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Background

Radiographic detection of caries lesions adjacent to restorations is challenging due to limitations of two-dimensional imaging and difficulties distinguishing true lesions from restorative or anatomical radiolucencies. Artificial intelligence (AI)-based clinical decision support systems (CDSSs) have been introduced to assist radiographic interpretation; however, different AI tools may yield variable diagnostic outputs, and their comparative performance remains unclear.

Objective

To compare the diagnostic performance of commercial and experimental AI algorithms for detecting secondary caries lesions on bitewings.

Methods

This cross-sectional diagnostic accuracy study included 200 anonymized bitewings comprising 885 restored tooth surfaces. A consensus group reference standard identified all surfaces with a caries lesion and classified each lesion by type (primary/secondary) and depth (enamel-only/dentin-involved). Five commercial (Second Opinion®, CranioCatch, Diagnocat, DIO Inteligência, and Align™ X-ray Insights) and three experimental (Mask R-CNN-based and Mask DINO-based) systems were tested. Diagnostic performance was expressed through sensitivity, specificity, and overall accuracy (95% CI). Comparisons used generalized estimating equations, adjusted for clustered data.

Results

Specificity was high across all systems (0.957–0.986), confirming accurate recognition of non-carious surfaces, whereas sensitivity was moderate (0.327–0.487), reflecting frequent missed detections of enamel and dentin lesions. Accuracy ranged from 0.882 to 0.917, with no significant differences among models (p ≥ 0.05). Confounding factors, such as radiographic overlapping, marginal restoration defects, and cervical artifacts, were the main sources of misclassification.

Conclusions

AI algorithms, regardless of architecture or commercial status, showed similar diagnostic capabilities and a conservative detection profile, favoring specificity over sensitivity. Improvements in dataset diversity, labeling precision, and explainability may further enhance reliability for secondary caries detection.

Clinical Significance

AI-based CDSSs assist clinicians by providing consistent detection. Their high specificity is particularly valuable in minimizing unnecessary invasive treatments (overtreatment), though they should be used as adjuncts rather than a replacement for expert judgment.