A simplified dental examination for detection of cavitated carious lesions in school setting

Clinical dental examination has been the most

common method for detection of caries in field

conditions (1). It has usually been performed under

natural light using a dental mouth mirror and a

metallic dental probe (2). The objectives of using a

dental mirror are to enhance illumination by

reflecting light coming from the source onto teeth,

to facilitate indirect visualization of teeth in the

upper dental arch and to help retract cheeks, lips

and tongue to clear the field of examination. If

dental mirror alone is used, the method of dental

examination is called visual examination.

Metallic probes with sharp tips were previously

recommended to detect a ‘catch’ (when the probe

was arrested in deep pits and fissures on the tooth

surface) in enamel in order to label it as ‘carious’.

At present, their use is discouraged as it may

disturb the surface integrity of partially deminer-

alized enamel, hampering the chances of it getting

remineralized by either natural or non-invasive

means. This may iatrogenically lead to the pro-

gression of the carious lesion (1, 3–5). However,

dental probes with blunt or rounded tips are still

being used along with dental mirrors to confirm or

reject dubious carious lesions into dentine by

having a tactile feeling of softness at the base of

the cavity or in some proximal wall of the carious

tooth. This method is known as the visual ⁄ tactile

Community Dent Oral Epidemiol 2009; 37: 276–283All rights reserved

� 2009 John Wiley & Sons A/S

A simplified dental examinationfor detection of cavitated cariouslesions in school settingHaleem A, Khan AA, Siddiqui MI. A simplified dental examination fordetection of cavitated carious lesions in school setting. Community Dent OralEpidemiol 2009; 37: 276–283. � 2009 John Wiley & Sons A/S

Abstract – Objective: The objective of the study was to compare a simplifieddental examination involving the use of a wooden spatula and a toothpick(TS examination) with the conventional dental mirror and probeexamination (MP examination) for detection of cavitated carious lesions inschoolchildren. Methods: The study involved three groups of caries-positiveschoolchildren aged 4–5, 9–10 and 13–14 years with 179, 188 and 202children, respectively. All children were examined by a trained andcalibrated examiner using a wooden spatula and a toothpick under naturallight. After a week the same examiner examined the three groups ofchildren by a dental mirror and a Community Periodontal Index (CPI) probe.‘Teeth’ were considered as units of measurement for data analysis. TheWHO recommended criteria (2) for decayed, missing and filled teeth werefollowed for recording dental caries on a specially designed recording form.The sensitivity, specificity, positive predictive value, negative predictivevalue, false-positive rate and false-negative rate of TS examination werecalculated using MP examination as the standard method. Results: Thespecificity of TS examination was well above 95% in three types of dentition.Although the sensitivity of this type of examination in deciduous andmixed dentitions was almost comparable with that of MP examination, it wasthe lowest for permanent dentition but still within the acceptablelimits. Conclusion: The TS examination can provide an alternative totraditional MP examination to undertake regular check-ups of schoolchildrenfor dental caries.

Abdul Haleem1, Ayyaz Ali Khan2

and Muhammad Irfanullah Siddiqui3

1Community Dentistry Department, Dr.

Ishrat-ul-Ebad Khan Institute of Oral Health

Sciences, Dow University of Health Sciences,

Karachi, Pakistan, 2Faculty of Dentistry,

Riphah University, Islamabad, Pakistan,3Department of Community Health Sciences,

Hamdard College of Medicine and Dentistry,Karachi, Pakistan

Key words: dental caries; dental check-ups;simplified dental examination

Abdul Haleem, Community DentistryDepartment, Dr. Ishrat-ul-Ebad KhanInstitute of Oral Health Sciences, DowUniversity of Health Sciences, SarfarazRafiqui H. J. Shaheed Road, SMC Campus,Karachi-35, PakistanTel: +92 21 9204768Fax: +92 21 9204769e-mail: [email protected]

Submitted 13 September 2007;accepted 21 January 2009

276 doi: 10.1111/j.1600-0528.2009.00464.x

method of examination. Dental probes are also

thought to be instrumental in removing any food

debris that may mask the presence of a carious

lesion on the tooth surface (6, 7).

