Australian Dental Journal 2009; 54: 2330

S C I E N TI F I CAR TI C LE

doi: 10.1111/j.1834-7819.2008.01084.x

Clinical detection of caries in the primary dentition with and

without bitewing radiography
B Newman,* WK Seow,< S Kazoullis, D Ford, T Holcombe*

*Southside Health Service District, Queensland Health.

<School of Dentistry, The University of Queensland.
Private Practice, Queensland.

ABSTRACT

Background: Inadequate detection of caries in the primary dentition due to non-use of bitewing radiography is commonly
encountered in paediatric practice. The present study investigated the increased benefits of using bitewing radiography in addition
to the visual-tactile examination technique for detection of primary dentition caries in a non-fluoridated community, and determined
the prevalence of hidden occlusal caries in the primary dentition.

Methods: Primary teeth were scored for caries at the restorative threshold using a visual-tactile technique followed by bitewing
radiographic examination in a sample of 611 schoolchildren aged 6.4 0.5 yrs to 12.1 0.8 yrs residing in a non-fluoridated city.

Results: Overall, at the restorative threshold, the visual-tactile technique could detect 62 per cent of occlusal caries compared to 74
per cent for bitewing radiography (p < 0.001). The prevalence of hidden occlusal caries was 12 per cent. In contrast, for primary
molar proximal surface caries, the visual-tactile technique could detect only 43 per cent of caries compared with 91 per cent for
bitewing radiography (p < 0.001).

Conclusions: In the primary dentition, use of bitewing radiography increases the detection rate of proximal surface caries
substantially. It is recommended that bitewing radiography be included as part of the routine examination of children with proximal
surfaces that cannot be visualized.

Key words: Primary dentition caries, deciduous caries, hidden caries, bitewing radiography.

Abbreviations and acronyms: dmft = decayed, missing due to caries, filled, teeth; dmfs = decayed, missing due to caries, filled, surfaces.

(Accepted for publication 23 April 2008.)

2009 Australian Dental Association

INTRODUCTION

The majority of studies which investigate the efficacy of

the visual-tactile technique for caries detection have been
largely in vitro, and performed mainly on extracted
17

permanent teeth. To date, the few studies performed on

primary teeth are in vitro reports, and there is a paucity of
in vivo studies on the sensitivity and specificity of the
visual-tactile technique for caries diagnosis in the primary
dentition.

Although bitewing radiography for diagnosis of caries in

individual patients is an established clinical technique, the
value of bitewing radiography for the detection of caries in

visual examination for assessing caries experience in

young children for epidemiological purposes is thus
6

unclear. Studies in the permanent dentition suggest that

the improvement in caries detection was generally in the
order of around 35 per cent, and that bitewing
radiography probably has greatest value in those
913

populations with the highest caries rates.

In addi-tion,
hidden occlusal caries which refer to caries that cannot
be diagnosed by the visual-tactile techniques can be
revealed only by radiographic examination. Although
hidden caries is increasingly recognized as an important
clinical entity in paediatric dentistry, its prevalence in the
primary dentition has not been reported previously.

large population groups is still controversial. Previous

studies addressing this issue were performed mainly in
adults and adolescents, and there is limited information for
the primary dentition. The increased benefit of bitewing
radiographs over

The present study aimed firstly, to investigate the increased

benefits of bitewing radiography for detection of occlusal
and proximal caries compared to the visual-tactile
technique in the primary dentition, and to detect

23

B Newman et al.

the prevalence of hidden caries in the primary dentition. The second aim was to compare the sensitivity and
specificity of the visual-tactile clinical examination with
bitewing radiographic examination for detection of caries

in the primary dentition for children at Australian primary

school years 1, 3, and 7 (aged approximately 6, 8 and 12,
respectively). The sensitivity of a technique is related to the
accuracy of detecting disease when it is present, while the
specificity is related to the accuracy of diagnosing the
absence of disease.

14

SUBJECTS AND METHODS

The present study was approved by the relevant

institutional Human Research Ethics Committees. The
subjects were schoolchildren who were scheduled on their
records to have a full dental examination at primary
schools in the Logan-Beaudesert area, a non-fluoridated
community located in the Australian state of Queensland.
The consent rate for the study was 87 per cent.

The examinations were carried out by four examiners who

were calibrated for intra- and inter-examiner variability.
The calibration examinations were per-formed on six
children aged 512 years who were examined twice by
each of the examiners on two separate occasions, a week
apart. The Kappa statistic was used to test inter- and intra15

examiner reliability.

