AUC
To determine the laser fluorescence pen’s diagnostic precision,
an ROC curve was traced. The AUC value of the ROC curve
for the laser fluorescence system for permanent molars was
0.924 (Fig. 1).
4. Discussion
Not only is the occlusal surface the area that is most suscepti-
ble to dental caries, it is also the most difficult surface for the
reliable detection of caries (Pinheiro et al., 2008). For this rea-
son, several investigators have attempted to discover a method
capable of assisting the clinical examination in diagnosing
occlusal caries.
Table 7 Sensitivity and specificity.
Disease No disease
Positive test a b
Negative test c d
Sensitivity = a/(a + c).
Specificity = d/(b + d).
Positive Predictive Value = a/(a + b).
Negative Predictive Value = d/(c + d).
Among the methods reviewed, the laser fluorescence of the
DIAGNOdent pen appliance (KAVO, Biberach, Germany)
has shown the greatest promise. The caries-detection capability
of the DIAGNOdent has been tested on occlusal surfaces in
numerous studies (Lussi et al., 1999, 2001; Shi et al., 2000; At-
trill and Ashley, 2001; El-Housseiny and Jamjoum, 2001;
Heinrich-Weltzien et al., 2003; Anttonen et al, 2003; Côrtes
et al., 2003; Lussi and Francescut, 2003), and its performance
has been compared with that of visual inspection, histology,
radiography, and quantitative light-induced fluorescence.
This study evaluated the clinical applicability of the DIAG-
NOdent laser device as a complementary tool in the visual
exploration of the occlusal surfaces of permanent first molars.
The criteria adopted in this study to determine the validity of
carious lesions were published by Ekstrand et al. (1997), which
classified the integrity of the occlusal surface according to its
histological validation. However, histological validation was
not possible in this clinical study and thus we used the gold
standard, visual examination, which is essential for confirma-
tion of the laser device’s diagnosis, similar to other authors
(Heinrich-Weltzien et al., 2003; Sheehy et al., 2001).
The DIAGNOdent evaluation criteria in this study used
were those defined previously by the manufacturer. In addi-
tion, several authors (Rocha et al., 2003; Alwas-Danowska
et al., 2002; Lussi et al.,1999; Heinrich-Weltzien et al., 2003;
Comparison between a laser fluorescence device and visual examination in the detection of occlusal caries in children
Konig et al., 1993) used the same criteria as those used in other
in vitro studies (Côrtes et al., 2003; Seremidi et al., 2011).
This study included 156 first permanent molars from 40 pa-
tients aged from 7 to 12 years old. The mean patient age was
9.5 ± 1.8 years, with 21 male and 19 female. This study, like
others (Huth et al., 2008; Toraman Alkurt et al., 2008),
detected caries in the occlusal surface of first permanent mo-
lars. The study of Tomasik et al. (2005) also included 237 first
permanent molars, not sealed and non-cavitated due to caries,
in 84 children aged 6–7 years (mean age 6.74 ± 0.63). The
study of Sheehy et al. (2001) included 170 first permanent
molars and compared the DIAGNOdent with a visual caries-
scoring system (Ekstrand et al., 1997).
4.1. The kappa value
The kappa coefficient, which is very important for assessing
the reproducibility of a method, was employed to measure
the agreement between the categorical data. In the present
study, the kappa value was 0.94 indicating good repeatability
for both the laser fluorescence device and visual examination
(Landis and Koch, 1977). The reported kappa value in similar
comparative studies in the literature varies widely: it was 0.98
in the study of Lussi et al. (1999), 0.89 in the study of Sheehy
et al. (2001), 0.93 in the categorical data study of Lussi et al.
(2001), 0.85 in the study of Anttonen and Vuokko (2007),
0.88 in the study of Heinrich-Weltzien et al., 2003, 0.816 in
the study of Zaidi et al. (2010), but just 0.231 in the study of
Duruturk et al. (2011), revealing ‘‘poor’’ statistical agreement
between the two diagnostic methods. This may be because
the method is correct for the early caries lesions in newly
erupted first permanent molars only. All these studies of the
occlusal surface were in vivo and these figures represented good
to excellent agreement. Nonetheless, reproducibility is not al-
ways important, because a test may be reproducible, but inac-
curate. Accordingly, the sensitivity and specificity tests are
vital for assessing the worth of a diagnostic method.
4.2. Sensitivity and specificity
In this study, the sensitivity and specificity of the laser fluores-
cence system were 97% and 52%, respectively. Various in vivo
studies have evaluated DIAGNOdent’s sensitivity and specific-
ity (Barbarı́a et al., 2008; Sheehy et al., 2001). Although most
sensitivity values tended to be high, they varied widely, from
0.19 to 1.0. Specificity values exhibited a similar pattern, rang-
ing from 0.52 to 1.0 (Bader and Shugars, 2004). The sensitivity
value obtained in this study was 97%, which was 17% higher
than that obtained by Verdonschot et al. (2002), 40% higher
than that of Barbarı́a et al. (2008), 81% higher than that of
Angnes et al. (2005), and 92% higher than that obtained by
Sheehy et al. (2001).
The sensitivity and specificity of the DIAGNOdent experi-
mental method in the study of Lussi et al. (2001) were 92% and
86%, respectively, when carious dentin was the cut-off point;
when carious enamel was the threshold, the sensitivity was
about 96%. In the literature, varying sensitivities and specific-
ities have been reported: 93% sensitivity and 75% specificity in
the study of Costa et al. (2008), 88.9% sensitivity and 53.7%
specificity that of Krause et al. (2007), 92% sensitivity and
82% specificity in that of Anttonen and Vuokko (2007),
44% specificity in that of Chu et al. (2009), and 62% sensitivity
173
and 87% specificity in the study of Rodrigues et al. (2011).
These differences may be due to the fact that some of the stud-
ies excluded lesions with cavities, thereby increasing the per-
centage of healthy teeth and caries limited to enamel.
4.3. AUC
The AUC value for the ROC curve for the laser fluorescence
system was 0.924, which is similar to the 0.92 obtained by Reis
et al. (2006), but higher than obtained by Huth et al. (2008),
the 0.72 obtained by Barbarı́a et al. (2008), and the 0.6 ob-
tained by Angnes et al. (2005). Thus, as the AUC in this study
for first permanent molars was close to 1, these results make it
possible to state that the laser device is a highly precise tool for
the diagnosis of occlusal caries in permanent molars.
5. Conclusions
From the results of this study we believe that the DIAGNO-
dent pen is a reproducible and accurate diagnostic tool that
may be valuable as an adjunct to visual examination for occlu-
sal caries detection in first permanent molars in children.
5.1. Clinical Implications
In daily practice, dentists can consider the laser fluorescence
system a complementary tool in the visual exploration of
occlusal surfaces of first permanent molars. On the other hand,
this procedure avoided the problem of false negative findings,
which are common in clinical studies with respect to ethical
aspects.
Although the evidence recommends the use of laser fluores-
cence as a diagnostic adjunct, further in vivo studies are re-
quired, preferably comparing laser fluorescence (LF) to a
combination of visual examination (VE) and radiographic
examination (RE).
Future studies should also include all types of teeth tested
under varying conditions found in the oral cavity (restorations,
sealants, staining, calculus and plaque).
Larger sample sizes from varying age groups and diverse
ethnicities will also help strengthen the results, and provide
greater confidence when applying the findings to clinical prac-
tice (Aversa et al., 2008).
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