Received: 13 May 2019 Revised: 3 July 2019 Accepted: 11 August 2019

DOI: 10.1111/jerd.12522

RESEARCH ARTICLE

The dental esthetic screening index: A new tool for assessment

of dento-facial esthetics in restorative dentistry

Cornelia Frese Prof. (apl) Dr. med. dent.1 | Florian Leciejewski Dr. med. dent.1 |
Regina Specht1 | Theresa Wohlrab Dr. med. dent.1 | Christopher Büsch2 |
Wolfgang Boemicke PD Dr. med. dent.3 | Kirsten Probst Dr. med. dent.4 |
Eleni N. Katsikogianni Dr. med. dent.5 | Diana Wolff Prof. Dr. med. dent.6

1
Department of Conservative Dentistry,
Dental School, University Hospital Heidelberg, Abstract
Heidelberg, Germany Objectives: There is a lack of comprehensive indexes, which can measure conditions
2
Institute of Medical Biometry and Informatics,
or changes in dento-facial esthetics before and after treatment. Therefore, the
University Heidelberg, Heidelberg, Germany
3
Department of Prosthodontics, Dental 12-item Dental Esthetic Screening Index (DESI) was developed and validated.
School, University Hospital Heidelberg, Materials and Methods: Reliability was tested by five dental professionals, who eval-
Heidelberg, Germany
4
uated 30 standardized patient photographs baseline and after 14 days. Clinical vali-
Department of Prosthodontics, Dental
School, University Hospital Würzburg, dation was done on 52 patients before and after restorative treatment. For
Würzburg, Germany
subjective assessment, patients completed a validated questionnaire before and after
5
Department of Orthodontics, School of
Dental Medicine, University Hospital
treatment. Statistical analysis included inter and intrarater reliability, Wilcoxon test
Heidelberg, Heidelberg, Germany and linear regression analysis.
6
Department of Conservative Dentistry, Results: The single item analysis identified two weak extraoral items (κ = 0.15;
Dental School, University Hospital Tübingen,
Tübingen, Germany κ = −0.05), that were removed from the DESI. After this modification, both inter-
(κ = 0.83-0.86) and intrarater reliability (ICC1-5 = 0.75-0.86) were in excellent to good
Correspondence
Cornelia Frese, University Hospital Heidelberg, agreement. In the clinical validation, the DESI was significantly lower after restorative
Department of Conservative Dentistry, School treatment (P < .0001). The patients' perception questionnaires showed significant
of Dental Medicine, Im Neuenheimer Feld
400, 69120 Heidelberg, Germany. improvement after restorative therapy (P < .0001). A correlation of the DESI and the
Email: cornelia.frese@med.uni-heidelberg.de results of patients' perception questionnaires could be assumed (P < .0001; R2 = 0.32).
Funding information Conclusions: The DESI was found to be a reliable and valid instrument for the quanti-
Deutsche Gesellschaft für Zahn-, Mund- und tative assessment of dento-facial esthetics. It correlated well with the subjective
Kieferheilkunde. Open access funding enabled
and organized by Projekt DEAL assessment of the patients.

[Correction added on 24th October 2020, after Clinical Significance

first online publication: Projekt Deal funding
statement has been added.]
This comprehensive index would allow for objective quantification of clinical situa-
tions, for reliable baseline and outcome assessment in esthetic dentistry. As patients'
esthetic feelings and sensations are subjective, this objective index is also proven to
be congruent to patients' individual subjective assessment of dento-facial esthetics.

KEYWORDS
dento-facial esthetics, index, quantitative evaluation, restorative dentistry

This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes
© 2019 The Authors. Journal of Esthetic and Restorative Dentistry published by Wiley Periodicals LLC

572 wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2019;31:572–582.