Considering the substantial cost of dental mirror

and probe (fixed cost), their use as disposables

cannot be justified. Hence they need to be sterilized

before reuse. The additional cost of handling and

sterilization, and the metal instruments getting

corroded and rusted (wear and tear cost) are some

of the factors that make their efficacy questionable.

Sometimes, the application of a metal probe in the

diagnosis of dental caries has not been found to

add much to the diagnosis of the visual ⁄ tactile

method of dental examination (1, 3, 4, 8, 9).

Furthermore, in the existing era of awareness about

cross-infection control, the use of reusable instru-

ments may pose an unnecessary risk (social cost),

especially if some more cost-effective, equally valid

and virtually non-invasive alternative is available.

The examinees, especially young children, may

feel apprehensive while undergoing examination

with metallic probe and mirror. These instruments

may also not be user-friendly as regards non-

operating dental and non-dental auxiliaries when

they may be asked to carry out dental examination.

Examination for detection of dental diseases on a

regular basis forms an essential component of

preventive dental care provided to schoolchildren

in many countries. The basis behind this is to detect

disease and provide treatment as early as possible

so that time, expense and human suffering could be

avoided at a later stage. In Pakistan there has been

a consistent finding of WHO Pathfinder surveys

that the caries prevalence in 12-year-old children is

low (10). However, about 97% of DMFT (Decayed,

Missing due to caries, Filled Teeth) score includes

the ‘D’ component. It has also been shown that the

DMFT score keeps on increasing with age with a

concomitant increase in the missing component.

The issue of increasing burden of untreated dental

caries in the country has been continuously raised

at different forums. A recent development has been

the setting up of a National Task Force on Oral

Health (NTFOH) by the Federal Government of

Pakistan (11). This task force has proposed a plan

that includes provision of dental treatment to the

school-aged population as an essential component

of School Health Service (SHS). The SHS has been

in existence in Pakistan since 1977 and mainly

includes health education. Furthermore, over the

last one and a half decade, the establishment of

new dental colleges has resulted in a substantial

increase in the number of dentists in the major

cities of Pakistan (11, 12). The dental hospitals

affiliated to these dental colleges also provide

dental services to people at subsidized rates. Under

the circumstances, dental check-up programs in

schools are required to increase awareness in

people about their dental treatment need. This

may not only increase utilization of existing dental

services but may also raise public demand for

implementation of oral health plan formulated by

the NTFOH.

The oral examination in the school setting is

usually performed under natural or artificial light

by a dentist using a mouth mirror and a metallic

dental probe. Because of the reasons mentioned

above, it forms an expensive component of dental

care provided to schoolchildren.

ObjectivesThe objective of the present study was to compare a

simplified dental examination involving the use of

a wooden spatula and a tooth pick (TS) with the

conventional dental mirror and probe (MP) exam-

ination for the detection of cavitated carious

lesions. The variation in caries detection by the

two methods because of the increasing depth of the

oral cavity with age of children was also investi-

gated.

RationaleThe logic behind the conduct of the study was to

find a way out to make examination for dental

caries in a school setting simple and acceptable so

that dental check-ups at appropriate intervals

could be made a regular feature of school dental

services in Pakistan.

Methods

Study design and study subjectsBefore the conduct of this cross-sectional study, all

children belonging to three age groups (4–5, 9–10

and 13–14 years) and studying in classes KG

(Kindergarten) II, V and VIII of a Boys’ and a

Girls’ Government School were examined for

dental caries using WHO methods and criteria

(2). Children with a DMFT ⁄ dft score £1 were

excluded, leaving a group of children having a

DMFT ⁄ dft score ‡2. Children with toothache,

severely crowded teeth, difficulty opening the

mouth, fixed orthodontic appliances, severe fluo-

rosis, severe hypoplasia or some serious systemic

277

Simplified examination for dental caries

disease were further excluded to finally select the

study groups. In case of class KG II and VIII,

children with full set of deciduous and permanent

teeth were included. In order to compare the two

methods of dental examination, ‘teeth’ were con-

sidered as the units of measurement at the stage of

data analysis.

Before screening, a written consent form was

sent to the parents of each child selected for

inclusion in the oral examination, informing them

about the objectives of the study, its potential

benefits and the methods involved in simple

language. Moreover, all children were promised a

detailed report about their dental status to take

home at the end of the study.

