Diagnóstico visual

táctil de caries dental

basado en evidencias
Como evaluar la evidencia científica desde de la
perspectiva de la MBE-OBE

Mauricio Rodríguez Godoy. OD-MSc

Profesor asociado
Departamento salud oral
Facultad Odontología

Universidad Nacional de Colombia.

Octubre 2013
Evaluación: ?
Eficacia Pregunta
Eficiencia de los pasos contestable
anteriores
MBE Búsqueda de la
Integración: CSBE mejor evidencia
Experiencia
Biología Revisión
Valores pacientes critica
Escenarios
?

Centro de medicina basada en evidencias de Toronto, disponible en: http://ktclearinghouse.ca/cebm/intro/howtopractice.

ESCENARIO CLINICO
En un paciente de 12 años de edad de sexo
masculino, quien es llevado por la madre para
control a su consultorio, pregunta sobre una
manera que conoció en internet de detectar
lesiones de caires, entonces, quiere saber si el
laser fluorescente llamado (DIAGNOdent)
detecta caries que posiblemente no se ven el
examen clínico.
1. Pregunta contestable

En niños de 12 años que asisten a control de salud oral, el laser

fluorescente es mejor que el examen visual-táctil ICDAS para detectar
lesiones no cavitacionales oclusales?

2. BUSQUEDA DE LA
EVIDENCIA
 !
En el proceso diagnóstico no se trata de
encontrar la verdad absoluta sino de
limitar la incertidumbre.!
Sackett DL, Straus SE, Rochardson WS, Rosenberg W, Haynes RB.

Evidence-Based Medicine. How to practice and teach EBM.

Churchill-Livingstone. Edinburgh. 2nd. Ed. 2000.
Proceso Diagnóstico
o  Historia clínica!
•  Signos, síntomas, antecedentes, examen físico !
o  Sospecha del diagnóstico!
o  Prueba diagnóstica (Examen, laboratorio, medida,
radiografía etc) !
o  Resultado: aumenta o disminuye la sospecha diagnóstica !
 El proceso diagnóstico

y ¿cuándo podemos afirmar que el individuo tiene
una enfermedad?
 El proceso diagnóstico
Umbral de! Umbral de!
Diagnóstico! Tratamiento!
(exclusión) (acción)

No haga Haga pruebas y No haga

pruebas trate de acuerdo pruebas
con los resultados
No trate Inicie
de las pruebas
tratamiento

Prevalencia (probabilidad pre-prueba) del desorden

 Diagnóstico de la caries

La verdad de la caries.

La evaluación de la verdad de
caries depende de la resolución de
los instrumentos de medición y
técnicas disponibles (Bader and Shugars, 1995)

Baelum V, Nyvad B. H-G. Grondahl, Fejerskov O: The foundations of good diagnostic practices DENTAL CARIES , Ed. Blackwell 2008
 PRUEBA DIAGNÓSTICA VISUAL TACTIL
El “iceberg de la caries dental”. N.B. Pitts. J Dent Res 83(Spec Iss C):C43-C47, 2004

D4 lesión Usado en
dentro de la pulpa examen de
encuesta
epidemiológica
D3 lesión clínicamente clásica.
detectable en dentina

D2 cavidades limitadas al esmalte En exámenes

clínicamente detectables. clásicos de
Investigación y
práctica.
D1 lesiones clínicamente detectables en
Considerados
Como libres de
esmalte con superficie intacta
caries
Ayudas dx. adicionales en
D0 lesiones detectables únicamente con ayudas algunas prácticas y E.C.
Diagnósticas adicionales. (ej. FOTI DIAGNOdent)
Para nuevas
herramientas
Lesiones iníciales subclínicas en un estadio dinámico de dx. ahora o
Progresión/regresión. en un futuro
 Posibilidades en la interpretación de una
Prueba Diagnóstica

o Que el resultado sea positivo y el paciente

SÍ tenga la enfermedad (Verdadero positivo)!
!
o Que el resultado sea positivo y el paciente
NO tenga la enfermedad (Falso positivo)!
 Posibilidades en la interpretación de una
Prueba Diagnóstica

o Que el resultado sea negativo y el paciente SÍ

tenga la enfermedad (Falso negativo)!
!
o Que el resultado sea negativo y el paciente NO
tenga la enfermedad (Verdadero negativo)!
Matriz de prueba diagnóstica para una
prueba de resultados dicotómica (P) !
en el diagnóstico de la caries

Estado de verdad de la
caries Gold Standard
Caries Caries Ausente
Presente!