FRESE ET AL.
1 | I N T RO D UC T I O N
Common knowledge on dental esthetics is primarily based on text-
books and articles published by experts and these are accepted
throughout the Western societies. 1-8
Therein, ideal measures of
dento-facial parameters are reported, assuming that deviations might
result in a lack of esthetic excellence. However, little is displayed
about the principles on which these expert opinions are based.
Esthetic perceptions are also quite subjective: As every dental profes-
sional might have experienced, the perception of dentists and patients
on dento-facial esthetics can be quite different. Measuring dento-
facial esthetics is a challenging task and there is need for a compre-
1,9
hensive index that is capable of doing so.
When planning and doing restorative treatments in the anterior
dentition, dentists try to meet as best as possible the wishes previ-
ously expressed by the patient. Photographs, diagnostic casts, wax-
ups and mock-ups can help to adjust expectations and feasibility in
the clinical setting. After the treatment, the results are subjectively
judged by the patients. For research purposes, objective judgments
are done by using categorical quantification ratings or indexes.10 Since
1973, the most widespread used clinical rating criteria for studies in
restorative dentistry were the Ryge/USPHS Criteria,11 or recently
12-14
redefined as the Modified USPHS or FDI Clinical Criteria. Those
criteria include biological, functional and esthetic parameters. By the
latter four aspects are evaluated, namely surface luster, staining, color
match, and translucency, and esthetic anatomical form. However, they
only provide insufficient detail for a comprehensive baseline and out-
come assessment of restorative treatments with an effect on anterior
1
teeth and dento-facial appearance (eg, smile assessment). In ortho-
dontics, there are a few indexes quantifying esthetics, for example,
both the Index of Orthodontic Treatment Need (IOTN)15 and the
Dental Aesthetic Index (DAI).16 The IOTN has two main components,
the Dental Health Component (IOTN-DHC) and the Aesthetic Com-
ponent (IOTN-AC), whereas only in the IOTN-AC a numerical scoring
for dental esthetics can be assessed.15 However, for restorative den-
tistry both orthodontic indices do not provide items for the quantifi-
cation of changes induced by restorative treatments. In restorative
dentistry the Prosthetic Esthetic Index (PEI) has been developed to
evaluate and measure oral esthetics on patients undergoing dental
17
prosthetics. This index represents an objective instrument that can
be used for clinical analyzed and treatment planning. However, the
PEI cannot be applied to quantify the total dento-facial appearance as
no assessment can be made related to surrounding soft and hard
tissues.
As an introduction to the topic, our group conducted a literature
review, in which essential esthetic parameters were identified that are
necessary for objective quantification: (a) the smile line, (b) the lip line,
(c) the location of dental and facial midline, (d) incisor angulations and
width-to-height-ratios of the maxillary anterior teeth, and (e) the gin-
gival contour/root coverage/papilla height. On the basis of these find-
ings, we established the “Dental Esthetic Screening Index” (DESI) with
five extraoral and seven intraoral items. The DESI uses a five-point
573
rating scale for the quantitative data assessment for each item, and a
sum score to categorize the esthetic outcome. A low sum score repre-
sents excellent esthetics, whereas a high sum score represents
poor ones.
The aim of this investigation was to determine, whether the DESI
can reliably assess dento-facial parameters and whether or not it is a
valid tool in clinical assessment.
The null hypotheses were:
1. A reproducible assessment of all DESI items cannot be done by
five independent dental professionals;
2. Clinical assessment before and after restorative treatment cannot
be done by the DESI;
3. The DESI does not correspond with the subjective assessment of
the patient.
2 | MATERIAL AND METHODS
2.1 | Development of the DESI
The initial version of the DESI is depicted in Figures 1A-C. It con-
sists of five extraoral and seven intraoral items, and grading scales
to record the sum scores for extraoral (5-20 points), intraoral (7-35
points), and overall assessment (12-60 points). A low sum score
represents excellent esthetics, whereas a high sum score repre-
sents poor esthetics. For quantification five-point rating scales are
used. The dot rates use millimeter, degree, or numeric subdivisions,
thus they allow for stepwise gradation of deviations from the given
ideal.
2.2 | Reliability analysis
The study was approved by the local medical ethics committee (S-
292/2011). Forty subsequent patients were asked for study partici-
pation. They all met the inclusion criteria, which were (a) being
older than 18 years of age, (b) giving written informed consent, and
(c) having good knowledge of the German language. All 40 subjects
approved and were included in the study. A series of photographs
were taken of each subject by one professional photographer under
standardized conditions. Each series was comprised of two extraoral
photographs, one full-face, and one smile image, and two intraoral
photographs captured with lip retractors. The latter two photo-
graphs depicted maxillary and mandibular teeth in habitual occlu-
sion. On the second photograph a piece of millimeter paper was
fixed to the gingiva as a reference (Figure 2C and F). SLR cameras
were used (Nikon D7000 + Nikkor 120 mm for extraoral images and
Nikon 5100 + Macro Nikkor 105 mm for intraoral images; Nikon
GmbH, Düsseldorf). The cameras were connected to a strobe light-
ing source. For extraoral photographs, a studio light source was
used to illuminate the subject with a flash reflected from a photo-
graphic umbrella. For intraoral photographs, a ring flash (Nissin MF
18 Macro, Nissin Marketing Ltd., Hong Kong) was used. Before tak-
ing the extraoral photographs, the photographer instructed the
574 FRESE ET AL.

