Evaluation of the margins and gingival status of full-crown restorations using a household intraoral camera

doi:10.21203/rs.3.rs-1501449/v1

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Evaluation of the margins and gingival status of full-crown restorations using a household intraoral camera

https://doi.org/10.21203/rs.3.rs-1501449/v1

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Objective: The purpose of this study was to compare the usefulness of intraoral photographs, acquired with a household intraoral camera operating in conventional, calibrated, and polarized modes, with clinical examinations for assessing the margins and gingival status of full-crown restorations.

Methods: The clinical examination is performed by a prosthodontist expert who classifies the marginal status of full-crown restorations according to the FDI World Dental Federation, and periodontal expert who classifies the gingival status according to the Modified Gingival Index (MGI). The margins and gingival status of the conventional, calibration, and polarization groups of full-crown restorations were independently assessed by three evaluators who obtained photographs using an intraoral camera. Cases where at least two of three assessors were in agreement were analyzed using Cohen’s kappa coefficient and the chi-square test were calculated.

Results: This study included 40 patients with 54 full-crown restorations. The conventional, calibration, and polarization groups differed significantly in marginal and gingival status of full-crown restorations. In the calibration group, there was good agreement between the camera-based and oral clinical examinations in terms of the gingival status of full-crown restorations (kappa = 0.945); this was also the case in the polarization group with respect to the margins of full-crown restorations (kappa = 0.917).

Conclusions: An intraoral camera with black and white calibrated images is useful to assess the gingival status of full-crown restorations. Polarization mode can be used to assess the margins of full-crown restorations. The camera is a feasible and valid diagnostic aid.

Dental

dental restorations

digital photography

diagnosis

To improve long-term outcomes, crown restorations require maintenance and follow-up. Previous studies suggested that the position of the margins affects gingival health[1, 2]. However, margin quality has a greater effect on gingival health than margin position. Gingivitis is more likely at the edge of a non-adherent restoration[3, 4]. The margin and irregular shape of restorations provide ideal conditions for the accumulation of food and plaque, and prevent adequate oral hygiene[2, 5]. Hospital visits for clinical examinations and evaluation of full-crown restorations are necessary.

Crown restorations should be followed up within 7–10 days to evaluate function and fit, patient comfort, plaque control, and residual bonding agent in the gingival junction. A second follow-up at 6 months is recommended to check for localized defects. In the past 10 years, due to oral hygiene practices, 61% of full-crown restorations had a poorly fitting margin and 80% of patients had gingivitis[6]. Due to modern lifestyles and the coronavirus 2019 (COVID-19) pandemic, many patients cannot be reviewed regularly[7, 8] and Teledentistry can provide dental care[9–11]. Therefore, innovative methods allowing self-examination by patients are urgently required for consistent and convenient follow-up.

The use of digital photography in dentistry has significantly advanced in the past decade. Digital photography can be used as a clinical diagnostic tool, and there are studies on its application to diagnose tooth decay[12–18], dental trauma[19, 20], and oral lesions[21, 22]. Signori et al. [23]compared intraoral photographs with the results of clinical evaluations of composite resin fillings, and showed that digital intraoral photographs are an indirect but efficient method for assessing fillings and treatment efficacy. De Almeida et al. [24]found significant differences between marginal fitness and esthetic ratings based on clinical examination and intraoral photographs. Guo et al. [25]concluded that photographic gingival color affects the judgment of results when assessing gingival health. However, both digital and intraoral photographs exhibit color deviation and reflection, which impact the accuracy of evaluation. Kim et al. [26]developed a digital shade-matching device for dental color determination based on a support vector machine algorithm; their device uses a commercial intraoral camera, where cross-polarization is prevented by the perpendicular polarizing filter such that color distortion caused by specular reflection on the tooth surface is eliminated. However, the equipment is not commonly available or easy to use.

The objective of the present study was to compare the usefulness of portable intraoral camera photographs and intraoral clinical examinations for assessment of the margins and gingiva of full-crown restorations. The camera was operated in conventional, calibration, and polarization modes, to improve the accuracy of evaluations of the edge of full-crown restorations and gingival status.