Resultado de ! + (VP)! (FP)

la prueba
visual tactil - (FN) (VN)
 U n m é t o d o d e
diagnóstico es bueno,
si combina información
útil para el profesional y
para el paciente

Baelum V, Nyvad B. H-G. Grondahl, Fejerskov O: The foundations of good diagnostic practices DENTAL CARIES , Ed. Blackwell 2008
 Valor Predictivo
o  Positivo: La probabilidad de que un ó una
paciente con un examen positivo sea realmente
positivo (que sí tenga la enfermedad) !
o  Negativo: La probabilidad de que un ó una
paciente con un examen negativo sea realmente
negativo (no tenga la enfermedad) !
Desde el punto de vista del paciente:

o  Si el resultado del examen es positivo,

¿entonces tengo la enfermedad?!
o  Si el resultado del examen es negativo,
¿entonces estoy sano?!
Características operativas de una prueba

!
a VP!
VPP+ !
a+b VP +FP
Características operativas de una prueba

!
d VN!
VPN- !
c+d FN +VN
Sensibilidad y Especificidad
o  Sensibilidad: La cantidad de personas
enfermas y con un examen positivo entre
las personas enfermas: a/a+c!
o  Especificidad: La cantidad de personas
sanas y con un examen negativo entre las
realmente sanas: d/b+d!
Características operativas de una prueba

!
a VP!
Sensibilidad !
a+c VP + FN
Proporción de pacientes con la
enfermedad que tienen un test
positivo.
Un test con una sensibilidad
del 77%….significa que el test
identificará 77 de 100
pacientes con la enfermedad.
Características operativas de una prueba

!
d VN!
Especificidad !
b+d FP + VN
Proporción de personas sin la
enfermedad quienes tienen un
test negativo.
Un test con 75 % de
especificidad, será
NEGATIVO en 75 de 100
personas sin la enfermedad
 En resumen….
o  Entre quienes tienen un resultado positivo, ¿quiénes tienen
la enfermedad?!
•  Valor predictivo positivo !

o  Entre quienes tienen la enfermedad, ¿quiénes son

positivos?!
•  Sensibilidad!

o  Es mas útil, en el contexto del paciente, el valor predictivo

positivo!
 En resumen….
o  Entre quienes tienen un resultado negativo, ¿quiénes son
sanos?!
•  Valor predictivo negativo !

o  Entre los sanos, ¿quiénes tienen un resultado negativo? !

•  Especificidad !

o  Es mas útil en el contexto del paciente el valor predictivo

negativo!
 Curvas ROC
Verdaderos positivos

Falsos positivos
Likelihood ratios

Positive likelihood ratio (LR+) !

Cuanto más probable es que un test positivo se encuentre en una
persona con la enfermedad que en una persona sin ella?!
LR+ = sens/(1-espec) !
!
!
Negative likelihood ratio (LR-) !
Cuanto más probable es que un test negativo se encuentre en una
persona sin la enfermedad que en una persona con ella?!
LR- = (1-sens)/(espec) !
Que significa el LR?

LR=1 LR>10 =
LR<0.1 = resultado
resultado No valor fuertemente
fuertemente diagnóstico positivo
negativo
 En niños de 12 años que asisten a control de salud oral, el laser
fluorescente es mejor que el examen visual-táctil ICDAS para detectar
lesiones no cavitacionales oclusales?

3. REVISION CRITICA: V. I. A.

V: La pregunta esta bien planteada?. Las comparaciones son apropiadas?, con un estándar?
A todos los pacientes se les hizo la prueba y el gold estándar?.
Los resultados de las pruebas fueron enmascaradas e independientes?.
El estado de enfermedad y la forma de ejecutar las pruebas se describió?