F I G U R E 1 (A) Extraoral score of the DESI with five items. Quantification of esthetics was done by a five-point rating scale that allows for stepwise
gradation of the esthetic deviance from the ideal. Measuring scales using millimeter or degree subdivisions were applied to quantify or count esthetic
deviance from the ideal. Sum of extraoral items: 5-25 points; a low sum score represents excellent esthetics, whereas the highest sum score represents
poor esthetics. (B) Intraoral score of the DESI with seven items. Quantification of esthetics was done by a five-point rating scale that allows for stepwise
gradation of esthetic deviance from the ideal. Measuring scales using numeric subdivisions were applied to quantify or count esthetic deviance from the
ideal. Sum of intraoral items: 7-35 points; a low sum score represents excellent esthetics, whereas the highest sum score represents poor esthetics.
(C) Grading scales to interpret the sum scores of the intraoral, extraoral, and overall assessment. A low sum score represents excellent esthetics, whereas
the highest sum score represents poor esthetics. Sum of extraoral items: 5-25 points; sum of intraoral items: 7-35 points; overall sum: 10-60 points
FRESE ET AL.
FIGURE 1 (Continued)
subjects to smile. The brightness was adjusted for all images. On the
extraoral images, the area around the eyes was modified beyond
recognition, so that only the pupil remained of the original image to
allow for DESI assessment (Adobe Photoshop CS5, Adobe Systems
Inc., San Jose, California). All images were saved as jpeg files,
printed in color, sized 12.5 × 19.0 cm, and laminated.
Reliability assessment was conducted by each of the five den-
tal professionals on all the photograph series of the 30 subjects.
Of the five dental professionals, two were dentists specializing in
restorative dentistry, two in prosthetic dentistry, and one dentist
specializes in orthodontics. Before assessment, the dentists were
trained on the 10 additional photograph series. Interrater reliability
of the training was excellent with κ = 1 for the extraoral, κ = 0.95
for the intraoral, and κ = 0.91 for the overall score. For data assess-
ment, the dentists each were given the 30 photograph series, a
30-cm ruler, a permanent marker, and a drafting triangle. Data
assessment was repeated after 14 days.
2.3 | Clinical validation
This study was approved by the local medical ethics committee (S-
580/2015) and registered in the German Clinical Trial Register that is
linked to the WHO register (ID: DRKS0005019). Fifty-two consecu-
tive patients, who were scheduled for restorative treatment, took part
in the clinical validation. They all met the inclusion criteria defined as
follows: The patients (a) were older than 18 years of age, (b) gave
written informed consent, (c) were scheduled for a direct or indirect
restorative treatment in the anterior region of the maxilla, and (d) had
575
good knowledge of the German language. All 52 patients gave written
informed consent and the DESI was assessed by one calibrated exam-
iner, directly before and after restorative treatment. In case of incor-
poration of indirect restorations, the DESI was assessed directly after
definitive cementation.
The patients were given the validated Psychosocial Impact of Dental
Appearance Questionnaire (PIDAQ) to record their subjective assess-
ments of the changes, which they completed directly before and 14 days
after restorative treatment.18 The PIDAQ has four subscales, namely den-
tal self-confidence, social impact, psychological impact and esthetic con-
cern, and proved to be a valid test instrument in adults.19 The patients
were advised to complete the PIDAQ at home, 14 days after restorative
treatment. This 2-week period was considered appropriate to allow the
patients to become accustomed to their dento-facial appearance.
3 | S TA TI STI C A L A N A LY SI S
Statistical analysis was done separately for inter- and intrarater reli-
ability by evaluating the intraoral score, the extraoral score, and the
overall score for the two time points (baseline and 14 days). Agree-
ment with the rating was considered as ±1 score point for the
intraoral and extraoral score and ±2 score points for the overall score.
Assessment of interrater reliability was done by Cohen's kappa (κ) for
two and Fleiss' kappa for more than two raters, and assessment of
intrarater reliability was done by the intraclass coefficient (ICC). Both
Cohen's κ and ICC were presented with the respective 95% confi-
dence interval (CI). A κ coefficient of <0.2 was considered as weak,
576 FRESE ET AL.