The children were examined in school dental clinics. The

visual-tactile examination was performed in the dental
chair using an operating light, a dental mirror and dental
explorer. Teeth were dried with a triplex syringe prior to
examination. Bitewing radiographs were exposed using
standard techniques. These radio-graphs were read using a
radiographic viewer without magnification. The
radiographs were read blind to the data from the visualtactile examination. All primary

tooth surfaces were scored for caries using criteria listed in

Table 1.

The total dmft figure, i.e., decayed (d), missing due to

caries (m) and filled (f) teeth (t) was calculated from the
results for the visual-tactile examination and also for the
radiographic examination respectively. The diagnostic
information from bitewing radiographic examination was
used to compute the total dmfs, i.e., decayed (d), missing
due to caries (m), filled (f) surfaces

(s) values for each age group.

Table 1 describes the visual-tactile (clinical) and

radiographic criteria employed in the present study. As can
be noted in the table, a visual-tactile score of C3
(cavitations which are detected with an explorer) or a
radiographic score of R3 (radiolucent areas which are
present in the inner half of enamel) are thresholds which
are generally employed to determine the need for
restorative treatment. These criteria provide the restor-ative
threshold which determines restorative needs in a health
service district considered high risk for caries. The lesions
which meet the criteria C3 R3 to C5 R5 (clinical
radiographic evidence that caries is present in dentine) and
C8C9 R8 (clinical radiographic evidence of recurrent
caries) were thus categorized as caries present to follow
generally accepted clinical guidelines for caries diagnosis.
Those which meet the criteria of C1 R1 and C2 R2 were
considered non-carious (enamel) lesions (clinical
radiographic evidence that lesions are limited to enamel
only).

Sensitivity was computed by determining the pro-portion

of carious surfaces that were detected respec-tively, from
visual-tactile examination and bitewing technique
compared to the total number of lesions that can be
detected by both techniques. Specificity was computed by
determining the proportion of non-carious surfaces that
were detected respectively, from visual-tactile examination
and bitewing technique

Table 1. Clinical and radiographic criteria employed in the present study

Clinical

Radiographic

C1
Sound surface
R1
Sound
C2
Discoloured surface which the sickle explorer could not enter
R2
Radiolucency in outer half of enamel
C3
Decayed surface which the sickle explorer withdrew with some
R3
Radiolucency in inner half of enamel

resistance

C4
Decayed lesion, not involving pulp, in which the sickle explorer
R4
Radiolucency in the dentine

moved freely

C5
A lesion involving pulp
R5
Radiolucency with obvious spread in the outer half of the

dentine (less than halfway through to the pulp)

C6
Restoration present-amalgam
R6
Radiolucency with obvious spread in the inner half of the

dentine (greater than halfway through to the pulp)

C7
Restoration present-plastic
R7
Filled surface and sound
C8
Restored with recurrent caries- amalgam
R8
Filled, with secondary caries (radiolucency and filling on

the same surface)

C9
Restored with recurrent caries-plastic
R9
Extracted due to caries
C10
Fractured amalgam restoration no caries-needs redoing

C11
Fractured plastic restoration no caries-needs redoing

C12
Extracted due to caries

C13
Fractured teeth-trauma

24

2009 Australian Dental Association

compared to the total number of non-carious surfaces

determined by both techniques.

Sensitivity and specificity were determined at the C3 R3

level which is considered the level at which restorative
work is generally indicated for the commu-nity under
study (restorative threshold). For compari-son purposes,

specificity and sensitivity were also determined at C2 R2

level.

Data were recorded in comprehensive data charts and

analysed using the Chi-square, students t-test and ANOVA
tests. A level of 0.05 was employed to determine statistical
significance.

Detection of primary dentition caries

mean age of 8.5 0.4 yrs) and Year 7 (n = 123, mean age
of 12.1 0.8 yrs). The children were randomly selected on
the basis that they were scheduled for their two-year recall
examination within the public school dental programme.

RESULTS

The intra- and inter-examiner consistencies were high, and

there was substantial agreement reached among the four
examiners. The unweighted Kappa statistic for both intraand inter-examiner variability for visual-tactile
examination and bitewing radiography was 0.76.

