Quintus Julia Caroline, Schulze Ralf Kurt Willy
Department of Orthodontics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
Oral Diagnostic Sciences, School of Dental Medicine, University of Bern, Bern, Switzerland.
Clin Oral Investig. 2025 Sep 26;29(10):477. doi: 10.1007/s00784-025-06511-1.
This ex vivo study aimed to compare the accuracy in detection of interproximal natural carious lesions between intraoral (iBWR) and extraoral bitewing radiographs (eBWR) using a multi-observer design and a rigorous gold standard.
Eighty extracted teeth (40 premolars, 40 molars) were arranged in anatomical sequence within a simulated jaw composed of PMMA and modified gypsum, with an emphasis on creating natural interproximal contacts. Approximately 50% of the teeth exhibited enamel caries, while the remaining 50% were caries-free. Image acquisition was performed using a custom-designed PMMA phantom. iBWR were obtained with a CMOS intraoral sensor (XIOS XG Supreme, Sirona Dental Systems, Bensheim, Germany), and eBWR with a digital panoramic device (Orthophos SL 3D, Dentsply Sirona, Bensheim, Germany). Twenty-seven licensed dentists assessed caries presence and depth on 120 approximal surfaces (each surface assessed twice using both modalities) using a 5-point confidence scale and a 4-point lesion depth scale. Observers were blinded to the true caries status, which was determined through histological serial sectioning and brightfield microscopy. Diagnostic accuracy was evaluated via ROC analysis, with Youden's index used to calculate sensitivity, specificity, predictive values, and likelihood ratios. Statistical analyses were conducted at a significance level of α = 0.05.
Overall accuracy was higher for iBWR (Az = 0.58) than for eBWR (Az = 0.54). Both intra-rater (test-retest, eBWR [Formula: see text] = 0.44, iBWR [Formula: see text] = 0.48) as well as inter-rater reliability (mean ICC eBWR = 0.19, iBWR = 0.27) were low. For enamel caries detection, iBWR outperformed eBWR in terms of specificity and positive predictive values, while eBWR in the first reading round achieved significantly higher sensitivity.
Overall, our multi-observer ex vivo study using microscopy as ground truth revealed higher diagnostic accuracy for intraoral bitewing radiography as compared to its extraoral counterpart.
Our results from a highly standardized study using a rigorous gold standard support the assumption that intraoral bitewing radiography still represents the radiographic state-of-the-art in interproximal caries detection. For minute enamel, diagnostic accuracy of both methods is just above random guessing.
本体外研究旨在采用多观察者设计和严格的金标准，比较口内（iBWR）和口外翼片X线片（eBWR）检测邻面自然龋损的准确性。
80颗拔除牙（40颗前磨牙，40颗磨牙）按解剖顺序排列在由聚甲基丙烯酸甲酯（PMMA）和改良石膏组成的模拟颌骨内，重点是形成自然邻面接触。约50%的牙齿有釉质龋，其余50%无龋。使用定制设计的PMMA模型进行图像采集。iBWR用CMOS口内传感器（XIOS XG Supreme，德国本斯海姆西诺德牙科系统公司）获取，eBWR用数字全景设备（Orthophos SL 3D，德国本斯海姆登士柏西诺德公司）获取。27名持牌牙医使用5点置信度量表和4点病损深度量表，对120个邻面（每个面使用两种方式各评估两次）的龋病存在情况和深度进行评估。观察者对真实龋病状态不知情，真实龋病状态通过组织学连续切片和明场显微镜检查确定。通过ROC分析评估诊断准确性，用约登指数计算敏感性、特异性、预测值和似然比。统计分析在显著性水平α = 0.05下进行。
iBWR的总体准确性（Az = 0.58）高于eBWR（Az = 0.54）。评分者内（重测，eBWR[公式：见正文]= 0.44，iBWR[公式：见正文]= 0.48）以及评分者间信度（平均组内相关系数eBWR = 0.19，iBWR = 0.27）均较低。对于釉质龋检测，iBWR在特异性和阳性预测值方面优于eBWR，而在第一轮读数中eBWR的敏感性显著更高。
总体而言，我们以显微镜检查为金标准的多观察者体外研究表明，与口外翼片X线片相比，口内翼片X线片具有更高的诊断准确性。
我们使用严格金标准的高度标准化研究结果支持以下假设，即口内翼片X线片在邻面龋检测方面仍代表放射影像学的最新技术水平。对于微小釉质龋，两种方法的诊断准确性仅略高于随机猜测。
