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1 J Dent Hyg Sci Vol. 14, No. 4, 2014, pp RESEARCH ARTICLE Q-Ray View 활용이치위생과정을위한치아검사의신뢰도향상에미치는영향 오혜영 1,2 ㆍ정회인 2,4 ㆍ구혜민 2,3 ㆍ김백일 2,3,4 1 수원과학대학교치위생과, 연세대학교치과대학 2 예방치과학교실, 3 BK21 플러스통합구강생명과학사업단, 4 구강과학연구소 The Effects of the Q-Ray View on Reliability of Assessing a Tooth Status for Dental Hygiene Process Hye-Young Oh 1,2, Hoi-In Jung 2,4, Hye-Min Ku 2,3 and Baek-Il Kim 2,3,4 1 Department of Dental Hygiene, Suwon Science College, Hwaseong , 2 Department of Preventive Dentistry and Public Oral Health, Yonsei University College of Dentistry, Seoul , 3 BK 21 Plus Project, Yonsei University College of Dentistry, Seoul , 4 Oral Science Research Center, Yonsei University College of Dentistry, Seoul , Korea The objective of this study was to evaluate the impact of the Q-ray view, a novel optical device on reliability of assessing a tooth status by dental hygiene students in the training for dental hygiene process. Twenty patients were enrolled in this study. Oral examinations were conducted by both seventeen third-year dental hygiene students and a trained faculty member. Traditional visual inspection was performed in phase I and then re-examined with Q-ray view in phase II. Restoration codes and lesion codes for each tooth were recorded separately according to the predefined criteria. As a measure of reliability, percent agreement and Cohenʼs kappa were determined. Agreements for each intraoral regions and types of lesion and restoration were calculated. Paired t-test and Pearson chi-square test for two proportions were used to compare mean Cohenʼs kappa and percent agreement at each phase. For the lesion code, mean kappa values of phase II for intraoral regions were significantly greater than that of phase I (p=0.017). For the both of the lesion code and restoration code, percent agreements of phase II for each types of lesion and restoration were significantly greater than that of phase II (p<0.001 and p<0.001, respectively). Especially difference of percent agreements between phase I and II for incipient caries, caries and fracture were significant for the lesion code (p=0.046, p<0.001, and p=0.029, respectively) and for not restored or sealed, tooth-colored restoration were significant for the restoration code (p<0.001 and p=0.011, respectively). The reliability of assessing a tooth status was improved when the Q-ray view used in dental hygiene student with beginner level of expertise. Q-ray view can be a promising device for conducting and educating the dental hygiene process better. Key Words: Dental education, Dental hygiene, Dental instruments, Dental hygiene assessment, Quantitative Light-induced Fluorescence-Digital, Q-ray view 서론 치위생과정은대상자의구강병을예방하고증진시키기위해치과위생사가수행하는체계적인과정으로서치위생사정 (dental hygiene assessment), 치위생진단 (dental hygiene diagnosis), 계획 (planning), 실행 (implementation), 평 가 (evaluation) 로이루어져있다 1). 