I: Son presentados los rendimientos operativos de las pruebas, de manera que puedan ser
calculados?, podrían ocurrir por azar?, presentan los intervalos de confianza?

A: Pueden ser aplicados los resultados y las pruebas a la población de interés?.

El resultado de la prueba puede conducir al bien estar o cambio de tratamiento del paciente?
.
www.phru.nhs.uk/learning
 ions.
ars fromThe teeth were
26 patients agedselected
10 to 13 yearsaccording to the
were selected. radiolucency; (1) radiolucency confined to enamel, and (3)
dy usedthat
criteria posterior
have permanent
already been teeth withinand
used without
a similar Laser
radiolucency Fluorescence
extending into Method
dentin3,4,17.
chlesions.
surfaceThe had teeth were selected
to meet one of the according
three listed to the A laser fluorescence system (DIAGNOdent - KaVo,
bengincluded
criteria thatin the have already
study: been used in a intact
macroscopically similar Laser Fluorescence
Biberach, Germany) was Method used for this study. Initially, a non
Each surface had to meet
ssure that exhibited absolutely no signs of caries;one of the three listed carious portion of each system
A laser fluorescence tooth was (DIAGNOdent
selected in- order KaVo, to
to be with
ssure includeda in the study:
discolored, brownmacroscopically
or black areaintact
at Biberach,
provide a Germany)
baseline was used for this
measurement. The study.
probe Initially,
tip A a non
(narrow)
al fissureUSE that
OFexhibited
DIAGNODENT  FOR DIAGNOSIS
absolutely no signs OFof caries;
NON-CAVITATED carious DENTIN
OCCLUSAL portionCARIES of each tooth was selected in order to
cal examination without cavitation; grey was then tracked across the occlusal fissure and a peak
al fissure with a discolored, brown or black area at provide a baseline measurement. The probe tip A (narrow)
on from the underlying dentin without enamel reading recorded. The probe tip was positioned on this spot
inical examination without cavitation; grey was then tracked across the occlusal fissure and a peak
n.ration from MATERIAL
USE OF DIAGNODENT AND FORMETHODS
DIAGNOSIS OF NON-CAVITATED OCCLUSAL
the underlying dentin without enamel and
readingrotated
DENTIN around
recorded. CARIESitsthe
associate The probe vertical
visual axis
tip was until theofhighest
appearance
positioned onthe thistoothvalue
spot and the
xaminers,
own. experienced in caries diagnosis, were was found radiographic
and rotated
15
. The instrument
around film. Theaxis
its vertical presence
must until ortilted
be the absence
highest ofvalue
around occlusal
the caries
Oneequipment
hundred and ninety-nine permanent molarsmeasuring
and was established
ensurebythat the criteria shown in Table up 1: (0) no
ouse the laser
examiners,
MATERIAL experienced AND
(DIAGNOdent,
in caries
METHODS diagnosis, KaVo, were was found 15site
. The
associate
toinstrument
the visual must thebetip
appearance tiltedhadaround picked
of the totooth theandand the(3)
Germany) premolars fromthe26manufacturer
patients aged 10 to 13 years were selected. radiolucency; (1) radiolucency confined enamel,
to use thefollowing instructions. fluorescence from to the slopes of thethe tipfissure walls . The
14
laser equipment (DIAGNOdent, KaVo, measuringradiographic site ensure
film. that
The presence had
or absence picked up
3,4,17 of occlusal caries
dentists Thehadstudyalreadyused posterior
participated permanent
in an teeth with and withoutpresence or radiolucency
absence of extending
caries wasintodetermined
dentin . 14 using
ch, Germany) following
Onelesions.
carious hundredThe the manufacturer
andteethninety-nine in
permanent
were selected
vitro
instructions. molars and
3 according to the
fluorescence from the slopes of
was established by the criteria shown the fissure walls
in Table . The 1:the
(0) no
orming
me dentists apremolars
similar
had alreadydiagnostic with
participated this device
in an in . vitro cut-off
presence points
or suggested
absence of by
caries Lussi,
was et al. 16
determined : (0) 0 to
using 20:the no
following from criteria26 patients
that have aged 10 to 13
already been years were selected.
3used in a similar
radiolucency;
Laser Fluorescence (1) radiolucency Methodconfined to enamel, and (3)
erforming
electionstudy The a similar
of the3 subjects,
study diagnostic
used an
posterior with
explanation this
permanent device
about
teeth .
the
with and cut-off
active
without carepoints
or suggested
preventive
radiolucency by
care
extending Lussi,
is et
advised
into al.
dentin : (0). 0ortoPCA);
(NCA
16 3,4,17
20: no(1)
. Each surface had to meet one of the three listed A laser fluorescence system (DIAGNOdent - KaVo,
ergiven
selection
and of
cariousthe the subjects,
legal
lesions. The an
guardians explanation
teeth of
were the aboutaccording
patients
selected the to21active
theto carepreventive
29: or preventive or care is advised
operative care (NCA
