LAUSR

We read with much interest the published review article ‘‘Accuracy of dental images for the diagnosis of dental caries and enamel defects in children and adolescents: A systematic review’’. We wish to share our scientific views on this review paper. The purpose of the study was to review evidence on the accuracy of dental images for the diagnosis of dental lesions. To our knowledge, the present systematic review is the first in teledentistry research to implement quality assessment of diagnostic accuracy studies (QUADAS-2). With the dearth of systematic reviews and meta-analysis regarding teledentistry practice, such studies contribute to the existing literature review on teledentistry. The authors used a tailored QUADAS-2 tool to assess the risk of bias and applicability of the included studies. The QUADAS-2 is designed to assess the quality of primary diagnostic accuracy studies. Diagnostic accuracy studies compare an index test to an existing reference test, to determine the presence or absence of the condition of interest. The outcomes of the two tests are then compared with one another in order to assess the accuracy of the index test. Diagnostic accuracy is commonly represented by two measures, sensitivity and specificity; however, sometimes other measures, including predictive value, likelihood ratio and area under the receiver operating characteristic curve are used. Recent systematic reviews on diagnostic accuracy of a diagnostic procedure only included studies in the final analysis if they reported at least one of the diagnostic accuracy measures (mentioned above) or presented sufficient data that allow calculation of diagnostic accuracy. Our concerns with the published review article include some shortcomings in the methodology, in particular, study selection and eligibility criteria. The inclusion and exclusion criteria were very briefly outlined in the Methods section. Unlike previous systemic reviews, in this review, seven of the 16 included studies do not present any diagnostic accuracy measure such as sensitivity and specificity, but were (surprisingly) included in this review. For instance, the included studies by Patterson and Botchway (1998), Wong et al. (2005), Golkari et al. (2011), Chen et al. (2013), Tabari et al. (2000), CruzOrcutt et al. (2012) and Al-Malik et al. (2001) reported intra/inter-examiner reliability values (kappa), caries prevalence or severity in their results rather than diagnostic accuracy measures. Almost half of the included studies provided insufficient evidence on the diagnostic validity of a teledentistry approach as these lacked accuracy measures. Therefore, it is not clear why the authors did not exclude the studies mentioned above from the analysis as these could contribute to a high risk of bias. In Table 4, despite the Kopycka-Kedzierawski et al. (2007), Boye et al. (2013) and Morosini et al. (2014) papers presenting some accuracy measures such as sensitivity and specificity, the authors did not provide these results in Table 4, and instead they presented prevalence estimates or Decayed, Missing, Filled Teeth (DMFT) scores. Finally, it would have been very helpful if the authors had presented a table of the results of the QUADAS-2 assessment for all included studies, summarising the number of studies that found low, high or unclear risk of bias/concerns regarding applicability for each domain. This would help the readers to understand the assessment or judgment of each paper. In light of the methodologic limitations, in-depth answers to these questions should have been added in the Methods or Discussion section. Overall, we congratulate the authors and thank the editor for publishing such an interesting review.