Subsequently, the three selected groups of chil-

dren were examined by a single examiner who was

trained and calibrated for the study. At first, the

examination was carried out by using a wooden

spatula and a toothpick, and then by employing a

dental mirror and Community Periodontal Index

(CPI) probe under natural light coming through a

window. All examinations were performed on

days with bright sunlight and whenever it was

cloudy the examinations were postponed. The

children who were absent on the day the examin-

ations were being conducted in a particular class

were examined on another day. An interval of

1 week was allowed between two types of exam-

inations for the memory of the examiner to fade

about the findings of the TS examination before he

undertook the MP examination.

Examination procedureDuring MP examination, subjects were seated in a

plastic chair (with a slightly inclined back having a

rounded upper edge) facing the window while the

examiner was seated on the right side of the

subjects on an examination stool with adjustable

height. A dental mirror (plain mouth mirror) was

used for indirect visualization of teeth in the upper

dental arch, to enhance illumination of teeth by

reflecting light on them, and to retract cheeks and

lips. A CPI probe was employed to remove any

food debris from the tooth surfaces and to confirm

‘caries into dentine’. This was done by feeling

softness at the base of an occlusal cavity or in the

wall of a proximal cavity. A sterilized set of MP

was used for every child and all instruments were

cleaned, disinfected and autoclaved before they

were reused.

The TS examination was conducted under the

same conditions. However, while performing this

examination the back of the examinee’s head was

made to rest against the rounded upper edge of the

back rest of the chair, with an extended neck and

the face facing upwards. This was done to facilitate

the examination of teeth in the upper jaw. For

examination of lower teeth, the subjects were

seated in a normal position with the lower jaw

almost parallel to the ground. Wooden tongue

spatula was used to help retract cheeks, lips and

tongue to clear the field of vision. Toothpick was

used to remove any food debris from tooth

surfaces. Wooden spatulas and toothpicks were

used as disposables.

In both types of examination, teeth were exam-

ined in a clockwise direction, taking a start from

the last tooth in the right upper quadrant of the oral

cavity and ending with the last one in the right

lower quadrant. The mesial surface of every tooth

was examined first followed by occlusal ⁄ incisal,

distal, labial ⁄ buccal and finally lingual ⁄ palatal.

Dental index and criteria for detection ofdental cariesDMFT index for permanent and dft index for

deciduous teeth were used to record dental caries

in both types of examinations. The various codes

which were entered into the boxes of a specially

designed recording form included: tooth with no

decay (N), decayed tooth (D ⁄ d), filled tooth (F ⁄ f),tooth missing because of caries (M), tooth

missing because of any other reason (O), broken

tooth (B), crowned tooth (C) and excluded tooth

(E).

In MP examination, the WHO diagnostic criteria

(2) were followed for all these conditions. A filled

tooth having a carious lesion, irrespective of

whether the lesion was in physical association

with the filling or not, was included in the category

of ‘decayed tooth’. In primary and mixed denti-

tions, missing deciduous teeth were not recorded.

In TS examination, the detection of ‘caries into

dentine’ was based on the presence of an open

cavity on any surface of the tooth being examined.

Discoloration on the marginal ridge and the

adjoining area was assumed to indicate a proximal

carious lesion underneath.

Training and calibration of examinerThe only examiner involved in the study was

trained and calibrated by the first author who

was previously trained and calibrated for WHO

methodology for Pathfinder Surveys (2). The

recorder was trained along with the examiner.

278

Haleem et al.

A 4-h training session was conducted comprising

of a theoretical discussion and practical training.

The latter included an exercise on 20 extracted

teeth (a mix of carious and sound teeth) and an

examination of three groups (deciduous, mixed

and permanent dentition groups) of 10 children

each (not included in the main study). Children

in each group had non-carious teeth as well as

teeth with stained pits and fissures, enamel caries

and caries into dentine. They were examined by

the potential examiner as well as by the first

author using the two methods. The findings of

the two examiners were recorded as per instruc-

tions of the trainer and were compared. The

controversial cases were discussed and re-exam-

ined. The errors in the recording of the findings

were brought to the notice of the recorder who

was given further exercises to ensure a reason-

able understanding of the recording procedure on

his part.

