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This paper aims at illustrating the different diagnostic methods and compare the reliability of the Digital Imaging Fiber Optic Transillumination (DIAGNOcamTM, KaVo Kerr, Brea, California, US) with the use of intraoral radiographs. Since the discovery of radiography, various methods have been introduced in order to provide early diagnosis of caries. In this review, specific keywords have been chosen on different search engines and medical databases. Scientific pa-pers published from 1990 to 2022 were included. Nine articles comparing two different methods for early detection of carious lesions were selected. An analysis of the existing literature seems to support the hypothesis that making diagnosis by using the Digital Imaging Fiber Optic Transillumination systems represents a safe and effective support for early diagnosis of interproximal carious lesions within enamel. However, it is still to be considered a complementary method to traditional bitewing and periapical radiographs.
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1971-1441
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2
en
Alberto  De Stefani
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Annali di stomatologia
Restorative Dentistry
Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review
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Original Article
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Alberto  De Stefani
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Dental Clinic, Department of Neuroscience, University of Padua, 35121 Padua, Italy; Department of Pharmacological Sciences, University of Padua, 35121 Padua, Italy
1971-1441
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Restorative Dentistry
en
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Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review
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                                                                                                   Original Article


Diagnostic reliability of the Digital Imaging Fiber
Optic Transillumination: a review




Giovanni Bruno1,2*                                          pers published from 1990 to 2022 were included. Nine
Michele Basilicata*2,3                                      articles comparing two different methods for early de-
Alessandra Semisa1                                          tection of carious lesions were selected.
Simona Giani7                                               An analysis of the existing literature seems to support
Antonio Gracco1                                             the hypothesis that making diagnosis by using the
Patrizio Bollero2,5                                         Digital Imaging Fiber Optic Transillumination systems
Raffaella Docimo8                                           represents a safe and effective support for early diag-
Roberto Sorrentino6                                         nosis of interproximal carious lesions within enamel.
Alberto De Stefani1,4                                       However, it is still to be considered a complementary
                                                            method to traditional bitewing and periapical radio-
                                                            graphs.
1
    Dental Clinic, Department of Neuroscience, University
    of Padua, 35121 Padua, Italy                            Keywords: DIFOTI, Digital Imaging Fiber Optic
2
    Department of Experimental Medicine and Surgery,        Transillumination, Caries, Pediatric Dentistry , Spe-
    University of Rome Tor Vergata, 00133 Rome, Italy       cial Care Dentistry, Early Diagnosis, Restorative
3
    UOSD Special Care Dentistry, Policlinico Tor Vergata,   Dentistry.
    00133 Rome, Italy
4
    Department of Pharmacological Sciences, University
    of Padua, 35121 Padua, Italy                            Introduction
5
    Department of Systems Medicine, University of Rome      Dental caries represents nowadays the most prevalent
    Tor Vergata, 00133 Rome, Italy                          chronic disease throughout most of the world, affecting
6
    Department of Neurosciences, Reproductive and           approximately 97% of the population [1,2] with a prev-
    Odontostomatological Sciences, Univerisity “Federico    alence of 21,6% among the 4-years-old children and
    II” of Naples, 80131 Naples , Italy                     43,1% among the 12-years-old children [3]. In the last
7
    Private Practice Casciago (VA), 21020 Varese, Italy     decades, the prevalence of this condition tended to de-
                                                            crease for the widespread use of fluoride in toothpastes
8
    Pediatric Dentistry, Department of Surgical Sciences,
                                                            and in foodstuffs. Due to its widespread diffusion, it is
    University of Rome Tor Vergata, 00133 Rome, Italy;
                                                            considered a major public health problem and thus re-
                                                            quiring efficient procedures for primary prevention, as
Corresponding author:                                       well as an early and correct diagnosis, with the goal
michele.basilicata@ptvonline.it (M.B.)                      of minimally invasive treatments. According to World
giobruno93@gmail.com (G.B.)                                 Health Organization (WHO), tooth decay is defined as
                                                            “an external and localized pathological process that aris-
(*) These authors are equally contributed to this work.     es after the eruption of the tooth and involves a softening
                                                            of the hard tissues with consequent formation of cavities”
                                                            [4]; more precisely it has been described by some au-
Abstract                                                    thors as a progressive, destructive, irreversible, and in-
This paper aims at illustrating the different diagnostic    fectious disease that affects the hard tissues (i.e. enam-
methods and compare the reliability of the Digital Im-      el, dentine, cement) of teeth from the outermost surfaces
aging Fiber Optic Transillumination (DIAGNOcamTM,           to the depth, thus inducing growing demineralization and
KaVo Kerr, Brea, California, US) with the use of in-        dissolution of the organic substances [5].
traoral radiographs. Since the discovery of radiogra-       Causal factors involved in the carious pathology are dif-
phy, various methods have been introduced in order          ferent (i.e. dental plaque, fermentable carbohydrates,
to provide early diagnosis of caries. In this review,       time factor, host receptivity, age, systemic health, intake
specific keywords have been chosen on different             of fluoride, degree of education, socio-economic status,
search engines and medical databases. Scientific pa-        previous caries), so defining a multifactorial etiology