is or PCA);
advised (PCA (1) or
criteria to be included in the study: macroscopically intact Biberach, Germany) was used for this study. Initially, a non
was
nformed given and
consent.
following the legal
Ethical
criteria guardians of
approvalabsolutely
that have the
was obtained
already beenpatients
used in a 21 to 29:
OCA), and (2)
similar preventive
Laser ³ 30: or operative
Fluorescence
operative care care
Method is advised
istooth
advised (OCA) (PCA or
(Table
occlusal fissure that exhibited no signs of caries; carious portion of each was selected in order to
an informed
study
thics Committee consent.
3
. Each
occlusal fissure Ethical
surface
of thewith Health approval
had to meetwas one
Science Center
a discolored, obtained
brown ofof the three
or black area OCA),
listed
1). at and (2) A ³ 30:
laser operative
fluorescence care is advised
system (OCA)
(DIAGNOdent
provide a baseline measurement. The probe tip A (narrow) (Table - KaVo,
e Ethics Committee
criteria
sity of Brasília. to be of the
included Health
in the Science
study:
the clinical examination without cavitation; grey Center
macroscopically of 1).
intact Biberach,
was thenGermany)tracked across was used theforocclusal
this study. Initially,
fissure andaanon peak
versity discoloration
of Brasília.
occlusal fissure that exhibited absolutely
from the underlying dentin without enamel no signs of caries;
Validationreading carious
method portion
recorded. The probe tip was positioned on thisto
of each tooth was selected in order spot
occlusal fissure with a discolored, brown or black area Validation
at method
provide a baseline measurement. The probe tip A (narrow)
nspection breakdown. The validation and rotatedmethod around for its vertical (gold
diagnosis axis untilstandard)the highestwas value
l Inspection theTwoclinicalexaminers,examination
experienced without
in caries cavitation; grey
diagnosis,determined
were The was
validation
was then tracked
method
found eradication
15 across
for the
diagnosis
. The instrument occlusal
(gold fissure
standard)
must be tilted and
was a
8 around the
peak
cleaning
er cleaning
and
discoloration
and
drying from
drying
the tooth
the
the tooth
surface,
underlying
surface,dentinvisual without
visual enamel by
reading
determined measuring
fissure
recorded.
by fissure eradication The probe or enameloplasty
tip was
or enameloplasty positioned 8 on using
using this spot
ntion waswas trained
performed to use the laser equipment
in ina conventional (DIAGNOdent,
dental KaVo,
an invasive fissure sealingsite to
kit ensure
(KGSorensen, that
Sorensen, the tip
Barueri, had picked
SP,value up
breakdown.
performed a conventional dental an invasive and rotated
fissure aroundkit
sealing its(KG
vertical axis until the highest
Barueri, SP,
Biberach, Germany) following the manufacturer instructions. fluorescence from the slopes of the fissure walls . The 14
t under
ment under artificial
Two artificial light
examiners, light without
experienced
without probing
in
probing oror
caries diagnosis, Brazil).
were
Brazil). However,
was found
However, not
not
15 all fissures could be validated as this
.all
The instrument
fissures must be tiltedasaround the
The same dentists had already participated in an in vitro presence or absence ofcould
caries bewas validated
determined thisusing the
ion. trained to use the laser equipment (DIAGNOdent,
ication. study performing a similar diagnostic with this deviceis. an invasive is
KaVo,
3 an invasive method.
measuring
method.
cut-off points
Thus,
site
Thus, to for
ensureethical
for ethical
suggested
that reasons,
the
reasons,
by Lussi,
tip opening
had
opening
et al. 16 picked
: (0) of
of up
0 to 20: no
esence
e presence Biberach,
or absence
or absence Germany)
of occlusal
of following
occlusal caries the
caries wasmanufacturer
was recorded
recorded instructions.
the
the cavities
cavities fluorescence
occurred
occurred from
only
only the
in
in slopes
cases
cases of
when
when the fissure
both
both walls14. The
examiners
examiners
After selection of the subjects, an explanation about the active care or preventive care is advised (NCA or PCA); (1)
cores
he scores The
shown same
shown in Tabledentists
ingiven
Table 1:andhad
(0)(0)
1: already
nono caries;participated
caries; (1)(1)caries
caries in an in vitro
agreed
agreed to
to presence
the presence
presence or of absence
of dentin
dentin of caries
caries.
caries. was
The
The determined using the
decision-making
decision-making
study was the legal guardians of the patients 21 to 29: preventive or operative care 16is advised (PCA or
denamel, study
andand performing
(2) caries a similar
beyond diagnostic
thethedentinoenamelwith this device 3
.
about
about invasive cut-off points
treatment suggested by Lussi, et al. :least
(0) 0one
toone
20: no
to enamel,
signed an(2) caries
informed beyond
consent. dentinoenamel
Ethical approval was obtained invasive OCA), treatment