F I G U R E 2 (AF) Two-patient photo series are presented to show the best and worst results of the DESI assessment. (A) Extraoral view of the patient
showing lowest (best) DESI scores during smiling. Extraoral DESI score = 5, representing good-to-excellent esthetics. (B,C) Intraoral view in habitual
occlusion. The photographs in plot C show a millimeter subdivision that was fixed on the gingiva. Intraoral DESI score = 9, representing excellent
esthetics. Overall DESI score = 14, representing excellent esthetics. (D) Extraoral view of the patient showing highest (worst) DESI scores during smiling.
Extraoral DESI score = 9, representing satisfactory esthetics. (E,F) Intraoral view in habitual occlusion. The photograph in F shows a millimeter subdivision
fixed on the gingiva. Intraoral DESI score = 21, representing satisfactory esthetics. Overall DESI score = 30, representing satisfactory esthetics

0.21-0.40 as low, 0.41-0.60 as moderate, 0.61-0.80 as good, and
0.81-1 as excellent.20
Due to not normally distributed, one-sample data sets of the DESI
and PIDAQ before and after treatment, the two-sided Wilcoxon
signed rank test for one sample with a significance level of .05 was
performed. The calculated P values were derived by a normal approxi-
mation due to present ties.
A descriptive analysis was done. Median, minimum, maximum,
Q1, Q3, and IQR of the overall DESI were calculated for the sub-
groups (number of treated teeth (1, 2, 3 + 4, and 5 + 6) and for
FRESE ET AL. 577

T A B L E 1 Interrater reliability (n = 5 raters) of each item from the Analysis of the baseline assessment of the DESI showed moderate
DESI with five extraoral and seven intraoral items using Cohen's agreement for the extraoral score, with κ = 0.53 (0.37-0.70) and good
kappa κ
agreement for both intraoral and overall scores (intraoral κ = 0.70
Interrater reliability Item κ Lower 95CIa Upper 95CIa [0.57-0.82], overall κ = 0.64 [0.49-0.78]) (Table 2). For the second
Extraoral #1* 0.15 0.02 0.33 assessment of the DESI after 14 days, moderate agreement for the
#2 0.45 0.19 0.54 extraoral score, κ = 0.42 (0.25-0.61) and good agreement for both