Demography of study population

The study sample consisted of a total of 611 primary

school children (322 boys and 289 girls) from a total of
nine schools in the Logan-Beaudesert health service
district of Queensland. The region is non-fluoridated and
has one of the lowest socio-economic status in the state.
The children examined for primary denti-tion caries were
selected from primary school Year 1 (n = 242, mean age of
6.4 0.5 yrs), Year 3 (n = 246,

Comparison of dmft and dmfs determined by visualtactile examination with and without bitewing
radiography

Table 2 shows the differences in dmft and dmfs values

obtained with and without bitewing radiography. As shown
in the table, the mean dmft rates obtained from visualtactile examination were 4.1 4.1 for primary school Year
1, 3.4 2.8 for Year 3 and 1.3 1.7 for Year 7. When
bitewing radiographs were employed, the dmft increased to
4.9 4.2 in Year 1, 4.0 2.9 in Year 3 and 1.5 1.8 in
Year 7 (Table 2). As shown in Fig 1, the percentage
increases in dmft rates when bitewing radiography was
employed was around 20 per cent for Year 1 (p = 0.05) and
Year 3 (p = 0.01), and 13 per cent for Year 7 (n.s.).

In the case of dmfs, the rates obtained from visual-tactile

examination were 8.3 11.8 for Year 1 primary school, 5.9
6.7 for Year 3 and 2.5 3.9 for Year 7 (Table 2). When
bitewing radiographs were employed, the dmfs increased
to 9.6 12.1 in Year 1, 7.2 7.0 in Year 3 and 3.0 4.5 in
Year 7. As shown in Fig 2, the percentage increases in
dmfs rates when bitewing radiography was employed was
around 16 per cent for Year 1 and 20 per cent for each of
Years 3 and 7 (n.s. for Year 1, p < 0.05 for Year 3 and n.s.
for Year 7).

Table 2. dmft and dmfs obtained using visual-tactile (clinical) and radiographic examination techniques

Year 1 (Mean age 6.4 0.5 yrs)

Year 3 (Mean age 8.5 0.4 yrs)

Year 7 (Mean age 12.1 0.8 yrs)

N = 242 children
N = 246 children
N = 123 children

N = 1843 primary teeth

N = 1797 primary teeth
N = 472 primary teeth

dmft

Visual-tactile (clinical)

Mean
4.1
3.4
1.3
SD
4.1
2.8
1.7
Visual-tactile + radiographic

Mean
4.9
4.0
1.5
SD
4.2
2.9
1.8
Difference

Mean
0.8
0.6
0.2
SD
1.3
1.2
0.6
p-value (visual-tactile vs. radiograph)
p = 0.05
p = 0.01
n.s.
dmfs

Visual-tactile (clinical)

Mean
8.3
5.9
2.5
SD
11.8
6.7
3.9
Visual-tactile + radiographic

Mean
9.6
7.2
3.0
SD
12.1
7.0
4.5
Difference

Mean
1.3
1.3
0.5
SD
1.8
1.7
1.2
p-value (visual-tactile vs. radiograph)

n.s.
p = 0.01
n.s.

n.s. = not significant.

2009 Australian Dental Association

25

B Newman et al.

Fig 1. Caries experience of children at primary school Years 1, 3

and 7 obtained using visual-tactile technique with and without
bitewing radiographs expressed in percentages of dmft.

*The difference in dmft among the year groups using visual-tactile

technique with and without radiographic examination is statistically
significant (p < 0.001).

120

*p<0.001
dmfs Percentage Difference

dmfs VT alone

100

80

cent

20

60

per

Year 7meanage12.10.8years

Year 1meanage6.40.5years

40

Year 3
mean age8.50.4years

All yearsmeanage8.42.2years

the maxillary first molar, to 0.93 for the mandibular first

primary molar (Table 3).
Fig 2. Caries experience of children at primary school Years 1, 3
and 7 obtained using visual-tactile technique with and without
bitewing radiographs expressed in percentages of dmfs.

*The difference in dmfs among the year groups using the visualtactile technique with and without radiographs is statistically
significant (p < 0.001).

Overall, the sensitivity for bitewing radiography for

occlusal surfaces was 0.74 compared to 0.62 for the visualtactile technique (Table 3). The additional 12 per cent of
occlusal lesions which were detected from bitewing
radiographs but not detectable by visual-tactile
examination alone is the prevalence rate of occlusal
hidden caries.

Sensitivity and specificity of visual-tactile and bitewing

radiographic examination techniques

The sensitivity of occlusal and proximal caries detection at

the restorative threshold of C3 R3 for the visual-

tactile and bitewing radiography is depicted in Table 3,

while the corresponding specificity values are shown in
Table 4.