치과위생사는대상자의구강건강요구를충족시키기위해치위생사정단계에서대상자의정보를명확한기준과근거에의거하여체계적으로수집해야한다. 치위생사정단계에서대상자의인구학적특성, 전신건강상태, 구강건강상태, 사회경제적상태등을파악하는것은 Received: August 21, 2014, Revised: October 28, 2014, Accepted: October 29, 2014 ISSN (Print) / ISSN (Online) Correspondence to: Baek-Il Kim Department of Preventive Dentistry and Public Oral Health, Yonsei University College of Dentistry, 50, Yonsei-ro, Seodaemun-gu, Seoul , Korea Tel: , Fax: , Copyright 2014 by the Korean Society of Dental Hygiene Science This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 J Dent Hyg Sci Vol. 14, No. 4, 2014 대상자의요구에맞는치료계획을수립하고수행하기위해요구되는매우중요한과정이다 2). 병소및수복물에대한평가를포함한치아검사는치위생사정의핵심과정으로대상자에적합한치위생과정을수행할뿐만아니라추후대상자가구강건강을증진하고유지시키기위한방향을제시하고교육하기위한근거자료가된다. Quantitative Light-induced Fluorescence-Digital (Biluminator; Inspektor Research Systems BV, Amsterdam, The Netherlands) 는초기우식증의발생여부및진행상태를평가하는데유용한장비로인정받고있는 QLF 시스템의 2 세대버전이다. 최초의 QLF 시스템은 405 nm 청색광영역의가시광선을조사할때건전한법랑질과병소에서발생하는형광의차이를이용하여전통적검사방법인시진 (visual inspection) 과촉진 (tactile assessment) 으로발견하기어려운초기우식증을탐지할수있도록개발되었다 3,4). QLF-D 는구내카메라에백색광원과청색광원이부착되어있는형태로한번의촬영을통해백색광의일반이미지와청색광의형광이미지를동시에얻을수있다. 또한특수필터를내장하여세균으로부터발생한포피린 (porphyrin) 으로부터발생한붉은형광을탐지할수있도록하였고, 이에따라초기우식증뿐아니라치석, 치면세균막, 심미수복물, 실란트의구분도용이해졌다 5-8). QLF-D는암실과같이외부의빛이차단된환경에서 QLF-D 자체의광원만으로촬영할때가장높은질의이미지를제공한다. 촬영된이미지는시스템의일부로제공되는 C3 소프트웨어를이용하여수집및관리하고 QA2 소프트웨어 (QA2 v 1.23; Inspektor Research Systems BV) 를이용하여분석하게된다. 이와같은이미지분석은재광화와탈회와같이병소의미세한변화를정량적으로측정하는장점이있지만촬영환경의영향을받고분석결과를모니터를통해서확인해야하는단점이있다. 이를극복하기위하여푸른색광원과특수필터가부착된보안경으로구성된 Q-ray view (All in One Bio Inc., Seoul, Korea) 가개발되었다. Q-ray view는 QLF-D의핸디형으로휴대가간편하고사용이편리하여치위생과정에서유용하게사용될것으로기대된다. 시진과촉진만으로치아상태를정확하게평가하는것이매우어려운일인데, 특히치위생실습을처음경험하는치위생과학생들은치아우식증을포함한병소와다양한수복물을구분하는데어려움을겪는다 9). Q-ray view를활용할경우학생들이병소나수복물을보다용이하게구분할수있어실습교육환경에서올바른판단을내리는경험을반복한다면학생들의치아상태평가역량또한증진될것이다. 따라서본연구에서는치위생과정실습교육에참여하고있는치위생과 3학년학생이새롭게개발된광학장비인 Q-ray view를이용함으로써치아검사의신뢰성이향상되는지알아보고자하였다. 연구대상및방법 1. 연구대상본연구는 2013년 3월부터 5월까지경기도수원시에위치한일개치위생과대학에서수행되었으며치위생과정실습에참여하는 3학년학생 17명이참여하였다. 학생들은치위생과정실습에참여의사를밝힌실습대상자 (client) 의제 3대구치를제외한 28개의치아에대하여검사를수행하였다. 학생들은최소 1인, 최대 2인의대상자에대하여검사를수행하였다. 대상자수는총 20명이었고분석대상이된치아수는상하악전치부각 120개, 상악구치부 160개, 하악구치부 160개로총 560개였다. 2. 사전교육학생들은치아상태를병소와수복물로나누어치아단위로적절한코드를기록할수있도록사전교육을받았다 (Table 1). 