Are there hidden caries or is this another limitation of the diagnostic conventional exams?

  • Valdeci Elias dos Santos Junior University of Pernambuco
  • Andreza Cristina de Lima Targino University of Pernambuco
  • Arnoldo Vasconcelos de Alencar Filho University of Pernambuco
  • Aronita Rosenblatt University of Pernambuco
Keywords: Computed microtomography, Dental diagnostics, Incipient lesions, Dental caries


Objective: To verify the existence of hidden caries and compare the diagnosis agreement among different Examiners between the visual and radiographic exam and computed microtomography images of incipient dental lesions on the occlusal surface of extracted molars.
Methods: Two hundred and fifteen healthy teeth were extracted from the corpses of children with a mean age of 12 years and analysed by visual examination. However, only 11 teeth were included in current study because they showed suggestive caries image when examined by microtomography (micro CT scan). Occlusal sites were examined both visually and by dental radiograph by 3 different dental practitioners and results were compared and validated independently by each Examiner with computed microtomography, henceforth a gold-standard in current investigation. The coefficient of agreement was calculated by Cohen’s kappa test.
Results: the coefficient of agreement among Examiners for the diagnosis by standard microtomography was excellent (K = 0.924) and moderate for both the visual (K=0.515) and the radiographic (K=0.583) examinations. Computed microtomography-produced images allowed the Examiners to visualize radiolucent areas, unseen in previous radiographic images and visual exams, in which there existed communication between enamel and/or dentine and the external environment.
Conclusion: Hidden caries was the product of the conventional exam´s limitations, or rather, the lesion was due to enamel non-collapse. Consequently, conventional exams were not accurate enough to detect the lesions.

Author Biography

Valdeci Elias dos Santos Junior, University of Pernambuco
Estudante de Graduação da Faculdade de Odontologia de Pernambuco, Universidade de Pernambuco. Pesquisador PIBIC/CNpQ


McDonald SP, Sheiham A. The distribution of caries on different tooth surfaces at varying levels of caries -– a compilation of data from 18 previous studies. Community Dent Health. 1992;9:39-48.

Beltrán-Aguilar ED, Estupiñán-Day S, Báez R. Analysis of prevalence and trends of dental caries in the Americas between the 1970s and 1990s. Int Dent J. 1999;49:322-9.

Whelton H. Overview of the impact of changing global patterns of dental caries experience on caries clinical trials. J Dent Res. 2004; 83 Spec No C:C29-34.

Bernabé E, Sheiham A, Sabbah W. Income, income inequality, dental caries and dental care levels: an ecological study in rich countries. Caries Res. 2009;43:294-301.

Bagramian RA, Garcia-Godoy F, Volpe AR. The global increase in dental caries. A pending public health crisis. Am J Dent 2009;22:3-8.

Weerheijm KL, Gruythuysen RJ, van Amerongen WE. Prevalence of hidden caries. ASDC J Dent Child. 1992;59:408-12.

Weerheijm KL. Occlusal ‘hidden caries’. Dent Update 1997;24:182-4.

Millman CK. Fluoride syndrome. Br Dent J. 1984;24;157:341.

Lewin DA. Fluoride Syndrome (latter). British Dental Journal 1985;158:39.

Creanor SL, Russell JI, Strang DM, Stephen KW, Burchell CK. The prevalence of clinically undetected occlusal dentine caries in Scottish adolescents. Br Dent J. 1990;169:126-9.

Ismail AI. Clinical diagnosis of precavitated carious lesions. Community Dent Oral Epidemiol. 1997;25:13-23.

Ricketts D, Kidd E, Weerheijm K, de Soet H. Hidden caries: what is it? Does it exist? Does it matter? Int Dent J. 1997;47:259-65.

Ekstrand KR, Ricketts DN, Kidd EA. Occlusal caries: pathology, diagnosis and logical management. Dent Update 2001;28:380-7.

Lynch RJ, Ten Cate JM. The effect of lesion characteristics at baseline on subsequent de- and remineralisation behaviour. Caries Res 2006;40: 530-5.

Praetzel JR et al. Cárie oculta em dentes decíduos: relato de caso clínico. Jornal Brasileiro de Odontopediatria e Clínica do Bebê 1999;2:432-7.

Souza-Zaroni WC, Ciccone JC, Souza-Gabriel AE, Ramos RP, Corona SA, Palma-Dibb RG. Validity and reproducibility of different combinations of methods for occlusal caries detection: an in vitro comparison. Caries Res.2006;40:194-201.

Ricketts DN, Ekstrand KR, Martignon S, Ellwood R, Alatsaris M, Nugent Z. Accuracy and reproducibility of conventional radiographic assessment and subtraction radiography in detecting demineralization in occlusal surfaces. Caries Res. 2007;41:121-8.

Neuhaus KW, Ellwood R, Lussi A, Pitts NB. Traditional lesion detection aids. Monogr Oral Sci. 2009;21:42-51.

Brooks SL. Computed tomography. Dental Clinics of North American 1993;37:575-590.

Parks ET. Computed tomography applications for dentistry. Dent Clin North Am. 2000;44:371-94.

Maltz M, Correa PZ, Veeck R. Comparison between clinical and radiographic examination of occlusal surface. In: 74th General Session of IADR, 1996, Washington. J Dent Res 1996;75:1106.

Bulman JS, Osborn JF. Measuring diagnostic consistency. Br Dent J. 1989;166:377- 81.

Landis JR, Koch GG. An Application of Hierarchical Kappa-type Statistics in the Assessment of Majority Agreement among Multiple Observers. Biometrics 1977;33:363-374.

Seow WK, Wan A, McAllan LH. The prevalence of pre-eruptive dentin radiolucencies in the permanent dentition. Pediatr Dent. 1999;21: 26-33.

Seow WK. Pre-eruptive intracoronal resorption as an entity of occult caries. Pediatr Dent. 2000;22:370-6.

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 occult caries in extracted premolars. Pediatr Dent. 2003;25:441-9.

Poorterman JH, Weerheijm KL, Groen HJ, Kalsbeek H. Clinical and radiographic judgement of occlusal caries in adolescents. Eur J Oral Sci. 2000;108:93-8.

Thylstrup A, Fejerkov O. Radiologic diagnosis in caries management. Copenhagen: Munsgaard; 1994. p. 367-82.

Zafersoy-Akarslan Z, Erten H, Uzun O, Semiz M. Reproducibility and agreement of clinical diagnosis of occlusal caries using unaided visual examination and operating microscope. J Can Dent Assoc. 2009;75:455.

Thunthy KH. Technique for using films accidentally exposed to light. Oral Surg Oral Med Oral Pathol. 1988;65:371-5.

Original Article