The use of vertical bitewings compared to visual examination alone for dental caries diagnosis and treatment planning in paediatric dentistry

Abstract

Aim: The aim of the present study was to evaluate the use of vertical bitewing radiographs (VBWs) compared to visual examination alone for caries diagnosis and treatment planning in children. Secondary aims included the evaluation quality of vertical bitewings and common radiographic errors.

Methods: After local ethical approval (#2020507), 5 to 10 year old children eligible for treatment in the undergraduate dental clinic in paediatric dentistry at Dublin Dental University Hospital (DDUH) were invited to participate. Caries diagnoses and treatment decisions were made based on clinical examination alone followed by radiographic findings from vertical bitewing radiographs. All examinations were performed by three trained and calibrated examiners based on modified clinical/radiographic ICDAS criteria that included the evaluation of pulp necrosis. A standardised algorithm was used for treatment decisions based on current international guidelines and classified into control (CT), non-restorative treatment (NR), restorative treatment (RT) and pulpectomy/extraction. Quality rating of the radiographs included specific errors in processing, distortion and positioning. Descriptive and statistical analysis was performed using Stata 17.0 (α=5%). Individual reports were performed for primary molars, primary canines and first permanent molars at a tooth-level, surface-level, radiograph-level and child-level analysis. Cluster-adjusted logistic regression analysis was conducted to evaluate the factors associated with changes in the treatment decision. Ordinal logistic regression analysis was used to assess the quality rating of the radiographs and associated factors (age, type of positioner, side).

Results: A total of 841 teeth (197 primary canines, 529 primary molars and 115 first permanent molars) in 75 children were included (1,821 surfaces). The number of changes in the treatment decision for primary molars following radiographic diagnosis per child ranged from 0 to 6 (mean=1.88). Changes at tooth level occurred in 11% of all teeth and in 17.39% of primary molars. At a surface level, changes in the treatment plan were more often detected in proximal surfaces of primary molars (19.57%) when compared to other teeth/surfaces (p<0.05). The majority of those changes occurred from control to non-restorative treatment (n=116; 66.6%). Vertical bitewings detected the presence of furcation radiolucency in 19% of deep caries lesions, reflecting changes from restorative treatment to pulpectomy/extraction. The overall quality of the radiographs was high (10.67% excellent, 72% diagnostically acceptable and 17.33% diagnostically compromised). Positioning errors included child not biting fully (7.33%), vertical (13.33%) and horizontal errors (too far posterior=48.67%) and the presence of coning-off (38.67%). The use of the red Rinn XCP® vertical holder was associated with better quality radiographs when compared to the Snap-a-ray® holder (p=0.045). The side of the radiograph and the child’s age did not influence the quality of the VBW taken (p>0.05). The majority of VBWs (>80%) allowed visualisation of the crown and furcation of the primary teeth and the presence of a permanent successor.

Conclusion: VBWs increased the detection of proximal caries lesions in primary molars compared to visual examination. The majority of those lesions were restricted to enamel, and very few were into dentine. Changes in the treatment decision occurred more in the proximal surfaces of primary molars when compared to the occlusal surface. The majority of those changes occurred from control to non-restorative treatment with the detection of early caries lesions. Vertical bitewings allowed the determination of the depth of dentine caries, proximity to pulp and signs of pulp necrosis, all essential for treatment planning for deep caries lesions. The majority of VBWs was deemed diagnostically acceptable and the most common error was positioning error (too far posterior). The use of vertical bitewings holders was associated with better quality of vertical bitewing radiographs when compared to Snap-a-ray holders.