2.1 Study participants

This study included 40 patients with 54 full-crown prostheses seen at the Department of Prosthodontics, Peking University School and Hospital of Stomatology, China, between August and December 2021. We included patients aged ≥ 18 years with at least one full-crown restoration in the anterior or posterior tooth, no systemic disease or active periodontitis, full behavioral autonomy, the ability to express themselves, and good compliance. Patients were excluded if they had poor oral hygiene, acute or chronic disease in teeth adjacent to the full-crown restoration, orthodontic bracket attachments on the tooth surface, or other characteristics that may affect photography of fixed restorations.

All subjects provided written consent prior to participation. The study was performed in accordance with the Declaration of Helsinki and approved by the Biomedical Ethics Committee of Peking University Hospital of Stomatology, Beijing, China (No.: PKUSSIRB-202165097).

2.2 Sample size

Based on the experimental design, PASS 15 software (NCSS, LLC, Kaysville, UT, USA) was used to calculate the sample size with α = 0.05 and 80% statistical power. The calculations showed a required sample size of at least 40 full-crown restorations. All patients in the randomized trial were invited to participate in the study; given that individual patients may have more than one restoration, 54 full-crown restorations were included in the study.

2.3 Black and white calibration sheet

As a black and white calibration sheet, a 1.5-mm-diameter semicircle, which was half black (R:0, G:0, B:0) and half white (R:255, G:255, B:255), was printed on a piece of self-adhesive paper and calibrated (Fig. 1). A photograph of this card, along with one of a standard black and white card, was imported into Adobe Photoshop CC 2018 (Adobe Inc., Mountain View, CA, USA) to ensure that the black and white calibration sheet was consistent with the standard color card.

2.4 Examiners and calibration

To ensure reliability of the clinical examinations (the reference standard), prosthodontist expert was trained in the use of the index to assess the marginal status of full-crown restorations according to the FDI World Dental Federation [27] criteria, and periodontal expert was trained in the use of the index to assess the gingival status of full-crown restorations according to the Modified Gingival Index(MGI)[28].The prosthodontic and periodontal specialists who performed the clinical examinations were experts with more than 10 years of experience.

To ensure accurate evaluation of the full-crown restorations based on photographs obtained using an intraoral camera (Zhimei YF200B; Baden Co., Ltd., Beijing, China), three evaluators were trained. During training, the three evaluators assessed photographs similar to those evaluated in the actual study, to ensure that they understood the evaluation methods and criteria. The study photographs were assessed once the total agreement score for the three evaluators was ≥ 85%[27, 29]. The evaluators were general dentists with less than 3 years of clinical experience.

Table 1

Marginal adaptation levels in the FDI [27]and MGI[28] levels
	Marginal adaptation		MGI
1	Harmonious outline, no gaps, no white or discolored lines.	0	absence of inflammation.
2	Marginal gap (< 150 µm), white Lines; Small marginal fracture removable by polishing; Slight ditching, slight step/flashes, minor irregularities.	1	mild inflammation or with slight changes in color and texture but not in all portions of gingival marginal or papillary.
3	Slight ditching, slight step/flashes, minor irregularities; Gap < 250 µm not removable; Several small marginal fractures; major irregularities, ditching or flash, steps.	2	mild inflammation, such as the preceding criteria, in all portions of gingival marginal or papillary.
4	Gap > 250 µm or dentine/base exposed; Severe ditching or marginal fractures; Larger irregularities or steps (repair necessary).	3	moderate, bright surface inflammation, erythema, edema and/or hypertrophy of gingival marginal or papillary.
5	Restoration (complete or partial) is loose but in situ; Generalized major gaps or irregularities.	4	severe inflammation: erythema, edema and/or marginal gingival hypertrophy of the unit or spontaneous bleeding, papillary, congestion or ulceration.

2.5 Clinical examinations

The clinical examinations were performed by trained senior clinicians (a prosthodontist expert and a periodontal expert) with more than 10 years of clinical experience. The examinations were performed on the same day, using the same dental equipment and light conditions. The instruments used for the examinations included disposable mouth mirrors and triple syringes. Prior to the examination, the teeth were cleaned with sterile gauze to remove food deposits. Teeth were examined in a wet state, but excess saliva was removed using a triple syringe if necessary[24, 30, 31]. The average time spent on the examination was almost 1 min per patient. The prosthodontist assessed the margins of the full-crown restorations according to the FDI[27] criteria, and the marginal fit of the full-crown restorations was rated as clinically acceptable (levels 1–3; 0) or unacceptable (levels 4 and 5; 1). The periodontist assessed the gingival status of the full-crown restorations according to the MGI[28], and the gingival status was rated as clinically acceptable (levels 0–2; 0) or unacceptable (levels 3 and 4; 1)

2.6 Intraoral photographs

After the clinical examination, intraoral photographs were taken under standardized conditions by a dentist trained in the use of photographic equipment[30]. The intraoral camera (Zhimei YF200B; Baden Co., Ltd.) had a 6-LED light source and provided images with a fixed resolution of 1,600 × 1,200.