교육은 QLF-D 이미지를이용한두시간의이론수업과 Q-ray view 활용을실연하는한시간의실습수업으 Table 1. Distribution of the Codes for Tooth Status (Reference Examiner) Code Status n (%) Code for lesion 0 Sound 415 (74.11) 1 Incipient caries 2 (0.36)0 2 Caries 117 (20.89) 3 Attrition 9 (1.61)0 4 Fracture 4 (0.71)0 9 Missing 13 (2.32)0 Code for restoration 0 Not restored or sealed 425 (75.89) 1 Sealant 6 (1.07)0 2 Tooth-colored restoration 40 (7.14)0 3 Amalgam restoration 41 (7.32)0 4 Gold inlay 20 (3.57)0 5 Gold or Stainless steel crown 7 (1.25) 6 Porcelain or PFM crown 8 (1.43)0 9 Missing 13 (2.32)0 Total 560 (100.00) PFM: porcelain fused metal. The sum of the percentages for code for restoration does not equal 100% because of rounding. 462

3 오혜영 외 Q-Ray View의 치위생과정 치아 검사 신뢰도 평가 Fig. 1. The representative images used for pre-test training. (A) White light image corresponding to visual inspection with naked eyes. (B) Blue light image corresponding to visual inspection with Q-ray view. 로 구성되었다. 이론 수업에서는 QLF 시스템의 개발 배경 과 원리에 대해서 설명한 후 할당된 코드에 해당하는 병소 및 수복물의 백색광 사진과 청색광 사진을 동시에 보여주며 교육하였다(Fig. 1). 3. 치아 검사 및 기록 검사 전 대상자의 치석 및 치면세균막 제거가 이루어졌 다. 학생이 대상자의 치아를 검사하기에 앞서 숙련된 검사 자가 Q-ray view를 병용하여 치아를 검사하였다. 숙련된 검 사자가 결과를 기록하는 동안 학생은 대상자로부터 격리되 어 있었다. 학생은 그 후 시진으로만 평가하는 1차 검사를 수행하였다. Q-ray view를 병용한 2차 검사가 이루어지기 전 1차 검사에서의 기억이 2차 검사에 미치는 영향을 감소 시키기 위하여 1차 검사와 2차 검사 사이에 구강관리교육을 진행하였다. 구강관리교육을 마친 후 Q-ray view를 병용하 는 2차 검사를 수행하였다. 검사 결과를 수집하기 위하여 본 연구 목적에 맞게 숙련 된 검사자용, 학생의 1차 검사용, 학생의 2차 검사용으로 고 안된 세 종류의 기록지를 사용하였다. 학생의 1차 검사가 종 료된 후 1차 검사 기록지를 수거하여 2차 검사 시 참고할 수 없도록 하였다. 평가는 치아 단위로 이루어졌으며 병소와 수복물의 두 범주로 나누어서 기록하였다. 평가한 값과 기준값의 일치도를 Cohen s kappa와 일치율을 이용하여 확인하였다. 일치도 분석의 단위는 첫째, 구강 내 부위였고 둘째, 병소 및 수복물로 하였다. 치아우식증을 평 가하기 위한 International Caries Detection and Assessment System-II와 같이 코드가 순위척도인 경우 가중 kappa 계수를 이용하는 것이 더 바람직하지만 본 연구에서 는 코드가 명목척도였기 때문에 단순 kappa 계수를 이용하 였다. 1차 검사와 2차 검사의 평균 kappa값의 차이가 유의 한지 검정하기 위해서 paired t-test를 이용하였고 일치율의 차이가 유의한지 검정하기 위해서 Pearson chi- squared test for two proportions를 이용하였다. 유의수준은 =0.05 로 하였다. 결 과 1. 치위생과정 대상자의 일반적 특성 치위생과 대학 치위생과정 실습수업에 방문하여 본 연구 에 동의한 대상자는 총 20명이었다. 대상자의 평균연령은 29.6±12.7세였고 연령 범위는 19 54세였다. 남자가 40%, 여자가 60%였으며 75% 이상이 미혼이었다. 직업은 학생이 65%로 대부분을 차지했다(Table 2). 4. 통계적 분석 2. Q-ray view를 사용한 경우와 사용하지 않은 경우 부 위별 비교 모든 분석은 IBM SPSS Statistics ver (IBM Co., Armonk, NY, USA)을 사용하여 수행하였다. 숙련된 검사 자의 결과를 기준값(reference value)으로 하였다. 학생들이 부위를 구분하지 않고 분석한 전체 병소에 대한 일치도는 Q-ray view를 사용한 경우 kappa값이 0.82로 Q-ray view를 사용하지 않은 경우의 0.49보다 훨씬 높았고, 전체 수복물에 463