As shown in Table 3, in total, the visual-tactile technique

showed that sensitivity of caries detection at restorative
threshold (C3 R3) for occlusal surfaces varied from 0.56
for the maxillary first primary molar to 0.73 for the
maxillary second primary molar. By contrast, for proximal
primary molar surfaces, the visual-tactile technique showed
significantly lower sensitivity ranging from 0.31 for the
mandibular second primary molar to 0.52 for the
mandibular first primary molar (p < 0.001) (Table 3).

In contrast, the bitewing technique gave sensitivity values

for occlusal surfaces ranging from 0.66 for the maxillary
second molar to 0.78 for the mandibular second molar. For
proximal molar caries detection using the bitewing
technique, the sensitivity values were significantly higher,
and ranged from 0.89 for the mandibular second molar and

26

2009 Australian Dental Association

16

For proximal caries detection at restorative thresh-old, the

sensitivity was 0.91 compared to only 0.43 for the visualtactile technique (p < 0.001). For both visual-tactile and
bitewing radiography technique, specificity values at the
restorative level of C3 R3 for all primary occlusal and
proximal tooth surfaces are very high (> 0.90; p < 0.001)
(Table 4).

At the non-restorative level of C2 R2 (Table 5), the

sensitivity values are similar at 0.70 for caries detection of
occlusal caries using the visual-tactile technique and 0.65
for bitewing radiographs. However, the sensitivity was
only 0.43 for proximal surface caries detection in all
primary molar teeth but at the non-restorative level,
specificity values for the visual-tactile technique for
detection of both occlusal and proximal surfaces was high
(0.94 and 0.99, respectively) (Table 6).

DISCUSSION

Although it is well accepted that bitewing radiography has

additional benefit in the detection of non-cavitated and
small cavitated proximal lesions, evidence for their value
in epidemiological studies is still controversial. Hopcraft
17

and Morgan reported that a clinical exam-ination

detected only 60 per cent of all occlusal and proximal
dentine caries on posterior teeth of young adults, and
suggested that epidemiological surveys

Detection of primary dentition caries

Table 3. Sensitivity of occlusal and proximal caries detection using visual-tactile and bitewing examinations at the
restorative threshold

Occlusal surfaces
N

Sensitivity

Visual-tactile

Bitewing

Y1
Y3
Y7
All
p-value

Y1
Y3
Y7
All
p-value

Maxillary D
969
0.64
0.39
0.67
0.56
p < 0.001
0.70
0.89
0.50
0.74
p = 0.05
Maxillary E
1099
0.77
0.68
0.65
0.73
p = 0.01
0.65
0.62
0.74
0.66
n.s.
Mandibular D
948
0.69
0.36
0.75
0.58
p < 0.001
0.82
0.67
0.75

0.76
p = 0.01
Mandibular E
1084
0.74
0.34
0.56
0.59
p < 0.001
0.77
0.77
0.82
0.78
n.s.
All occlusal surfaces

0.72
0.42
0.63
0.62*
p < 0.001
0.74
0.73
0.75
0.74*
n.s.
N

1843
1785
472
4100

1843
1785
472
4100

p-value

n.s.
p < 0.001
p < 0.001
p = 0.01

n.s.
p < 0.001
p < 0.001
p = 0.05

Proximal surfaces
N

Visual-tactile

Bitewing

Y1
Y2
Y3
All
p-value

Y1
Y3
Y7
All
p-value

Maxillary C
1787
0.67
0.91
0.6
0.74
n.s.
0.72
0.36
0.60
0.59
p < 0.001
Mandibular C
1635
0.33
1.00
1.0
0.60
p < 0.001
0.89
0.50
NA
0.67
p < 0.001
Maxillary D
1932
0.43
0.46
0.41
0.44
n.s.
0.92
0.85
0.91

0.88
n.s.
Maxillary E
2192
0.44
0.42
0.38
0.42
n.s.
0.89
0.94
0.95
0.92
n.s.
Mandibular D
1900
0.55
0.45
0.44
0.52
p < 0.001
0.96
0.90
0.82
0.93
p = 0.01
Mandibular E
2177
0.42
0.15
0.64
0.31
p = 0.01
0.93
0.95

0.89
0.89
n.s.
All proximal surfaces

0.47
0.38
0.46
0.43
n.s.
0.92
0.9
0.88
0.91
n.s.
N

5355
5083
1185
11623

5355
5083
1185
11623

p-value

p < 0.001 p = 0.05 p < 0.001

n.s.

p < 0.001 p = 0.01

p < 0.001
n.s.