After 2 days, a calibration exercise was arranged

in a school, picking up three groups of 20 children

each like the ones chosen for the training session.

All children were first examined by the examiner

and then by the trainer using wooden spatula and

toothpick. The findings were recorded and not

revealed to the two examiners who undertook MP

examination of the same groups of children after

2 days. This completed the first round of exami-

nation, after which an interval of 1 week was

allowed. During the second round, the same

children were re-examined by the two examiners

using the two methods, with TS examination

preceding the MP examination. However, the

sequence of children during examination was

changed at random.

The intra- and inter-examiner reliability values

were calculated for TS and MP examinations

separately using the kappa test. The intra-examiner

reliability values of 0.87 and 0.89 and the inter-

examiner reliability values of 0.85 and 0.90 for TS

and MP examinations, respectively, were obtained.

The recorder’s performance was also found to be

up to the mark.

Statistical analysis of dataThe data were entered and analyzed by using the

Statistical Package for Social Sciences (SPSS)

version 12.0. The sensitivity, specificity, positive

predictive value, negative predictive value, false-

positive rate, and false-negative rate of TS

examination were calculated using MP examina-

tion as the standard method.

Results

Tables 1 and 2 show the distribution of the total

number of subjects who were examined for the

purpose of the study by age, sex and dentition

status. A total of 1825 children studying in classes

KG II, V and VIII were examined for dental caries

using WHO method and criteria (2). Of these, 904

children were found to be caries-positive in the

three age groups having deciduous, mixed and

permanent dentitions. The children with a

DMFT ⁄ dft score of £1 were excluded, leaving

behind a total of 574 children (with a DMFT ⁄ dft

score of ‡2) in the three age groups. Five children

(three from KG II and one each from classes V and

VIII) were further excluded based on the exclusion

criteria leaving 569 children who participated in

the study.

There was no statistically significant difference

between boys and girls with regard to DMFT ⁄ dft

score at a = 0.05. The proportion of boys and girls

in the selected sample like that in the total

number of children examined was almost equal

in all three age groups. Of 179 4–5 year olds, 91

were boys while in the other two age groups

(9–10 years and 13–14 years), their number was 95

and 99 of a total of 188 and 202, respectively.

Table 3 shows the distribution of sound and

decayed teeth among children with a DMFT ⁄ dft

score of ‡2 who were selected for the study. As

the number of filled teeth and teeth missing

because of caries was negligible, only teeth found

to be sound or decayed were included in the final

analysis.

Of all the teeth declared by MP examination as

decayed, 97.25% of teeth in deciduous dentition,

97.08% in mixed and 86.15% in permanent denti-

tion were correctly picked up by TS examination as

carious. The sensitivity of TS examination

in deciduous and mixed dentitions was almost

comparable with that of MP examination, but it

was lower for permanent dentition. The specificity

values for TS examination in all three types of

dentition were very high (Tables 4–6). Similar was

Table 1. Distribution of children examined

Age(years)

No. (%)Examined

Gender, no. (%)

Boys Girls

4–5 608 (33.32) 318 (52.30) 290 (47.70)9–10 599 (32.82) 298 (49.75) 301 (50.25)11–13 618 (33.86) 316 (51.13) 302 (48.87)Total 1825 932 893

279


the case with the positive and negative predictive

values. The values of false-positive rate for TS

examination turned out to be negligible in all three

dentitions. The false-negative rate of TS examina-

tion in permanent dentition was the highest

(Table 6) and it was the lowest for deciduous

dentition (Table 4).

Discussion

The present study was designed to compare a

simplified method of oral examination performed

by using wooden spatula (tongue depressor) and a

toothpick under natural light with the conven-

tional mirror-probe examination in a school set-

ting. The results of the study revealed that the

simplified method of dental examination in ques-

tion (TS) holds the promise of providing a work-

able substitute to the conventional MP method to

examine schoolchildren for dental caries. The

sensitivity of the simplified method for deciduous

and mixed dentitions was almost as good as that of

mirror-probe examination. However, in case of

permanent dentition the value was lower. The

variation in sensitivity with different types of

dentition seems to be related to the size of the oral

cavity as was hypothesized in the beginning of the

Table 2. Dentition status of children examined

DentitionCaries-freeno. (%)