4 J Dent Hyg Sci Vol. 14, No. 4, 2014 대해서는 Q-ray view를사용한경우와사용하지않은경우의 kappa값이각각 0.98과 0.89로 Q-ray view를사용한경우가높은것으로나타났다 (Table 3). 상악전치부, 상악구치부, 하악전치부, 하악구치부로나누어분석한결과병소에대한일치도는 Q-ray view를사용한경우 kappa의범위가 으로사용하지않은경우인 에비해더높은일치도를나타내었다. 하악의 kappa가 으로상악의 에비해더높은일치도를보였다 (Fig. 2). 수복물에대한일치도는 Q-ray view를사용한경우 kappa의범위가 로, 사용하지않은경우인 에비해더높은일치도를 Table 2. Individual Characteristics of Client by Dental Hygiene Process 나타냈다 (Fig. 3). Q-ray view를사용한경우와그렇지않은경우부위별로산출된 kappa값의평균은병소에대해서유의한차이를보였다 (p=0.017). 반면수복물에대해서는유의한차이를보이지않았다 (p=0.2). 3. Q-ray view를사용한경우과사용하지않은경우의병소및수복물별비교병소및수복물별비교에서전체병소에대한일치도는 Q-ray view를사용한경우일치율 92.14% 로 Q-ray view를사용하지않은경우인 80.36% 보다유의하게높았고 (p< 0.001) 전체수복물에대한일치도는 Q-ray view를사용한경우와사용하지않은경우일치율이각각 99.29% 와 95.54% 로 Q-ray view를사용한경우가유의하게높게나타났다 (p< Classification n (%) Gender Male 8 (40) Female 12 (60) Marital status Single 15 (75) Married 5 (25) Job Student 13 (65) Employee 3 (15) Housewife 2 (10) Salesperson 1 (5) Self-employed 1 (5) Total 20 (100) Table 3. Kappa Values for Tooth Status by Region, Interexaminer Reliability Intraoral region Phase I Phase II p-value Lesion 0.49± ±0.03 Max. anteria 0.13± ±0.07 Max. posterior 0.53± ±0.07 Man. anteria 0.62± ±0.07 Man. posterior 0.36± ±0.07 Mean Restoration 0.89± ±0.02 Max. anteria 0.65±0.09 1±0.09 Max. posterior 0.93± ±0.04 Man. anteria a N/A N/A Man. posterior 0.86± ±0.04 Mean Values are presented as mean±standard error. Max.: maxillary, Man.: mandible, N/A: not applicable. a No restorations were placed in mandibular anterior teeth and kappa coefficient was not calculated. p-values were calculated by paired t-test. Fig. 2. Kappa values for lesion by region. Max.: maxillary, Man.: mandible. Fig. 3. Kappa values for restoration by region. Max.: maxillary, Man.: mandible. 464

5 오혜영외 :Q-Ray View 의치위생과정치아검사신뢰도평가 Table 4. Percent Agreement for Tooth Status by Type of Lesion and Restoration Type of tooth status n Phase I Phase II p-value Lesion <0.001 Sound Incipient caries Caries <0.001 Fracture Attrition a N/A Restoration <0.001 Not restored or sealed <0.001 Sealant a N/A Tooth-colored restoration Amalgam Gold inray Gold or SS crown a N/A Porcelain or PFM crown a N/A N/A: not applicable, SS: stainless steel, PFM: porcelain fused metal. a Observed percentages of phase I and II were equal and tests were not performed. p-values calculated using Pearson chi-squared test for two proportions. Fig. 4. Percent agreement for lesion by type of tooth status. * Indicates statistical significance different among phases by Pearson chi-squared test for two proportions ; Table 4). 전체병소와수복물에대한분석에이어세부항목별분석을시행하였다 (Table 4). 그결과병소에서는초기치아우식증, 치아우식증, 파절에서 Q-ray view를사용한경우유의하게높은것으로나타났다 (p<0.001, p=0.046, p=0.029; Fig. 4). 수복물에서는수복물또는치면열구전색이없을때와심미수복재에서 Q-ray view를사용한경우유의한차이로높게나타났다 (p<0.001, p<0.011). 치면열구전색, 금관또는스테인레스스틸관, 도재관에서는 Q-ray view 병용여부와관계없이모두기준치와 100% 일치하였다 (Fig. 5). 고찰 본연구의대상자는치위생과대학의치위생과정실습에참여하는 3학년학생 17명과대상자 20명이었다. 