and (2) was ³was carriedout
30:carried
operative out when
when
care atat
is advised least(OCA) (Table
After selection of the subjects, an explanation about the active care or preventive care is advised (NCA or PCA); (1)
n. . from the Ethics Committee of the Health Science Center
17 3,4,17
diagnostic
diagnostic
of method
1). showed
showedscore score22by byeacheachexaminer.
examiner.
study was given and the legal guardians of the patients 21 to 29: preventive or operative care is advised (PCA or
eteria
criteria
used used
to to record
record theofthe visual
visual appearanceofofteeth
appearance teeth When both examiners decided totoconduct ananoperative
the University
signed an informed Brasília.
consent. Ethical approval was obtainedWhen OCA), examiners
and (2) ³ 30: decided
operative conduct
care is advised operative
(OCA) (Table
ased on Ekstrand, et al. (1998). A sound tooth (score
7 7
intervention,Validationa conservative methodpreparation was used to remove
/A, Sensitivity, specificity, accuracy, area under the
xam- Ballerup, Denmark) using silicon 3 2
using (60 lm of grain size) cooled under ROC curve (Az) and likelihood ratios (LR+) were 4
per Table 1. ICDAS-II criteria (2) calculated (MedCalc for Windows, version 9.3.0.0, Total 14
as to
Progression of the grinding process
bility
cting
ICDAS-II
grain code
size 30,Clinical
18, criteria
8 and 5 lm) was
description
Results
DAS Table 2. Criteria used in the histological examination
checked0 under Sound the tooth surface: no evidence of caries
microscope (magni-
after prolonged air drying (5 s)
From the 163 occlusal test sites analyzed in this
Criteria proposed by
5·) until 1 the periphery of the
First visual change siteopacity
in enamel: wasor study Score
(one site in each
Ekstrandtooth),
et al. (13) the histological
discoloration (white or brown) is visible at
he teeth surfacesthe were then
entrance to thecolored with
pit or fissure after examination
0 revealedNothat
enamelseven of them were
demineralization
prolonged air drying, which is not or
hodamine B (Fluka, hardlyBuchs,
seen on a Switzerland).
wet surface caries-free,
1 12 had caries extending
Demineralization up totothehalfway
limited outer
on e-half of the enamel thickness
2 Distinct visual change in enamel: opacity or
ogical assessments, the rhodamine B
discoloration distinctly visible at the
through2 the enamel, 67 had caries between
Demineralization extending in the
inner one-half
olars,
fromeither into the enamel
entrance to the pitorand both thewet,
fissure when inner half of enamel, 47of the enamel and outer one-third
had caries in dentin and 30
of the dentin
lesion must still be visible when dry
dozen
the dentin
3 tissues
Localized (magnification
enamel breakdown due 10·)
to caries had deep
3 dentin caries. Table 3 inshows
Demineralization thethird
the middle cross
was with no visible dentin or underlying of the dentin
ed.
t the
Two different histological
shadow: classifica-
opacity or discoloration tables 4with both Ekstrand et al. (13)
Demineralization in and Lussi
the inner third et al.
than the natural fissure ⁄ fossa
s – Ekstrand et wider
teeth al. (13)
when wet and andafter Lussi
prolongedet airal.
drying
of the dentin
(1) histological scores for the ICDAS-II.
s
usedin to record caries
4 Underlying extension at each
dark shadow from
F- in dentin ± localized enamel breakdown
dTable
the 2).
5 Distinct cavity with visible dentin: visual
evidence of demineralization and dentin Table 3. Cross-tabulation for ICDAS-II with the two
caler exposed
USA).
histological classification system
6 Extensive distinct cavity with visible
analysis
water dentin and more than half of the surface
ICDAS-II
intra-examinerinvolved
Trisa, reproducibility was
y calculating unweighted kappa coeffi- 0 1 2 3 4 5 6 Total
Kappa values above 0.75 denoted excel- Ekstrand et al. (13)
ment, while values between 0.40 and 0.75 0 4 1 2 7
ood agreement (15). 1 3 1 3 4 11
2 6 6 42 51 2 107
examiner, the relationship between the
3 1 3 12 2 3 21
riteria and both the histological classifi- 4 2 7 3 5 17
ems were determined using the Spear- Total 14 8 50 76 5 10 163
Community
rrelation Dent Oral Epidemiol
coefficient. 2009; 37: 399–404
A correlation Lussi et al. (1) ! 2009 John
All rights reserved 0 4 1 2 7
of 0.70 or above indicates a strong
1 3 1 4 4 12
 Operative intervention was indicated for 86 teeth by the
dentists. Forty-eight teeth were not drilled because the
examiners did not indicate restorative treatment. In fact, the
examiners detected enamel caries or stained fissure in most
of these teeth. They were excluded from the sample because
teeth were considered without dentin caries by both
examiners. The first and third quartiles showed that score 1
was the most frequent score (Table 2).
Sixty-five teeth were considered sound exhibiting
absolutely no signs of caries nor demineralized or stains in