DMFT ⁄ dft = 1no. (%)

DMFT ⁄ dft‡2no. (%)

MeanDMFT ⁄ dft

MeanD ⁄ d

MeanM

MeanF ⁄ f

Deciduous 284 (46.71) 142 (23.36) 182 (29.93) 1.19 1.19 – 0.00Mixed 335 (55.93) 75 (12.52) 189 (31.55) 0.98 0.97 0.00 0.01Permanent 302 (48.87) 113 (18.28) 203 (32.85) 1.34 1.25 0.07 0.02Total 921 330 574

D, Decayed teeth (permanent); d, decayed teeth (deciduous); M, missing teeth (permanent) due to caries; F, filled teeth(permanent); f, filled teeth (deciduous); T, teeth.

Table 3. Distribution of sound and decayed teeth among children with DMFT ⁄ dft ‡2

Deciduous dentitionN = 179n = 3544m = 19.8

Mixed dentitionN = 188n = 4136m = 22.0

Permanent dentitionN = 202n = 5594m = 27.7

TS exam. MP exam. TS exam. MP exam. TS exam. MP exam.

Sound teeth 2978 2962 3627 3623 4960 4879Decayed teeth 566 582 509 513 634 715

N, no. subjects; n, no. teeth; m, mean no. teeth.

Table 4. Deciduous dentition

TS exam.

MP exam.

TotalCaries +ve Caries )ve

Caries +ve 566 0 566Caries )ve 16 2962 2978Total 582 2962 3544

Sensitivity = 97.25%; specificity = 100%; positive predic-tive value = 100%; negative predictive value = 99.46%;false-positive rate = 0.00%; false-negative rate = 2.75%.

Table 5. Mixed dentition

TS exam.

MP exam.



Sensitivity = 97.08%; specificity = 99.70%; positive pre-dictive value = 97.84%; negative predictive va-lue = 99.59%; false-positive rate = 0.30%; false-negativerate = 2.92%.

Table 6. Permanent dentition

TS exam.

MP exam.



Sensitivity = 86.15%; specificity = 99.63%; positive pre-dictive value = 97.16%; negative predictive va-lue = 98.00%; false-positive rate = 0.37%; false-negativerate = 13.85%.

280

Haleem et al.

study. In younger children with deciduous denti-

tion because of the smaller size of the oral cavity,

the examination of posterior teeth was easier than

that in case of older children according to the

examiner’s experience. In children with mixed

dentition, though the size of the oral cavity was

larger than that of the younger group, most of the

carious lesions still remained confined to decidu-

ous teeth with very little caries occurring in

permanent teeth lying on the back of their decid-

uous counterparts. With further deepening of oral

cavity in the oldest age group, visual examination

under natural light without the help of dental

mirror was more difficult than that in the other two

groups.

The specificity of the simplified method of dental

examination in all three types of dentition was

almost comparable. The false-negative rate of TS

examination in permanent dentition was the high-

est (13.85%), while it was 2.75% and 2.92% in

deciduous and mixed dentitions, respectively. This

means that these percentages of carious teeth were

misdiagnosed as sound and could have been left

untreated. However, if schoolchildren are sub-

jected to TS examination at regular intervals,

the chances are that these missed out cases will

be detected in subsequent examinations and will

be restored. As the delay in treatment in case of

non-life-threatening diseases like dental caries is

not expected to lead to any grave consequences in

most of the cases, an examination method having

higher specificity than sensitivity should be pref-

erable (13). The sensitivity of TS examination for

deciduous dentition turned out to be the highest

with negligible false-positive rate. This shows the

desirability of the method to detect dental caries in

younger children with primary dentition who may

feel less apprehensive while undergoing TS exam-

ination than MP examination.

A search conducted through MEDLINE for

articles related to the study in English revealed

one study in which case the simplified method of

dental examination using tongue spatula was

compared with the visual ⁄ tactile examination (14).