Hidden occlusal caries: *Difference between visual-tactile and bitewing sensitivity values: 0.12.

Table 4. Specificity of occlusal and proximal caries detection using visual-tactile and bitewing examinations at the
restorative threshold

Primary tooth

Specificity

Visual-tactile

Bitewing

Y1
Y3
Y7
All
p

Y1
Y3
Y7
All
p

Occlusal
Maxillary D
0.97
0.99
0.96
0.98
n.s.
0.96
0.96
0.97
0.96
n.s.
surfaces*
Maxillary E
0.93
0.97
0.96
0.95
n.s.
0.95
0.98
0.95
0.96
n.s.

Mandibular D
0.97
0.97
0.94
0.97
n.s.
0.95
0.94
0.94
0.94

n.s.

Mandibular E
0.94
0.97
0.97
0.96
n.s.
0.93
0.91
0.93
0.92
n.s.

All occlusal
0.95
0.98
0.96
0.96
n.s.
0.95
0.95
0.94
0.95
n.s.

p-value
n.s.
n.s.
n.s.
n.s.

n.s.
n.s.
n.s.
n.s.

Proximal
Maxillary C
0.99
0.99
0.99
0.99
n.s.
0.99
1.00
0.99
1.00
n.s.
surfaces*
Mandibular C
1.00
1.00
0.97
1.00
n.s.
0.99
1.00
1.00
1.00
n.s.

Maxillary D
0.99
0.98
0.99
0.98

n.s.
0.90
0.92
0.90
0.91
n.s.

Maxillary E
0.99
0.99
0.99
0.99
n.s.
0.93
0.94
0.92
0.93
n.s.

Mandibular D
0.99
0.98
0.96
0.99
n.s.
0.89
0.91
0.93
0.90
n.s.

Mandibular E
0.99
0.99
0.98

0.98
n.s.
0.90
0.86
0.91
0.91
n.s.

All proximals
0.99
0.99
0.98
0.99
n.s.
0.94
0.93
0.93
0.93
n.s.

p-value
n.s.
n.s.
n.s.
n.s.

n.s.
n.s
n.s.
n.s.

n.s. = not significant.

*Number of surfaces assessed were the same as in Table 3.

which did not use bitewings will underestimate the caries

prevalence by about 10 per cent. Pooterman and co18

workers also reported underestimation figures of between

1 to 12 per cent in the absence of bitewing radiography. On
the other hand, other authors have reported that the use of
bitewing radiography did not result in a significant
increase in permanent dentition

caries experience rates in subjects under the age 12

years.

1921

As the majority of permanent teeth in

children under 12 years have been erupted for relatively

2009 Australian Dental Association

short periods of time and their proximal caries expe-rience

was low, inclusion of bitewing radiography for
epidemiological purposes for this age group of children

would yield only a minimal increase in caries rates over

the visual examination.

9,10,22

Previous studies suggest that bitewing radiography has the

greatest value in detecting caries in subjects with the
highest susceptibility to caries. The present results support
this hypothesis in that inclusion of bite-wing radiography
in these high-caries risk children of

27

B Newman et al.

Table 5. Sensitivity of occlusal and proximal caries detection using visual-tactile and bitewing examinations at the
non-restorative threshold

Primary tooth

Sensitivity

Visual-tactile

Bitewing

Y1
Y3
Y7
All
p-value

Y1
Y3
Y7
All

p-value
n.s.
Occlusal
Maxillary D
0.71
0.47
0.83
0.64
surfaces
Maxillary E
0.83
0.75
0.74
0.80

p < 0.001
n.s.
p = 0.025
Proximal
Maxillary C
0.75
0.85
0.60
0.76
surfaces
Mandibular C
0.33
0.80

Mandibular D
0.74

1.00
0.56

0.44
0.83
0.64

Maxillary D
0.43
0.46

Mandibular E
0.80

0.41
0.44

0.47
0.68
0.67

Maxillary E
0.42
0.42

All occlusal
0.78

0.40
0.42

0.52
0.74
0.70

Mandibular D
0.54
0.46

p-value

0.53
0.51

0.61
Mandibular E
0.40
0.18
0.68
0.33

0.75
0.69
n.s.
p < 0.001
0.71
0.65

All proximals
0.46
0.38
0.50
0.43

0.71
0.69
n.s.
p < 0.001
0.70
0.63
0.67

p-value
p < 0.001

0.65
n.s.

n.s.
p < 0.001
p = 0.01

n.s.
p < 0.001
p < 0.001
n.s.

n.s.
0.60
0.77
0.50
0.65
n.s.
p = 0.025
0.57
0.53
0.63
0.57
n.s.
p < 0.001
0.74

n.s.
0.65
0.39
0.60
0.55
p < 0.001
p < 0.001
0.89
0.60
0.00
0.69
p < 0.001
n.s.