#3* −0.05 −0.12 0.09 intraoral and overall scores were measured (intraoral κ = 0.64
[0.50-0.78]; overall κ = 0.60 [0.44-0.75]) (Table 2).
#4 0.86 0.85 0.92
Four of the five dentists achieved good-to-excellent intrarater
#5 0.60 0.41 0.73
agreement of the final DESI (baseline–14 days). One rater showed
moderate-to-good intrarater agreement. The ICCs for the overall
Intraoral #1 0.50 0.39 0.68
scores of the DESI were ICC1 = 0.84 for rater #1, ICC2 = 0.81 for rater
#2 0.46 0.20 0.56
#2, ICC3 = 0.75 for rater #3, ICC4 = 0.86 for rater #4, and ICC5 = 0.86
#3 0.50 0.32 0.66
for rater #5 (Table 3).
#4 0.49 0.32 0.67
#5 0.43 0.27 0.62
4.3 | Clinical validation of the final DESI
#6 0.60 0.45 0.75
#7 0.61 0.46 0.76 The two-sided Wilcoxon signed rank test yielded highly significant
a
The extraoral items #1 and #3 are showing very weak κ coefficients. A κ changes in extraoral, intraoral and overall DESI scores, when compared
coefficient of <0.2 was considered weak; 0.21-0.40, low; 0.41-0.60, before and after restorative treatment (all P values <.0001) (Table 4). The
moderate; 0.61-0.80, good; and 0.81-1, excellent.19 CI, Confidence extraoral score improved by mean ± SD of 1.10 ± 1.14, the intraoral by
interval.
6.10 ± 4.19, summing up to an overall DESI improvement of 7.19 ± 4.69.

score differences (before-after). To investigate possible associa- The more teeth were treated by restorative intervention, the higher the

tions between DESI and PIDAQ, a linear regression model was per- DESI improvement was (Table 5). When only one or two teeth were

formed with the DESI as independent and the PIDAQ as treated, DESI improvement was with median (min, max) 4.0 (0, 6.0) and

dependent variable. Also, a scatter plot with a fitted linear regres- 4.5 (−1.0, 11.0) distinctively lower than after treatment of 3-4 and 5-6
teeth (10.0 [5.0, 19.0], 10.5 [6.0, 21.0]), respectively (Table 5).
sion line was generated.
The overall PIDAQ was with 41.74 ± 12.02 points (mean ± SD) sig-
As this is an exploratory analysis, all P values are only of descrip-
nificantly lower 14 days after restorative treatment than before with
tive nature and P values smaller than .05 will only be considered sta-
63.62 ± 16.27 (P < .0001). The linear regression model identified a sig-
tistically significant in a descriptive manner. All analyses were
nificant relationship between the DESI and the PIDAQ (P < .0001,
performed using R version 3.5.1.
R2 = 0.32) (Figure 4). The null hypotheses (2) and (3) could be rejected.

