Although visual inspection is the most commonly used method for caries detection, and consequently the most investigated, studies have not been concerned about the clinical relevance of this procedure. Therefore, we conducted a systematic review in order to perform a critical evaluation considering the clinical relevance and methodological quality of studies on the accuracy of visual inspection for assessing caries lesions. Two independent reviewers searched several databases through July 2013 to identify papers/articles published in English. Other sources were checked to identify unpublished literature. The eligible studies were those which (1) assessed the accuracy of the visual method for detecting caries lesions on occlusal, approximal or smooth surfaces, in primary or permanent teeth, (2) used a reference standard, and (3) reported data about sample size and accuracy of the methods. Aspects related to clinical relevance and the methodological quality of the studies were evaluated. 96 of the 5,578 articles initially identified met the inclusion criteria. In general, most studies failed in considering some clinically relevant aspects: only 1 included study validated activity status of lesions, no study considered its prognosis, 79 studies did not consider a clinically relevant outcome, and only 1 evaluated a patient-centred outcome. Concerning methodological quality, the majority of the studies presented a high risk of bias in sample selection. In conclusion, studies on the accuracy of the visual method for caries detection should consider clinically relevant outcomes besides accuracy; moreover, they should be conducted with higher methodological quality, mainly regarding sample selection.

1.
Bader JD, Shugars DA, Bonito AJ: A systematic review of the performance of methods for identifying carious lesions. J Public Health Dent 2002;62:201-213.
2.
Baelum V: What is an appropriate caries diagnosis? Acta Odontol Scand 2010;68:65-79.
3.
Baelum V, Heidmann J, Nyvad B: Dental caries paradigms in diagnosis and diagnostic research. Eur J Oral Sci 2006;114:263-277.
4.
Baelum V, Hintze H, Wenzel A, Danielsen B, Nyvad B: Implications of caries diagnostic strategies for clinical management decisions. Community Dent Oral Epidemiol 2012;40:257-266.
5.
Braga MM, Mendes FM, Ekstrand KR: Detection activity assessment and diagnosis of dental caries lesions. Dent Clin North Am 2010;54:479-493.
6.
Deville WL, Bezemer PD, Bouter LM: Publications on diagnostic test evaluation in family medicine journals: an optimal search strategy. J Clin Epidemiol 2000;53:65-69.
7.
Ferreira Zandona A, Santiago E, Eckert GJ, Katz BP, Pereira de Oliveira S, Capin OR, Mau M, Zero DT: The natural history of dental caries lesions: a 4-year observational study. J Dent Res 2012;91:841-846.
8.
Gimenez T, Braga MM, Raggio DP, Deery C, Ricketts DN, Mendes FM: Fluorescence-based methods for detecting caries lesions: systematic review, meta-analysis and sources of heterogeneity. PLoS One 2013;8:e60421.
9.
Guedes RS, Piovesan C, Ardenghi TM, Emmanuelli B, Braga MM, Ekstrand KR, Mendes FM: Validation of visual caries activity assessment: a 2-yr cohort study. J Dent Res 2014;93(7 suppl):101S-107S.
10.
Ismail AI: Visual and visuo-tactile detection of dental caries. J Dent Res 2004;83(Spec No C):C56-C66.
11.
Juni P, Holenstein F, Sterne J, Bartlett C, Egger M: Direction and impact of language bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol 2002;31:115-123.
12.
Leeflang MM, Deeks JJ, Gatsonis C, Bossuyt PM; Cochrane Diagnostic Test Accuracy Working Group: Systematic reviews of diagnostic test accuracy. Ann Intern Med 2008;149:889-897.
13.
Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, van der Meulen JH, Bossuyt PM: Empirical evidence of design-related bias in studies of diagnostic tests. JAMA 1999;282:1061-1066.
14.
Mendes FM, Novaes TF, Matos R, Bittar DG, Piovesan C, Gimenez T, Imparato JC, Raggio DP, Braga MM: Radiographic and laser fluorescence methods have no benefits for detecting caries in primary teeth. Caries Res 2012;46:536-543.
15.
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097.
16.
Moher D, Pham B, Klassen TP, Schulz KF, Berlin JA, Jadad AR, Liberati A: What contributions do languages other than English make on the results of meta-analyses? J Clin Epidemiol 2000;53:964-972.
17.
Montori VM, Wyer P, Newman TB, Keitz S, Guyatt G: Tips for learners of evidence-based medicine: 5. The effect of spectrum of disease on the performance of diagnostic tests. CMAJ 2005;173:385-390.
18.
Nyvad B, Machiulskiene V, Baelum V: Construct and predictive validity of clinical caries diagnostic criteria assessing lesion activity. J Dent Res 2003;82:117-122.
19.
Sackett DL, Haynes RB: The architecture of diagnostic research. BMJ 2002;324:539-541.
20.
Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM: QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529-536.
21.
Whiting PF, Westwood M, Burke M, Sterne J, Glanville J: Systematic reviews of test accuracy should search a range of databases to identify primary studies. J Clin Epidemiol 2008;61:357-364.
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