0.92

0.93

0.84

0.95

0.91

0.86

0.89

0.89

n.s.

n.s.

n.s.

n.s.

0.89

0.92

0.93

0.89

0.93

0.86

0.91

0.90

n.s.

n.s.

n.s.
0.96
0.91
0.82
0.93

p < 0.001
p < 0.001
p < 0.001
p = 0.025

p = 0.01
n.s.

Table 6. Specificity of occlusal and proximal caries detection using visual-tactile and bitewing examinations at the
non-restorative threshold

Primary tooth

Specificity

Visual-tactile

Bitewing

Y1
Y3
Y7
All
p-value
Y1
Y3
Y7
All
p-value

Occlusal
Maxillary D
0.95
0.98
0.96
0.97
n.s.
0.96
0.96
0.99
0.96
n.s.
surfaces*
Maxillary E
0.89
0.96
0.94
0.93
n.s.
0.96
0.98
0.96
0.97
n.s.

Mandibular D
0.95
0.96
0.94
0.96
n.s.
0.95
0.94
0.96
0.95
n.s.

Mandibular E
0.91
0.94
0.94
0.93
n.s.
0.93
0.91
0.94
0.92
n.s.

All occlusal
0.93
0.96
0.94
0.94
n.s.
0.95
0.95
0.96
0.95

n.s.

p-value

n.s.
n.s.
n.s.
n.s.

n.s.
n.s.
n.s.
n.s.

Proximal
Maxillary C
0.99
0.99
0.99
0.99
n.s.
0.99
1.00
0.99
1.00
n.s.
surfaces*
Mandibular C
1.00
1.00
0.97
1.00
n.s.

0.99
1.00
1.00
1.00
n.s.

Maxillary D
0.98
0.97
0.99
0.98
n.s.
0.89
0.91
0.90
0.90
n.s.

Maxillary E
0.99
0.99
0.99
0.99
n.s.
0.92
0.93
0.92
0.92
n.s.

Mandibular D
0.99
0.98
0.96
0.99

n.s.
0.88
0.90
0.93
0.89
n.s.

Mandibular E
0.99
0.99
0.98
0.98
n.s.
0.89
0.85
0.92
0.90
n.s.

All proximals
0.99
0.99
0.98
0.99
n.s.
0.93
0.93
0.93
0.93
n.s.

p-value

n.s.

n.s.
n.s.
n.s.

n.s.
n.s.
n.s.
n.s.

n.s. = non-significant.
*Number of surfaces assessed were the same as in Table 3.

approximate mean ages of 6 and 8 years, reveals a

significant increase of dmft of approximately 0.60.8 and
dmfs of 1.3. These differences represent significant
increases of around 20 per cent in both dmft and dmfs for
almost all age groups when bitewing radiography was
employed compared to the visual-tactile examina-tion
alone. The present data, therefore, suggest that previous
studies that did not include radiographs were likely to have
significantly under-reported the caries experience of the
primary dentition in children with high caries rates.

As in the permanent dentition, the sensitivity and

specificity of detection methods for occlusal and proximal
lesions of the primary dentition is likely to depend on
whether a cavitation (restorative) or non-cavitation
threshold level is used for caries detection.

28

differences in sensitivity and specificity of the visualtactile and bitewing radiography techniques when a
restorative threshold is employed compared to when a nonrestorative threshold is employed. In the present study, the
criteria used for caries detection at the restorative threshold

23

In an in vitro study, Lussi reported that the sensitivity for

detection of occlusal caries using a visual-tactile
examination increased from 14 per cent when a noncavitation threshold was employed, compared to 82 per
cent when a frank cavitation threshold was employed.
Similarly, in the case of the bitewing examination, the noncavitation threshold for caries was associated with only 45
per cent detection compared to 79 per cent when a
cavitation threshold was used. These figures are supported
24

by the studies of Verdonschot and co-workers who also

noted that frank cavitation significantly increased
diagnostic sensitivity of the visual-tactile technique.