4 | RESULTS
4.1 | Single item reliability analysis of the initial DESI
The reliability analysis for each initial DESI item yielded moderate to
good intrarater agreement among all five raters for three extraoral (#2,
#4 and #5) and all seven intraoral items (Table 1). The extraoral items
#1 (congruence of facial and dental midline) and #3 (parallelism of
canine line and bipupillar line) showed very weak interrater reliability
with κ coefficients (95% CI) of 0.15 (0.02-0.35) and −0.05 (−0.12-0.09),
respectively. Consequently, the initial DESI was modified and the
extraoral items #1 and #3 were removed. The final DESI is depicted in
Figure 3A-C. The null hypotheses (1) was hereby partly rejected.
4.2 | Reliability analysis of the final DESI
Interrater reliability (n = 5 rater) of complete data (baseline +14 days)
showed excellent agreement with κ = 0.85 (95% CI: 0.80-0.89) for the
extraoral scores, κ = 0.86 (0.81-0.89) for the intraoral scores, and
κ = 0.83 (0.77-0.87) for the overall scores (Table 2).
5 | DISCUSSION
We present the development, validation, and clinical testing of a novel
index, the DESI. Up to date, there was an evident lack of a quantita-
tive index, capable to assess conditions, and changes in dento-facial
esthetics.1 The aim was to evaluate the reliability and clinical validity
of the DESI. The DESI can be applied for the planning and documenta-
tion of restorative treatment outcomes, and for measuring clinical
conditions and changes in the course of restorative treatments, in
both clinical and scientific settings.
To achieve this goal, we first assessed the reliability of each item
of the original DESI in a standardized setup. After removing two
unconfident items from the index, the final DESI was tested for reli-
ability using inter- and intrarater correlations at baseline and after
14 days.
Therefore, patient photographs were used for maximum standard-
ization, and data were assessed by all raters under the same condi-
tions (Figure 2A-F). This is in accordance with procedural methods
used in the literature, as most esthetic assessment studies use
578 FRESE ET AL.

F I G U R E 3 (A) Extraoral score of the DESI after modification with three items. Quantification of esthetics was done by a five-point rating
scale that allows for stepwise gradation of the esthetic deviance from the ideal. Measuring scales using millimeter or degree subdivisions were
applied to quantify or count esthetic deviance from the ideal. Sum of extraoral items: 3-15 points; a low sum score represents excellent esthetics,
whereas the highest sum score represents poor esthetics. (B) Intraoral score of the DESI with seven items. Quantification of esthetics was done
by a five-point rating scale that allows for stepwise gradation of esthetic deviance from the ideal. Measuring scales using numeric subdivisions
were applied to quantify or count esthetic deviance from the ideal. Sum of intraoral items: 7-35 points; a low sum score represents excellent
esthetics, whereas the highest sum score represents poor esthetics. (C) Grading scales after modification to interpret the sum scores of the
intraoral, extraoral, and overall assessment. A low sum score represents excellent esthetics, whereas the highest sum score represents poor
esthetics. Sum of extraoral items: 3-15 points; sum of intraoral items: 7-35 points; overall sum: 10-50 points
FRESE ET AL. 579

FIGURE 3 (Continued)

T A B L E 2 Interrater reliability (n = 5 raters) of the modified DESI disciplines (restorative dentistry, prosthodontics, and orthodontics)
after removal of the extraoral items #1 and #3. Complete interrater were appointed as raters. The number of raters is considered suffi-
reliability represents data from baseline and the second assessment cient to estimate statistically valid correlation coefficients.35 The sin-
after 14 days. Data of baseline and second assessment are separately
gle item reliability analysis of the original DESI elicited two extraoral
depicted below. Assessment of interrater reliability was done by
items, item #1 (congruence of facial and dental midline) and item #3
Cohen's kappa (κ)
(parallelism of canine line and bipupillar line) with very weak interrater
Lower Upper
reliability (κ coefficients (95% CI) 0.15 (0.02-0.35) for #1 and −0.05
Interrater reliability κ 95CIa 95CIa
(−0.12-0.09) for #3 (Table 1)). They had to be removed from the origi-
Complete (baseline + extraoral 0.85 0.80 0.89
second assessment)
nal DESI subsequently emerging the final version of the DESI with
intraoral 0.86 0.81 0.89
10 items. For grading, it was decided to use a Lickert scale, which
overall 0.83 0.77 0.87
proved to be suitable, as it limits the categorical gradation of each
item and allows for increased interrater reliability.17 However, for the
Baseline extraoral 0.53 0.37 0.70
removed items #1 and #3 grading may have been ineligible. The clini-
intraoral 0.70 0.58 0.82 cal consequence of removing these two items is that extraoral grading
overall 0.64 0.49 0.78 and scoring is less represented in the DESI than intraoral grading and
scoring. This points to the fact that grading and scoring of extraoral
Second assessment extraoral 0.42 0.25 0.61 parameters is not always successfully applicable in clinical settings.
after 14 days intraoral 0.64 0.50 0.78 Yet, in contrast to comparable indices in restorative dentistry the
overall 0.60 0.44 0.75 extraoral component is still represented in the final version of the
a
A κ coefficient of <0.2 was considered weak; 0.21–0.40, low; 0.41-0.60, DESI and it achieved good to excellent inter- and intrarater reliability
moderate; 0.61-0.80, good; and 0.81-1, excellent.20 CI, Confidence (Tables 2 and 3).
interval. In a recent investigation on validation of the 13-item prosthetic
esthetic index (PEI), the authors stated that interrater reliability
standardized, computer-manipulated photographs rated by dental increased up to seven items with no further substantial increase. After
professionals or independent judges.8-10,21-34 To make the DESI appli- removal of two weak items, the DESI contains 10 items and is, there-
cable by dentists from diverse fields, dentists from three different fore, in agreement with the recently validated PEI.17
580 FRESE ET AL.