TABLE 1- Scores for diagnosis of occlusal caries by visual inspection, bitewing radiography, DIAGNOdent laser device and
validation method

Score Visual Radiograph Laser Validation

inspection method

0 No caries No radiolucency 0 to 20 No caries

1 Caries confined Radiolucency confined 21 to 29 Caries confined
to enamel to enamel to enamel
2 Caries extending Radiolucency extending ≥ 30 Caries extending
to dentin to dentin to dentin

TABLE 2- Comparison of DIAGNOdent’s scores for the excluded teeth, opened teeth and sound teeth

DIAGNOdent Excluded teeth Opened teeth Sound teeth

(48) (86) (65)

Examiner 1 Mean (average) 0.9791667 1.8372093 0.1692308

1 st
quartile 1 2 0
3 rd
quartile 1 2 0
Examiner 2 Mean (average) 0.9166667 1.7674419 0.1230769
1 st
quartile 1 2 0
3 rd
quartile 1 2 0

TABLE 3- Sensitivity (Se), specificity (Sp), positive (PPV), negative (NPV) predict value and likelihood ratio (LR) of the
methods for detection of dentin caries

Methods Se % Sp % PPV % NPV % LR

 %

Examen visual para Post test

caries en dentina en 95%
niños de 12 años? J Appl
Oral Sci. 2008;16(1):
18-23.
LR+ = 10.11

Pre test 57% ENSAB

III

Nomograma de Fagan
%
http://ktclearinghouse.ca/cebm/toolbox/statscalc