虫歯の検出に視覚的手法だけを信用していいのか？

Can we trust visual methods alone for detecting caries in teeth?

抄録

データソース電子データベースはPubMed, Embase, Scopusで検索した。未発表の文献はOpenSIGLE、IADR/AADR（International and American Associations for Dental Research）およびORCA（European Organisation for Caries Research）の2003年から2014年までのannalsで追跡した。研究は英語に限定した。研究の選択ヒトの乳歯または永久歯の一次冠状カリエス病変の検出のための目視検査を含む研究を検討した。すべての論文は、明確に定義された参照基準を含み、真の陽性、偽の陽性、真の陰性、偽の陰性の絶対数を報告するか、これらの数値を計算するのに十分なデータを提示する必要があった。基準となる方法としては、組織学的評価、外科的介入、一時的な歯の分離後の直接目視検査、X線撮影が適切と考えられた。同一のデータセットを用いた研究については、最も完全な研究のみを対象とした。データの抽出と合成対象となる研究の選択は2人の査読者によって独立して行われ、意見の相違は3人目の査読者との話し合いによって解決された。データは2人の査読者によって構造化された表にまとめられた。不一致はコンセンサスで解決した。メタアナリシスを行った。以下の情報が抽出された：参照標準法、設定（臨床または実験室）、歯の種類（乳歯または永久歯）、評価された表面（平滑面、近位面または咬合面）、サンプルサイズ、検査者の経験。また、視覚的なスコアリングシステムも記録された。基準を報告していない研究は「基準なし」と分類した。著者が既発表の研究を参照せずに基準を用いた場合は、「独自の基準」と分類した。結果プールされた感度、特異度、診断オッズ比、要約受信者動作特性曲線の算出にデータを使用した。また、研究の異質性を評価した。合計102本の原稿と1つの抄録が含まれていた。分析の結果，視覚的方法はむし歯病変の検出に良好な精度を示すことがわかった．臨床的に得られた特異性の方が高かった。また、中等度から高度の異質性と出版バイアスの証拠が認められた。よく知られた視覚的スコアリングシステムを採用した研究は、独自の基準を用いた研究よりも有意に精度が高かった。結果はグループ化され、歯列の種類（永久歯か原始歯か）、病変の種類（初期か進行か）、近位面か咬合面か、臨床現場か実験室かで区別されていた。感度は0.274～0.77で，永久歯の近心面を対象とした臨床研究が最も低く，永久歯の咬合面の初期う蝕を対象とした3つの研究が最も高かった．結論視覚的う蝕検出法は全体的に良好な性能を有していた。集められた研究は異質性が高く，バイアスのリスクも高いが，詳細に検証された指標を使用することで，本法の精度が向上すると思われる．

Data sourcesElectronic Databases searched in PubMed, Embase and Scopus. Unpublished literature was traced through OpenSIGLE, annals of IADR/AADR (International and American Associations for Dental Research) and ORCA (European Organisation for Caries Research) from 2003-2014. Studies were limited to English.Study selectionStudies involving visual inspection for detection of primary coronal caries lesions in primary or permanent human teeth were considered. All papers needed to include a clearly defined reference standard and the reporting of absolute numbers of true positives, false positives, true negatives and false negatives or a presentation of sufficient data to calculate these figures. Reference methods considered appropriate were histologic evaluation, operative intervention, direct visual inspection after temporary tooth separation and radiography. For studies with the same data set only the most complete study was included. Articles that reported caries detection using artificial caries, root caries or recurrent decay adjacent to restorations were excluded.Data extraction and synthesisStudy selection for inclusion was performed independently by two reviewers and disagreements were resolved by discussion with a third reviewer. Data were collected by two reviewers on structured tables. Discrepancies were resolved by consensus. A meta-analysis was performed. The following information was extracted; reference standard method, setting (clinical or laboratory), type of teeth (primary or permanent), surface evaluated (smooth, proximal or occlusal), sample size, examiner's experience. Also recorded were visual scoring systems. Studies that did not report any criteria were classified as 'with no criteria'. If authors used criteria with no reference to previously published studies they were classified as 'own criteria'. The PRISMA guideline was followed to report the review and the QUADAS-2 checklist (Quality assessment of studies of diagnostic performance included in systematic reviews) was used to assess the risk of bias of the included studies.ResultsData were used to calculate the pooled sensitivity, specificity, diagnostic odds ratio and summary receiver operating characteristics curve. Heterogeneity of the studies was also assessed. A total of 102 manuscripts and one abstract were included. The analysis demonstrated that the visual method had good accuracy for detecting carious lesions. Clinically obtained specificity was higher. Also observed was moderate to high heterogeneity and evidence of publication bias. Studies employing well known visual scoring systems were significantly more accurate than those that used their own criteria. The results were grouped and differentiate the type of dentition (permanent or primary), type of lesion (initial or advanced), proximal or occlusal surface and clinical settings from laboratory settings.The pooled specificity calculated was high in most of the groups and ranged from 0.573 to 0.992 mostly > 0.90; the lowest was in the occlusal initial caries lesions in primary teeth.The sensitivity ranged from 0.274 to 0.77; the lowest from clinical studies in proximal surfaces in permanent teeth, the highest from three studies evaluating the occlusal initial caries lesions in permanent teeth. Most of the pooled sensitivities were around a low level.ConclusionsVisual caries detection method has good overall performance. Although the studies together had high heterogeneity and risk of bias, the use of detailed and validated indices seems to improve the accuracy of the method.