That study involved a group of forty-four 12-year-

old Brazilian schoolchildren who were subjected to

three types of epidemiological dental examinations

for dental caries: one involving the use of a tongue

blade; the second employing dental mirror and CPI

dental probe (visual ⁄ tactile); and the third one

using dental mirror alone (visual). All three types

of examinations were performed with or without

diagnostic adjuncts (previous dental brushing

and ⁄ or dental drying) in a schoolyard under

natural light. These examinations were followed

by examinations carried out in a clinical dental

setting under artificial light and with the help of a

dental mirror and CPI probe. The examination in

the clinical setting was preceded by dental pro-

phylaxis and drying of teeth using compressed air.

The children who were examined were divided

into low and moderate caries prevalence groups.

The study showed that the visual ⁄ tactile method of

dental examination with or without diagnostic

adjuncts in both groups gave the best performance

when practiced in a school setting for diagnosing

cavitated carious lesions. The visual method sup-

plemented with previous dental brushing also

produced satisfactory results in the moderate

prevalence group. The blade method even when

used with diagnostic adjuncts was the least satis-

factory in detecting cavitated lesions, which is in

contradiction with the findings of the present

study. The authors commented that the better

results obtained in case of mirror-probe and mirror

examination could be because of the use of the

mouth mirror and previous dental brushing which

helped in improving the field of vision by illumi-

nating teeth and by removing any dental bio-film

deposited on tooth surfaces having carious cavities.

In addition, the CPI probe used in visual ⁄ tactile

examination was cited as helpful in confirming the

presence of carious cavities in doubtful cases.

However, they pointed out that WHO-recom-

mended visual ⁄ tactile examination underestimated

caries by 30% in the low prevalence group. It is

important to note that the present study also dealt

with a population with low prevalence of dental

caries. Here the examination was not preceded by

dental drying and tooth brushing in both TS and

MP examinations. However, CPI probe in MP and

toothpick in TS examination were used to remove

any food debris from tooth surfaces during exam-

ination. Although the carious cavities were

detected by direct visualization of teeth without

dental mirror in TS examination, an attempt was

made to improve the visibility by retracting soft

tissues with tongue spatula and also by reposition-

ing the head of the subjects during examination of

upper teeth. These factors might be responsible for

higher sensitivity of blade examination achieved in

the present study than the one obtained in the

study under discussion.

Despite the positive outcome of the study about

the utility of the simplified method of dental

examination in a school setting for detecting teeth

281


with ‘caries into dentine’, caution should be exer-

cised in interpreting the results because of several

limitations. First, the criteria for detecting ‘caries

into dentine’ as used in the present study have

been a matter of debate. It is now an established

fact that although the progression of the carious

lesion, especially on occlusal surfaces, continues in

the dentine underlying the macroscopically intact

enamel, ‘cavitation’ occurs at a late stage (15–17).

Such type of carious lesion is called ‘hidden or

occult caries, the diagnosis of which is presenting a

special problem in dentistry these days (3, 6). It is

because of the increasing prevalence of this type of

caries (18) that the presence of an open cavity is no

longer considered a valid criterion for ‘caries into

dentine’ in many western countries. In these

countries, the consensus is upon an entirely visual

diagnosis that relies on careful assessment of clean,

dry and well-illuminated teeth to ascertain changes

in tooth color associated with a carious lesion to

reach a diagnosis (6).

In the present study, although the MP exam-

ination followed the visual ⁄ tactile method recom-

mended by the WHO, the TS examination was

entirely visual. In TS examination the detection of

‘caries into dentine’ was based on the presence of

an open cavity in the occlusal surface which

might have resulted in an underestimation of

hidden caries. Moreover, the proximal lesions

were not confirmed by a probe as was the case

with MP examination. This again might have

underestimated proximal caries in TS examina-

tion.

Secondly, because of the reasons mentioned

earlier, the visual ⁄ tactile method of dental exami-

nation with which the TS examination was com-

pared in the study cannot be taken up as the ‘gold

standard’. In the absence of the latter it is logically

difficult to prove the validity of the simplified

method of dental examination tested in the study.

Hence the values of sensitivity, specificity, etc.

calculated for TS examination in the study are

merely the comparative values and do not reflect

the absolute validity of the method.

Thirdly, as the study was conducted in a pop-

ulation with low prevalence of dental caries, the

results cannot be generalized to populations with

moderate to high prevalence of the disease. Fur-

thermore, as no data is available at present about

the incidence and progression rate of carious

lesions in the study population, it is difficult to

speculate about the desirable frequency of dental

check-ups.