As previous studies have reported that inclusion or noninclusion of cavitated lesions can impact on occlusal caries
detection, it is of interest to note

2009 Australian Dental Association

are those generally used for making a clinical decision for

determining need for restorative treatment for the present
cohort of children, who have relatively high caries risk.
When such a restorative threshold was employed, the
radiographic technique was more sensitive in detecting
early occlusal caries compared to the visual-tactile
technique. The present findings are thus supported by

previous in vitro studies which reported similar trends in

extracted teeth.

The prevalence rate of occlusal caries which cannot

be detected by visual-tactile examination alone, or

hidden caries

3,2527

is found by the difference in

sensitivity values between the visual-tactile and radiographic techniques. The present finding of a prevalence of
occlusal hidden caries of 12 per cent suggests that a
significant number of occlusal caries lesions in the primary
dentition will be missed if bitewing radio-graphs are not
exposed. While the occurrence rates of hidden caries in the
permanent dentition have been reported to be around 450
3,25

per cent in adolescents and young adults,

the prevalence
of this condition in the primary dentition has not been
reported before. To the authors knowledge, the present
study thus provides the first in vivo data of the prevalence
rate of hidden occlusal caries in the primary dentition.

Proximal surface caries are well known to be more difficult

to detect using a visual-tactile technique compared to
occlusal lesions. Hence it is not surprising that the present
study reveals that sensitivity of the visual-tactile technique
for detecting proximal lesions was only 0.43. By contrast,
bitewing radiography gave a sensitivity value twice as
high, which suggests that the majority of proximal lesions
at the restorative threshold will be detected by bitewing
radiography.

In contrast to sensitivity, the specificity of both visualtactile and bitewing techniques for primary molars are
consistently high with all values greater than 90 per cent
for both occlusal and proximal lesions. While there are no
previous similar studies on primary teeth, comparisons
with the permanent dentition showed similar high
2833

specificity values.
The present data thus suggest that
both visual-tactile and bitewing techniques have high
accuracy in detecting the absence of caries in the primary
dentition of both occlusal and proximal surfaces at the
restorative level.

The present results support the recommendations of

paediatric dentistry worldwide that bitewing radiogra-phy

be considered part of the routine initial dental examination

of children who are old enough to cooperate and have
proximal surfaces that cannot be

2009 Australian Dental Association

Detection of primary dentition caries

34,35

visualized.
For recall examinations, the frequency of
bitewing radiographs is usually tailored to the individuals
caries risk as determined clinically.

Downer MC. Validation of methods of caries diagnosis. Int Dent J

1989;39:241246.

Chong MJ, Seow WK, Purdie DM, Cheng E, Wan V. Visual-tactile

examination compared with conventional radiography, digital radiography
and Diagnodent in the diagnosis of occlusal hidden caries in extracted
premolars. Paediatr Dent 2003;2:314 319.

Ricketts DN, Kidd EA, Wilson RF. A re-evaluation of electrical

CONCLUSIONS
resistance measurements for the diagnosis of occlusal caries. Br Dent J
1995;178:1117.

At the restorative threshold, for primary molar prox-imal

surface caries, the visual-tactile technique detected only 43
per cent of lesions compared with 91 per cent for bitewing
radiography. For occlusal caries, the visual-tactile
technique detected 62 per cent of lesions compared to 74
per cent for bitewing radiography. The prevalence of
hidden occlusal caries which is detect-able only by
radiography is approximately 12 percent.

REFERENCES

Bader JD. A systematic review of the performance of methods for

identifying carious lesions. J Public Health Dent 2002;62:201 213.

Cortes DF, Ekstrand KR, Elias-Beneta AR, Ellwood RP. An in vitro

comparison of the ability of fibre-optic transillumination, visual
inspection and radiographs to detect occlusal caries and evaluate lesion
depth. Caries Res 2000;34:443447.

Kidd EA, Naylor MN, Wilson RF. The prevalence of clinically undetected
and untreated molar occlusal dentine caries in ado-lescents on the Isle of
Wight. Caries Res 1992;26:397401.

Ketley CE, Holt RD. Visual and radiographic diagnosis of occlusal caries
in first permanent molars and in second primary molars. Br Dent J
1993;174:364370.

World Health Organization. Oral health surveys: basic methods. 4th edn.
Geneva: WHO, 1997.

Richardson PS, McIntyre IG. The difference between clinical and

bitewing detection of approximal and occlusal caries in Royal Air Force
recruits. Community Dent Health 1996;13:6569.

Kidd EA, Pitts N. A reappraisal of the value of the bitewing

radiograph in the diagnosis of posterior approximal caries. Br Dent J

1990;169:195200.