The patients were positioned on a dental chair, with the Frankfort plane at an angle of 45° relative to the floor. No external light source was used. The teeth were wet when photographed, but excess saliva was removed using a sterile gauze or triple syringe. The position of the full-crown restorations was determined and a black and white calibration sheet was taped over one third of the buccal side. After covering the intraoral camera with a disposable protective sheet, it was inserted into the mouth and photographs of the restoration were obtained with the camera located 3 cm from the tooth surface[23]. The camera was positioned perpendicular to the buccal and lingual surfaces of the anterior teeth, at a 45° angle relative to the buccal and lingual surfaces of the posterior teeth (Fig. 2). After conventional intraoral photographs were obtained, two linear polarizers (Edmund Industrial Optics, Barrington, IL, USA) were perpendicularly placed in front of the light source and prism to enable cross-polarization. Owing to the cross-polarization, the horizontally polarized reflected light was blocked by the perpendicularly polarizing filter, such that the color distortion caused by specular reflection on the tooth surface was eliminated[26]. Photographs taken using the intraoral camera under these conditions were categorized as polarized. The photographs were evaluated for acceptability and quality; more photographs were obtained as needed.

The photographs were saved on a personal computer (Inspiron 5408; Dell Inc., Round Rock, TX, USA) as JPG files and assigned a numerical code to protect patient identity[24, 30]. The photographs from the conventional intraoral photographs group were imported into Photoshop CC 2018 (Adobe) for editing and processing (of the black and white calibration). These photographs were classified as calibration photographs and stored on the personal computer as JPG files. Sample photographs are displayed in Fig. 3.

2.7 Photographic evaluation

Three trained dentists who did not participate in the data collection process evaluated photographs showing the full-crown restoration margins and gingival status based on the FDI [27] criteria. Photographs from the conventional, calibration, and polarization groups were randomly displayed on a 14-inch high-definition display. Each evaluator independently assessed the photographs for 30 s and rated the full-crown restoration margins and gingival status as clinically acceptable (0) or unacceptable (1). Cases where at least two of three assessors were in agreement were analyzed[23].

2.8 Statistical analysis

The data were analyzed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA). The margins and gingival status of full-crown restorations were compared among the conventional, calibration, and polarization groups. Cohen's kappa statistic was used to assess the agreement between the intraoral camera-based assessments of the margins and gingival status of full-crown restorations and the clinical examinations. Kappa values were classified as poor (≤ 0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), or very good (0.81–1.00)[32].

The χ² test was used to compare the assessment results among the three groups; p < 0.05 was considered to indicate a statistically significant difference.

This study included 40 patients with 54 full-crown restorations. Of the 40 patients, 11 had more than one full-crown restoration.

3.1 Gingival status evaluation of the conventional, calibration, and polarization groups

3.1.1 Results of the three methods for evaluating gingival status

The clinical examinations of the 54 full-crown restorations conducted by periodontal experts were considered the reference standard. In terms of successful determination of gingival status, overall, there were 43 “positive” and 11 “negative” cases. In the conventional, calibration, and polarization groups, 29, 42, and 14 cases were positive, respectively (67.44%, 97.67%, and 32.56%, respectively) (Table 2). The calibration group had the highest positivity rate, while the polarization group had the lowest positivity rate. The difference among the three groups was statistically significant (chi-square statistic = 40.522, p < 0.05).

Table 2

Results of the assessment of the gingival status of full-crown restorations in clinical and photographic evaluations
		conventional groups		calibration groups		polarization groups
clinical examination	Number	positive(n/%)	negative(n/%)	positive(n/%)	negative(n/%)	positive(n/%)	negative(n/%)
positive	43	29(67.44)	14(32.56)	42(97.67)	1(2.33)	14(32.56)	29(67.44)
negative	11	1(9.09)	10(90.91)	0(0)	11(100)	2(18.18)	9(81.82)

3.1.2 Comparison of the agreement between the camera-based assessments of gingival status and reference standard in the three groups

In the conventional, calibration, and polarization groups, 29, 42, and 14 results were positive, as stated above, and there was moderate (kappa = 0.405), very good (kappa = 0.945), and poor (kappa = 0.075) agreement with the reference standard, respectively (Table 3).