Finally, the exclusion of children with a DMFT

score of £1 might have introduced a selection bias

in the study. This was done to limit the number of

cases which were to be simultaneously examined

by trained teachers having time constraint. The

findings of the teachers’ examination will be

published later.

Conclusion

Based on the findings of the present study it can be

concluded that TS examination can provide an

alternative to traditional MP examination for

checking schoolchildren for cavitated carious

lesions.

Recommendations

1 A longitudinal study is recommended to prove

validity of the TS examination in a system that

will ensure periodic dental check-ups of school-

children. It is also indicated to estimate the

desirable time interval between dental check-ups

in the study population.

2 The cost-effectiveness and cost–benefit of TS

examination in comparison with the traditional

MP examination need to be estimated.

3 The effectiveness of the TS examination per-

formed by non-dental personnel in countries

lacking in trained dental manpower should be

evaluated.

References1. Meneghim MC, Assaf AV, Zanin L, Kozlowski FC,

Pereira AC, Ambrosano GMB. Comparison of diag-nostic methods for dental caries. J Dent Child2003;70:115–9.

2. WHO. Oral health surveys: basic methods. 4th edn.Geneva: WHO; 1997.

3. Kids EAM, Ricketts DNJ, Pitts NB. Occlusal cariesdiagnosis: a changing challenge for clinicians andepidemiologists. J Dent 1993;21:323–31.

4. Basting RT, Serra MC. Occlusal caries: diagnosis andnon-invasive treatments. Quintessence Int1999;30:174–8.

5. Lussi A. A comparison of different methods for thediagnosis of fissure caries without cavitation. CariesRes 1993;27:409–16.

6. Pitts NB. Current methods and criteria for cariesdiagnosis in Europe. J Dent Educ 1993;57:409–13.

7. Fyffe HE, Derry C, Nugent ZJ. Effect of diagnosticthreshold on the validity and reliability of epidemi-

282

Haleem et al.

ological caries diagnosis using the Dundee selectablethreshold method for caries diagnosis (DSTM).Community Dent Oral Epidemiol 2000;28:42–51.

8. le YL, Verdonschot EH. Performance of diagnosticsystems in occlusal caries detection compared. Com-munity Dent Oral Epidemiol 1994;22:187–91.

9. Penning C, van Amerongen JP, Seef RE. Validity ofprobing for fissure caries diagnosis. Caries Res1992;26:445–9.

10. Khan AA, Sharea I, Ayma S, Ambreena Q, Inayatul-lah P, Sofia S et al. Oral health in Pakistan: a situationanalysis. Dev Dent 2004;5:35–44.

11. Khan AA. Oral health in Pakistan: a situationanalysis. Islamabad: Ministry of Health, Governmentof Pakistan ⁄ WHO (Pakistan office); 2004.

12. Khan AA. Oral health in Pakistan (II): manpowerand facilities. J Pak Dent Assoc 1990;6:161–73.

13. Lussi A. Validity of diagnostic and treatment deci-sions of fissure caries. Caries Res 1991;25:296–303.

14. Assaf AV, Meneghim MC, Zanin L, Mialhe FL,Pereira AC, Ambrosano GMB. Assessment of differ-ent methods for diagnosing dental caries in epide-miological surveys. Community Dent OralEpidemiol 2004;32:418–25.

15. Pitts NB. The diagnosis of dental caries: 1. Diagnosticmethods for assessing buccal, lingual and occlusalsurfaces. Dental Update 1991;18:393–6.

16. Weerheijm KL, Groen HJ, Bast AJJ, Kieft JA, EijkmanMAJ, van Amerongen WE. Clinically undetectedocclusal dentine caries. A radiographic comparison.Caries Res 1992;26:305–9.

17. Weerheijm KL, de Soet JJ, van Amerongen WE, deGraaff J. Sealing of occlusal hidden caries lesions: analternative for curative treatment? ASDC J DentChild 1992;59:263–8.

18. Weerheijm KL, Gruythuysen RJ, van AmerongenWE. Prevalence of hidden caries. ASDC J Dent Child1992;59:408–12.

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