10.59987/ads/2023.2.13-17                                                                                                 13
     Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review

  and a pathogenesis based on the commonly accepted                  (this?) review through the citation searching of Scopus
  “chemico-parasitic” theory of Miller, who affirms the              and Google Scholar. National (Italian) guidelines for ra-
  chemical-acid nature of the lesions caused by the acid             diological diagnostics in childhood of 2018 and nation-
  products of bacterial metabolism of carbohydrates [5, 6].          al (Italian) guidelines for oral health promotion and oral
  Following the clinical course of the disease, based on             pathologies prevention in childhood of 2013 have also
  continuous and unbalanced processes of remineraliza-               been consulted. The systematic search has been carried
  tion and demineralization of tooth surface at the variation        out by three different operators in the period between
  of oral pH, it is reasonable to consider its progression           May 2020 and October 2022. All the articles published
  from early sub-clinical lesions – which are in a large             before October 2022 were eligible for inclusion in the
  number of cases not diagnosed by traditional methods               present systematic review.
  – to clinical evident cavities, that gradually involve den-
  tine and dental chamber, thus becoming more easily                 Search Strategy
  to recognize as the extension of tissue destruction in-
                                                                     All the articles selected for this review were acquired us-
  creases [7].
                                                                     ing searches strategies on
  Since the discovery of X-rays, radiographic examination
                                                                     PubMed and Scopus databases up until October 2022.
  has increasingly become the main diagnostic instrument             The search strategy was performed using Boolean op-
  used in the clinical practice for caries detection.                erators) in combination with the following key words:
  For this goal, different techniques of intraoral radiogra-         “Diagnocam” OR “DIFOTI” OR “transillumination”OR
  phy can be used, however,the mostly used in conser-                “near-infrared light transillumination” OR “caries detec-
  vative dentistry remains intraoral bitewing radiographs            tion”OR “caries diagnostics”OR “risk assessment” OR
  (BTW), which permits to observe adjacent teeth crowns              “non cavitated caries” OR “fluorescence”.
  and their proximal surfaces to evaluate caries presence
  and their extension [8,9].
  Despite the low sensibility (40-65%), the radiographic             Eligibility Criteria, Study selection
  examination high specificity (98-99%), in combination              and Methodological Quality Criteria
  with clinical inspection, allows to diagnose more than
  90% of proximal lesions [8,9] with the major precision             Inclusion and exclusion criteria have been based on
  for early lesions among other methods [10]. In pediatric           populations, interventions, comparisons, outcomes, and
  dentistry, considering the early age and the usual diffi-          study designs (PICOS guidelines). Details of inclusion
  culty to manage these young patients, there is a great             and exclusion criteria are given in flowchart. Three au-
  interest for an early and accurate detection of carious            thors reviewed independently the titles and abstracts of
  lesions. It can lead to an easier outpatient management,           the articles that emerged from the search strategy, for
  allowing therefore to reduce the timing of visits and at-          the inclusion in the present systematic (qui cambia se
  tain even more precise therapeutic results, by combining           prima hai scelto narrative!) review. In case of disagree-
  traditional diagnostic methods and more recent sensible            ment about the inclusion of possible sources for full text
                                                                     reading, it has been solved by discussion and mutual
  systems. Furthermore, young patients need even more
                                                                     consensus.
  attention regarding the radiation protection and safety
                                                                     The selected papers have been subjected to a full text
  procedures.
                                                                     reading from which authors excluded in-vitro and ret-
  Recently, a new technology has been introduced in the
                                                                     rospective studies. Quality assessment has been per-
  dental market, which is based on Digital Imaging Fiber
                                                                     formed on the final list, using a methodological quality
  Optic Transillumination (DIFOTI). It detects the laser
                                                                     criterion adapted from the CONSORT statement and
  light dispersion (i.e. scattering) differences between
                                                                     Jadad quality assessment scale. The selected studies
  healthy dental hard tissue and the decayed one, which
                                                                     were independently scored by 3 reviewers.
  appears in a shade of grays [11].
                                                                     In case of disagreement, the scoring has been assigned
  In conclusion, the aim of this systematic review is to
                                                                     after discussion and mutual consensus. Each article re-
  point out the importance of early diagnosis of caries and
                                                                     ceived a score out of 11 points based on the method-
  highlight the in-vivo reliability of DIFOTI, by analyzing its      ological quality criteria and classified as ‘good’ if higher
  advantages and limits in accordance with current scien-            than 9 points, ‘moderate’ if between 7 and 9 points, and
  tific evidences.                                                   ‘poor’ if lower than 7 points.