Table 3

Consistency of clinical oral examination and photographic evaluation of the gingival status of full-crown restorations
groups	Kappa	Level of agreement
conventional groups	0.405	moderate
calibration groups	0.945	very good
polarization groups	0.075	poor

3.2 Marginal fitness evaluation of the conventional, calibration, and polarization groups

3.2.1 Results of the three methods for evaluating the marginal fitness of restorations

The clinical examinations conducted by prosthodontic experts were considered the reference standard, and revealed 36 “positive” and 18 “negative” cases with respect to successful determination of the marginal fitness of the restorations. In the conventional, calibration, and polarization groups, 26 (detection rate = 72.22%), 26 (detection rate = 72.22%), and 40 (detection rate = 97.22%) cases were positive (Table 4). Thus, the positivity rate was highest in the polarization group. The difference among the three groups was statistically significant (chi-square statistic = 9.163, p < 0.05).

Table 4

Results of the assessment of the margins of full-crown restorations in clinical and photographic evaluations
		conventional groups		calibration groups		polarization groups
clinical examination	Number	positive(n/%)	negative(n/%)	positive(n/%)	negative(n/%)	positive(n/%)	negative(n/%)
positive	36	26(72.22)	10(27.78)	26(72.22)	10(27.78)	35(97.22)	1(2.78)
negative	18	2(11.11)	16(88.89)	2(11.11)	16(88.89)	1(5.56)	17(94.44)

3.2.2 Comparison of the extent of agreement between the camera-based and oral clinical examinations among the three methods for evaluating marginal fitness

In the conventional, calibration, and polarization groups, 26, 26, and 34 cases were “positive”, respectively, reflecting moderate (kappa = 0.550), moderate (kappa = 0.550), and very good (kappa = 0.917) agreement with the reference standard, respectively (Table 5).

Table 5

Consistency of clinical oral examination and photographic evaluation of the margins of full-crown restorations
groups	Kappa	Level of agreement
conventional groups	0.550	moderate
calibration groups	0.550	moderate
polarization groups	0.917	very good

In the present study, we used the Zhimei intraoral camera, which is portable, inexpensive, and easy to operate. It can connect via Bluetooth and allows real-time photography and video recording. The camera was used to photograph full-crown restorations, and the level of agreement between the clinical evaluations and camera-based assessments of the margins and gingival status was moderate in the conventional group. These findings were similar to those of Signori et al. [23]Digital photography is widely used in dental practice and allows clinicians to record the treatment process[33], and archive important information[33–35]. It also helps patients understand their clinical condition. However, conventional dental photography requires operator expertise and specialized equipment, such as oral retractors and reflectors, which may cause discomfort to patients. Compared to a conventional single-lens reflex camera, an intraoral camera can capture pictures without the need for retractors, reflectors, or other equipment. The patient can also see their oral cavity on the monitor in real time. The intraoral camera is small and convenient to use, thus reducing patient discomfort. Signori et al. [23]showed that using intraoral digital cameras to evaluate restorations is an indirect yet effective method. However, the photographs are affected by light, which can cause color distortion and reflections. Steinmeier et al.[12] found that remote examinations using intraoral scans were unable to assess periodontal status with accuracy, which may be related to the quality of the color images used by the software for colorimetric enhancement of the three-dimensional file. Moncada et al. [31]showed that calibration can restore the brightness, contrast, and color of images such that they match the actual clinical condition. A black and white calibration card was used to obtain photographs with parameters close to the actual clinical evaluations. Tobias et al. [36] proposed a dental self-timer to accurately assess gingival health through photographs. The present study evaluated the gingival status of full-crown restorations, and there was high agreement between the camera-based assessment and clinical examination in the calibration group. However, black and white calibrated images are more suited for assessing the gingival status of full-crown restorations as an indirect or complementary method.