치위생과정에서는대상자의구강상태를파악하여치과의사와상의하여치료및예방과교육계획을수립하고수행하게된다 10). 치위생과교육과정에서는위와같은과정을습득하기위한교육과실습이 2000년대포괄치위생학의개념이시작된이래로 ʻ임상치위생학및실습 ', ʻ포괄치위생학및실습 ', ʻ치위생실습 ' 등의커리큘럼으로운영되고있다 11). 치위생과정실습에서는임상치과위생사가수행하는모든과정에대해반복적인교육과실습을진행하는데치아검사는그중핵심 Fig. 5. Percent agreement for restoration by type of tooth status. * Indicates statistical significance different among phases by Pearson chi-squared test for two proportions. SS: stainless steel, PFM: porcelain fused metal. 적인과정중하나이다. 비록치과위생사가치아우식증등의병소를진단하지는않지만치과위생사는대상자의전반적인구강건강상태를파악하고이를바탕으로대상자가자신의구강을스스로관리하고예방할수있도록교육해야만하는책임이있기때문이다 3). 그러나경험이없는치위생과학생은전통적인검사법만으로는병소나수복물등을구분하는데많은어려움을겪는다. Q-ray view는검증된진단시스템인 QLF의일부로서치아검사의신뢰성을높이고치위생과정에서유용하게사용될것으로기대되었다 7). 465

6 J Dent Hyg Sci Vol. 14, No. 4, 2014 본연구의대상자인 3학년학생은 3학기에걸쳐이미치아검사방법인시진방법에대해여러번의경험과훈련을받아왔으며이에추가적으로 Q-ray view에대한교육과실습을통해사용법을익혔다. 치아검사시그동안시진만으로구분이어려웠던애매한판단에대해서 Q-ray view를병용함으로써더정확한판단을할수있었던것으로보인다. 부위별병소는전반적으로 Q-ray view를사용한경우에더높은일치도를보였다. Q-ray view를사용한경우상악보다하악이더높은일치도를나타내었다. 아마도하악의경우직접시진이가능한것에비해치경 (dental mirror) 사용에익숙하지않은학생이상악은치경을이용해간접시진을해야하는어려움이있기때문인것으로생각된다. 수복물에서도 Q-ray view를사용한경우사용하지않은경우보다더높은일치도를나타내었으며특히상악전치부는 Q-ray view를사용했을때기준값과 100% 일치한것으로나타났다. 상악전치부에는주로심미보철물과심미수복물이위치하고있다. Q-ray view를사용하면심미수복재나심미보철에서건전치아에비해형광을덜발현하여어둡게나타나므로경험이부족한학생도용이하게구분해낸것으로보인다. 심미수복재나심미보철물의경우치위생과정에서치석을제거하기위해사용하는초음파스케일러나, 수기구에매우취약하기때문에이를구분해내는일은중요하다. 수복재나보철의위치여부를판단하는것은대상자의치위생계획을수립하기위해서, 그리고치석제거및치면세마를안전하게수행하기위해서필요하다. 증상별병소와수복물의일치도차이를살펴본결과병소에서는치아우식증과초기우식증에서, 수복물에서는수복물이없는경우와레진에서유의한차이를보였다. 병소에서는치아우식증이나초기우식증같은병소가있는경우 Q-ray view를사용했을때좀더쉽게발견하는것으로나타났다 (Fig. 4). QLF는최초초기치아우식증 (white spot lesion) 을탐지하기위한장비로개발되었다. 본연구에서도눈으로쉽게구분이되지않는초기치아우식증을 Q-ray view를사용한경우탐지가가능했음을보여주었다 (Table 4). 치위생과정에서초기치아우식증을발견하는것은매우중요한의미를가진다. 초기치아우식증은비침습적인방법으로치료가가능하며치면세균막을제거하여병소의진행을막고불소를적용하여재광화를촉진시킴으로써병소의진행을역전시킬수있다 12). 따라서대상자에대한포괄적인접근방식인치위생과정에서진행중인우식증을초기치아우식증단계에서탐지해낼수있다면와동형성과치질의파괴를사전에예방할수있을것이다. 수복물의경우에도수복물이없는경우와 Q-ray view를사용했을때보다정확 한판단이이루어졌다 (Table 4). 수복물이나치면열구전색이위치하지않은경우와심미수복물이위치한경우 Q-ray view를이용함으로써일치도가유의하게증가하였다. 특히학생과같이경험이부족한경우건전치와심미수복재를구분하는것은매우어렵다. Q-ray view를이용함으로써건전치와는다른형광을발현하는레진을용이하게구분해낸것으로보인다. 치위생과정에서대상자의구강건강상태를정확히평가하는것은대상자에게적합한치위생계획을수립하고실행하기위해반드시필요한과정이다 2). 대상자의구강건강상태를정확히평가함으로써제공되는치위생과정을보다체계적이고구체화할수있기때문이다. 특히치아병소나보철, 수복물, 수복물주변의병소등을평가하기위해서는평가자의많은경험과능력과더불어신뢰할만한도구나장비를사용하는것이중요하다. 치아우식증을탐지하는장비로는 DIAGNOdent를비롯하여몇몇의장비 13,14) 가임상에서활용되고있다. 그러나이러한탐지장비는특정질환인치아우식증을탐지할뿐대상자의전반적인구강상태를평가하는치위생과정에적용하기에는적합하지않다. Q-ray view는치아우식증뿐만아니라치면세균막이나치석등을탐지할수있으며추가적으로심미보철이나심미수복재등의구분과수복재주변의병소등을쉽게탐지할수있다. 따라서 Q-ray view는치위생과정에서매우유용한장비로서활용될수있을것이며학생교육시이를반복사용하고정확한판단을내리는훈련을할수있도록함으로써치아검사역량을효과적으로증진시킬수있을것으로기대된다. 요약 본연구는치위생과대학에서이루어지고있는치위생과정실습에서 3학년학생들이대상자의치아상태를 Q-ray view를사용하지않고평가한방법과 Q-ray view를사용하여평가한방법을숙련된검사자의치아검사결과를기준치로하여부위별, 병소및수복물별일치도를비교하였다. 부위별차이에서병소와수복물은 Q-ray view를사용한경우에높은일치도를나타냈다. 특히상악전치부는수복물에서 100% 정답기준과일치하였다. 병소및수복물별차이에서 Q-ray view를사용한경우병소에서는치아우식증과초기우식증, 치아파절에서차이가있었고수복물에서는수복물또는치면열구전색이없는경우와심미수복물에서유의한차이가있었다. 본연구의결과 Q-ray view를병행해서치아검사를수행했을때경험이부족한치위생과학생의치아검사신뢰성이 466