  Materials and methods
  The present systematic review was conducted accord-                RESULTS
  ing to the Preferred Reporting Items for Systematic Re-
  views and Metanalysis (PRISMA) guidelines (www.pris-
                                                                     StudySelection
  ma-statement.org)
                                                                     After removing duplicate articles and repetitions, the sys-
                                                                     tematic research through PubMed/Medline, Web of Sci-
  Information Sources
                                                                     ence, Scopus, and Cochrane Collaboration Trial retrieved
  The authors developed a research strategy on electronic            126 articles. In the screening phase, a total of 117 articles
  databases including Medline, Web of Science, Scopus,               were excluded (articles were excluded after title read-
  and Cochrane Collaboration Trial. The electronic search            ing because regarding the unrelated topic of research,
  has been combined with a manual one, thus controlling              review articles, discussions, critical summaries, case re-
  the original reference lists and adding more articles to           ports, research reports, case series, and animal studies).



14                                                                                                       10.59987/ads/2023.2.13-17
G. Bruno et al.

A total of 43 articles were considered eligible according to        using a DIAGNOcamTM prototype, concluding that light
the inclusion and exclusion criteria and valuable for com-          source intensity represents the most significant parame-
plete full-text reading. After full-text reading, other 34 arti-    ter for image reproducibility [11].
cles were excluded because they were in-vitro studies. In           In the study by Schneiderman et al., experienced den-
the end, 9 articles met the inclusion and exclusion criteria        tists analyzed a sample of fifty extracted teeth, then the
and thus they were included in the present review.                  authors compared specificity and sensitivity of both the
                                                                    DIFOTI technology and radiography in detecting caries
Results                                                             on different tooth surfaces.
From literature review, it emerged that up to December              The results obtained brought out that DIFOTI sensitivity
2022, 9 studies evaluating the diagnostic qualities of              in proximal caries detection is twice as high as that of
DIFOTI technology were published; particularly, among               radiographs, it is ten times higher for vestibular and lin-
these, only 8 articles compared the use of DIAGNO-                  gual lesions and seven times higher for occlusal lesions,
camTM to intraoral radiographs in early diagnosis of                despite the lower specificity (10%) for these in compari-
carious lesions.                                                    son to radiographs. By relying on this evidence, Schnei-
It is interesting to note that a few studies have been con-         derman et al. affirmed that observing all tooth surfaces
ducted in-vivo, instead they were mostly performed on               and diagnosing incipient carious lesion with the DIFOTI
extracted teeth in-vitro.                                           was simple, whereas on the contrary, it was not using
Keem et al. selected 5 teeth and detected with great                radiographs; furthermore the correct interpretation of de-
sensitivity even small changes of the enamel surface by             tected images can be considered attainable as well [12].
      Identification




                       Records identified through                   Additional records identified
                          database searching                          through other sources
                               (n = 126)                                      (n = 0)




                                            Records after duplicates removed
                                                        (n =126)
      Screening




                                                      Records screened                         Records excluded
                                                         (n = 126)                                 (n = 83)
      Eligibility




                                                      Full-text articles                     Full-text articles excluded
                                                   assessed for eligibility                           (n = 34)
                                                          (n = 43)                          Article not in English,
                                                                                            Italian, Spanish (5)

                                                                                            Case-reports and books (7)
      Included




                                                    Studies included in                     Other diagnostic methods
                                                    qualitative synthesis                   (22)
                                                           (n =9)




10.59987/ads/2023.2.13-17                                                                                                         15
     Diagnostic reliability of the Digital Imaging Fiber Optic Transillumination: a review

     In a study conducted by Young and Featherstone, it has           novel early diagnosis approaches could aim at major
     been observed in vitro that DIFOTI technology does not           dental tissue preservation.
     permit to estimate the proximal caries depth towards the         For this reason, clinical diagnosis and decision-making
     dentine, unlike radiographs, and this was in accordance          processes still represent a challenge, even after many
     with other authors [18]; however, it provides the advan-         years of research that led to the development of inno-
     tage of early identification of lesions just after two weeks     vative examination technologies. The persisting limits of
     from their start, instead of four weeks as with other clini-     radiographs and DIAGNOcamTM make the early diag-
     cal and radiological methods [17, 18].                           nosis of caries still complicated but more easily achiev-
     Astvaldsottir et al. evidenced on a sample of fifty-six ex-      able, if these two examination systems are combined.
     tracted premolars that the DIFOTI technology showed              The early detection of proximal lesions can be obtained
     a significantly better sensitivity, but a lower specificity      by using DIAGNOcamTM, but radiographs still remain
     than radiographs for enamel lesions; on the contrary,            the most suitable method to evaluate the extension of
     for dentine cavities the results were comparable to              decayed tissues.
     each other, thus confirming the need for more studies            In conclusion, the application of DIFOTI to pediatric den-
     on this topic [19].                                              tistry is of great interest, as it appears to be a safe and
     Other authors have recently affirmed that the only use of        well accepted technique; nonetheless, it would be desir-
     DIFOTI in daily clinical practice cannot replace intraoral       able to have more comprehensive literature and scientif-
     radiographs [13,14], since it does not provide enough            ic evidences for a better understanding of its application
     information about conditions of dental pulp or periodon-         and limits.
     tium, however it certainly represents a safer instrument
     for periodic checkups by reducing frequent and repeated
     x-radiation [15,16].                                             References
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