The present study used an intraoral camera to evaluate the marginal fitness of full-crown restorations. The conventional and calibration groups had similar marginal fitness evaluation results. The moderate agreement was in line with the results of De Almeida et al. [24]who reported that digital images can provide evaluators with a sense of continuity during restorations and enhance the accuracy of evaluations of marginal fitness. During clinical evaluations, dentists use probes to obtain information regarding the marginal fitness of the restoration. To closely inspect the margin, this study used the polarization method to prevent the reflection of light from the restoration surface, such that color parameters could be obtained more precisely[26]. This technique also allowed the evaluators to identify poorly fitted restorations, because differences in color between the restoration and abutment were clearly visible. There was high agreement between the camera-based and clinical evaluation results in the polarization group. Therefore, polarization mode was effective for evaluating the marginal fitness of full-crown restorations.

This study showed that oral endoscopy was effective for evaluating the marginal fitness of full-crown restorations and associated gingival inflammation. Patients can use a standard intraoral camera to obtain photographs aiding telemedical evaluation. Professionals could then make preliminary assessments and determine whether the patient needs to visit the dentist or continue with their current oral hygiene practices. Patients who do not need to visit a dentist should receive online oral hygiene guidance. Remote evaluation of pictures obtained by an intraoral camera may promote rational allocation of medical resources and improve the efficiency of medical evaluations[10, 11]. Due to the COVID-19 pandemic, many patients were unable or unwilling to attend dental facilities for regular follow-ups during the past 2 years. The use of an intraoral camera for dental evaluations could reduce the risk of infection[11, 37].

Our study had a few limitations. First, the sample size was small, so we cannot definitively conclude that intraoral camera-based evaluations can replace clinical evaluations. At present, the camera should only be used as an auxiliary/supplementary evaluation method. Second, in the calibration group, a black and white calibration card had to be used on the tooth surface, while in the polarization group a linear polarizer was needed; these devices are not available for home use. The black and white calibration film and a simpler version of the polarizer should be integrated into intraoral cameras to allow patients to obtain their own photographs. Third, as this study was based on two-dimensional photographs, some details may have been missed; videotaping may be preferable for remote dental evaluations.

The use of a calibrated intraoral camera to assess the gingival status, and operation of the camera in polarization mode to assess the margins of full-crown restorations, are feasible and effective diagnostic aids that could facilitate the development of teledentistry.

MGI: Modified Gingival Index.

Acknowledgements

We would like to thank the residents who helped with the photographic evaluation (Dr. Feilong Wang, Dr. Jiahui Ye and Dr. Xiao Zhao) and the periodontist who performed the clinical examination (Dr. Wenjie Hu).

Authors’ contributions

The project was conceptualized by YSL and STC. HC, ML and STC designed the study. STC acquired and analyzed the data, wrote the original manuscript. YSL and YL revised the manuscript. All authors reviewed the manuscript.

Funding

This study was supported by a grant from the National Program for Multidisciplinary Cooperative Treatment on Major Diseases, Grant Number: PKUSSNMP-202004 and PKUSSNMP-201901.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study protocol was carried out in accordance with the Declaration of Helsinki and was approved by the Biomedical Ethics Committee of Peking University Hospital of Stomatology, Beijing, China (Ethical Batch Number: PKUSSIRB-202165097). Written informed consent was obtained from all individuals included in the study.

Consent for publication

Informed consent of all subjects for publication of identifying information/ images. all subjects understand that the text and any pictures or videos published in the article will be freely available on the internet and may be seen by the general public.

Competing interests

The authors declare no conficts of interest in this study.

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No competing interests reported.

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Evaluation of the margins and gingival status of full-crown restorations using a household intraoral camera

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Abstract

Figures

1. Introduction

2. Materials And Methods

2.1 Study participants

2.2 Sample size

2.3 Black and white calibration sheet

2.4 Examiners and calibration

2.5 Clinical examinations

2.6 Intraoral photographs

2.7 Photographic evaluation

2.8 Statistical analysis

3. Results

3.1 Gingival status evaluation of the conventional, calibration, and polarization groups

3.1.1 Results of the three methods for evaluating gingival status

3.1.2 Comparison of the agreement between the camera-based assessments of gingival status and reference standard in the three groups

3.2 Marginal fitness evaluation of the conventional, calibration, and polarization groups

3.2.1 Results of the three methods for evaluating the marginal fitness of restorations

3.2.2 Comparison of the extent of agreement between the camera-based and oral clinical examinations among the three methods for evaluating marginal fitness

4. Discussion

5. Conclusion

Abbreviations

Declarations

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