7 오혜영외 :Q-Ray View 의치위생과정치아검사신뢰도평가 향상되었다. 따라서치위생과정실습에서 Q-ray view는학생의치아검사역량증진에효과적인도구로활용될수있을것이다. References 1. Mueller-Joseph L, Petersen M: Dental hygiene process: diagnosis and care planning. Delmar Publishers, Albany (NY), p.2, 178, Fitch P: Cultural competence and dental hygiene care delivery: integrating cultural care into the dental hygiene process of care. J Dent Hyg 78: 11-21, Barnes CM: Dental hygiene participation in managing incipient and hidden caries. Dent Clin North Am 49: , vi-vii, Bozdemir E, Karaarslan ES, Ozsevik AS, Ata Cebe M, Aktan AM: In vivo performance of two devices for occlusal caries detection. Photomed Laser Surg 31: , Kim YS, Lee ES, Kwon HK, Kim BI: Monitoring the maturation process of a dental microcosm biofilm using the quantitative light-induced fluorescence-digital (QLF-D). J Dent 42: , Kim HE, Kwon HK, Kim BI: Recovery percentage of remineralization according to severity of early caries. Am J Dent 26: , Kim HE: Quantitative light-induced fluorescence: a potential tool for dental hygiene process. J Dent Hyg Sci 13: , Alammari MR, Smith PW, de Josselin de Jong E, Higham SM: Quantitative light-induced fluorescence (QLF): a tool for early occlusal dental caries detection and supporting decision making in vivo. J Dent 41: , Parviainen H, Vahanikkila H, Laitala ML, Tjaderhane L, Anttonen V: Evaluating performance of dental caries detection methods among third-year dental students. BMC Oral Health 13: 70, Wilkins EM: Clinical practice of the dental hygienist. 10th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, pp , Han SY, Kim NH, Yoo JH, Kim CS, Chung WG: Current status of clinical dental hygiene education based on dental hygiene process of care. J Dent Hyg Sci 9: , Tranaeus S, Al-Khateeb S, Bjorkman S, Twetman S, Angmar-Mansson B: Application of quantitative light-induced fluorescence to monitor incipient lesions in caries-active children. a comparative study of remineralization by fluoride varnish and professional cleaning. Eur J Oral Sci 109: 71-75, Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E: Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 33: , Bader JD, Shugars DA: A systematic review of the performance of a laser fluorescence device for detecting caries. J Am Dent Assoc 135: ,

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