In the clinical testing, the final DESI was assessed directly on DESI after treatment (P < .0001, Table 4). The extraoral, intraoral
patients before and after restorative treatment. Hereby, the trans- and overall DESI values were significantly lower after treatment,
fer of the standardized experimental setting to the clinical one was pointing to a measurable improvement of dento-facial esthetics.
evaluated. Restorative treatment in the anterior region was docu- Hereby, the median score differences before and after treatment
mented to lead to a highly significant improvement of the final increased with the number of treated teeth (Table 5). Three or
more treated teeth improved the difference of the median overall
DESI scores by more than double (Table 5). This result indicates
T A B L E 3 Intrarater reliability of the modified DESI for the five that this index might be able to discriminate between single
dental professionals after removal of the extraoral items #1 and #3.
esthetic interventions on one or two teeth and complex treat-
Correlation between baseline and second assessment of the DESI was
ments on multiple maxillary teeth.
done by the ICCa
Taking into account the subjective perceptions of patients con-
Intrarater Lower Upper
cerning dento-facial esthetics, the validated PIDAQ19 was assessed. It
reliability ICC 95CIa 95CIa
covers different fields of psychology, and considers that subjective
Rater #1 extraoral 1.0 1.0 1.0
physical attractiveness might be influenced by dento-facial appear-
intraoral 0.90 0.80 0.95
ances without gender or age-related differences.19 It was shown that
overall 0.84 0.69 0.92
esthetic ratings can vary between dentists and patients.17,36 There-
Rater #2 extraoral 1.0 1.0 1.0
fore, the score difference of the final DESI was compared with the
intraoral 0.91 0.83 0.96
overall difference of the PIDAQ (Figure 4). Interestingly, the linear
overall 0.81 0.63 0.90 regression analysis showed a significant correlation of the subjective
Rater #3 extraoral 0.47 0.15 0.71 perceptions of patients and the final DESI differences, even though
intraoral 0.58 0.29 0.78 the linear dependency of the model was low (P < .0001, R2 = 0.32).
overall 0.75 0.55 0.87 This agreement of subjective (patient) and objective (dentist) esthetic
Rater #4 extraoral 0.89 0.79 0.95 ratings is the strength of the final DESI and might allow for sufficient
intraoral 0.98 0.96 0.99 prediction and measurable esthetic improvements. In this study, a
overall 0.86 0.73 0.93 comprehensive quantitative esthetic assessment was achieved, which
Rater #5 extraoral 0.79 0.60 0.89 was in agreement with the subjective perceptions of patients. There-
intraoral 0.89 0.78 0.95 fore, by using the presented DESI, subjective perception and discrimi-
overall 0.86 0.73 0.93 nation can be assigned to objective esthetic items, and grading scales
a allow reliable quantification. Future studies should evaluate the sensi-
ICC, intra class coefficient. An ICC of <0.2 was considered weak;
0.21–0.40, low; 0.41–0.60, moderate; 0.6-0.80, good; and 0.81-1, tivity and specificity of this new tool in different settings in order to
excellent.20 CI, confidence interval. show if an esthetic smiling can be assessed reliably.

