Fuzzy gold standards: Approaches to handling an imperfect reference standard

There are many challenging aspects to the design, conduct and interpretation of a diagnostic test accuracy study. Given the utilisation of digital technology in dentistry the issues and complexities of how these new technologies can be compared to potentially 'fuzzy gold standards' needs to be addressed. This narrative aims to provide the reader with a brief review of the nature of such studies, and in particular to introduce the reader to issues in the choice and use of clinical reference standards. Potential solutions to problems of differential verification and the use of imperfect reference standards will be provided.