Fracaro MS, Seow WK, McAllan LH, Purdie DM. The sensitivity and
specificity of clinical assessment compared with bitewing radiography for
detection of occlusal dentine caries. Paediatr Dent 2001;23:204210.

Hintze H. Screening with conventional and digital bitewing radiography

compared to clinical examination alone for caries detection in low risk
children. Caries Res 1993;27:499504.

Stamm JW, Disney JA, Graves RC, Bohannan HM, Abernathy JR. The
University of North Carolina Caries Risk Assessment Study. I: Rationale
and content. J Public Health Dent 1988;48: 225232.

Cohen JA. A coefficient of agreement for nominal scales. Educ Psych

Meas 1960;20:3746.
Ismail AI. Clinical diagnosis of precavitated carious lesions. Community
Dent Oral Epidemiol 1997;25:1323.
29

B Newman et al.

Seow WK. Pre-eruptive resorption as an entity of occult caries. Paediatr

Dent 2000;22:370376.

Weerheijm KL, Groen HJ, Bast AJJ. Clinically undetected occlusal dental
caries: a radiographic comparison. Caries Res 1992;26:305309.

Seow WK, Wan A, McAllan L. The prevalence of dentine radiolucencies

in the permanent dentition: a analysis of bitewing radiographs. Pediatr
Dent 1999;21:2633.

Hopcraft MS, Morgan MV. Comparison of radiographic and clinical

diagnosis of approximal and occlusal dental caries in a young adult
population. Community Dent Oral Epidemiol 2005;33:212218.

18. Poorterman JH, Aartman IH,

Seow WK, Lu PC, McAllan L. Prevalence of pre-eruptive in-tracoronal

dentine defects from panoramic radiographs. Pediatr Dent 1999;21:332
339.

Kieft JA, Kalsbeek H. Value

of bitewing radiographs in a
clinical epidemiological study

and their effect on the DMFS index. Caries Res 2000;34:159 163.

Ruiken HM, Truin GJ, Konig KG. Feasibility of radiographical diagnosis

in 8-year-old schoolchildren with low caries activity. Caries Res
1982;16:398403.

de Vries HC, Ruiken HM, Konig KG, vant Hof MA. Radio-graphic
versus clinical diagnosis of approximal carious lesions. Caries Res
1990;24:364370.

Machiulskiene V, Nyvad B, Baelum V. A comparison of clinical and

radiographic caries diagnosis in posterior teeth of 12-year-old Lithuanian
children. Caries Res 1999;33:340348.

Downer MC. Concurrent validity of an epidemiological diag-nostic

system for caries with histological appearance of extracted teeth
validating criterion. Caries Res 1975;9:231246.

Mejare I, Grondahl HG, Carlstedt K, Grever AC, Ottosson E. Accuracy at

radiography and probing for the diagnosis of prox-imal caries. Scand J
Dent Res 1985;93:178184.

Lussi A. Comparison of different methods for the diagnosis of fissure

caries without cavitation. Caries Res 1993;27:409416.

Hintze H, Wenzel A. Diagnostic outcome of methods frequently used for

caries validation. A comparison of clinical examination, radiography and
histology following hemisectioning and serial tooth sectioning. Caries Res
2003;37:115124.

Rocha RO, Ardenghl TM, Olive RA, Rodrigues CR, Ciamdon AC. In vivo
effectiveness of laser fluorescence compared to visual inspection and
radiography for detection of occlusal caries in primary teeth. Caries Res
2003;37:437441.

Mitropoulos C, Holloway PJ, Davies T, Worthington HV. Relative

efficacy of dentifrices containing 250 or 1000 ppm F- in preventing dental
caries: report of 32 month trial. Community Dent Health 1984;1:193200.
Ashley P. Diagnosis of occlusal caries in primary teeth. Int J Paediatr
Dent 2000;10:166171.
Lussi A. Impact of including or excluding cavitated lesions when
evaluation methods for the diagnosis of occlusal caries. Caries Res
1996;30:389393.

Verdonschot EH, Bronkhorst EM, Burgersdijk RCW. Perfor-mance of

some diagnostic systems in examinations for small occlusal carious
lesions. Caries Res 1992;26:5964.

Reference Manual. American Academy of Pediatric Dentistry 2007, p

222.

Standards of Care Manual. Australasian Academy of Paediatric Dentistry,

2008.

Address for correspondence: Dr W. Kim Seow School

of Dentistry

The University of Queensland 200 Turbot Street

Brisbane QLD 4000 Email: k.seow@uq.edu.au

30

2009 Australian Dental Association