TABLE 4 Results of clinical validation of the modified DESI with three extraoral and seven intraoral itemsa

Before After Difference before-after Difference before-after

DESI Score (mean ± SD) (mean ± SD) (mean ± SD) (median, IQR, min, max) P value
Extraoral 6.06 ± 1.73 4.96 ± 1.55 1.10 ± 1.14 1, 2 (0, 3) <.0001
Intraoral 21.23 ± 5.48 15.13 ± 4.49 6.10 ± 4.19 5, 6 (−1, 19) <.0001
Overall 27.29 ± 6.57 20.10 ± 5.64 7.19 ± 4.69 6, 6.25 (−1, 21) <.0001
a
Sum of extraoral items: 3-15 points; sum of intraoral items: 7-35 points; overall sum: 10-50 points. The mean and SD for the two time points before and
after restorative treatment as well as the mean, SD, median, IQR, minimum and maximum for the difference of the two time points before and after
restorative treatment is shown for the extraoral score, the intraoral score as well as for the overall score.

T A B L E 5 Descriptive analysis for the

Number of treated teeth Median Min Max Q1 Q3 IQR
difference (before-after) of the overall
1 4.0 0 6 3.00 4.50 1.5 DESI score before and after treatment
2 4.5 −1 11 2.75 6.75 4.0 for the number of treated teeth
3+4 10.0 5 19 6.00 12.00 6.0
5+6 10.5 6 21 9.00 13.50 4.5

Abbreviations: Q, quartile; IQR, inter quartile range.

FRESE ET AL.
F I G U R E 4 Result of the linear regression model depicted in a
scatterplot with the linear regression line. It can be seen that a significant
relationship between the objective assessment (DESI) and the subjective
perception of patients (PIDAQ) exists (P < .0001, R2 = 0.32)
6 | CO NC LUSIO N
Although esthetic feelings are influenced by the subjective sensations
of patients, it can be concluded that the newly developed DESI is a
reliable and valid tool to quantify clinical situations and treatment out-
comes in accordance with the subjective perception of patients. In
addition, the DESI might be helpful to involve the patient in the esti-
mation of esthetic dental treatment. Now, further clinical investiga-
tions should be conducted to determine, whether the DESI is a valid
and reliable instrument in large-scale clinical and scientific settings.
ACKNOWLEDGMENTS
We are greatly indebted to Sybille Wegner for taking excellent stan-
dardized photographs for the reliability analysis. Furthermore, we
would like to thank Daniel Saure and Samuel Kilian for their expert
advice in statistical analyzing and interpretation of the data. Open
access funding enabled and organized by Projekt DEAL. Open Access
Veröffentlichung ermöglicht und organisiert durch Projekt DEAL.
CONF LICT OF IN TE RE ST
The authors do not have any financial interest in the companies
whose materials are included in this article.
DATA ACCES SIBILITY
The investigation was funded by the German Society of Dentistry and
Oral Medicine (Deutsche Gesellschaft für Zahn-, Mund- und
Kieferheilkunde, DGZMK, https://www.dgzmk.de).
581
OR CID
Cornelia Frese https://orcid.org/0000-0001-9875-9290
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How to cite this article: Frese C, Leciejewski F, Specht R,
et al. The dental esthetic screening index: A new tool for
assessment of dento-facial esthetics in restorative dentistry. J
Esthet Restor Dent. 2019;31:572–582. https://doi.org/10.
1111/jerd.12522