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detection and further research is required before they
could be used in caries clinical trials [Longbottom and
Huysmans, 2004].
In epidemiological examinations, caries has usually
been diagnosed according to the WHO standard, that is,
lesions are recorded at the cavitation level. As defined by
the WHO [1997], caries requires operative treatment (D 3
level) when exposed dentine is visible or undermined
enamel with softened margins can be felt. Such lesions
are likely to be extensive, extending well into dentine,
and rapidly progressive. Therefore, subtler indices are required
which can also register lesions at an earlier noncavitated
stage. This is the only way to establish a valid
basis for caries management aimed at remineralisation of
early enamel and dentine lesions. A system for clinical
caries diagnosis would be ideal if on the one hand it could
detect caries at an early stage and on the other provide
practitioners with a basis for suitable therapies.
The International Caries Detection and Assessment
System (ICDAS) for clinical caries diagnosis was developed
to provide clinicians, epidemiologists and researchers
with an evidence-based system which would allow
standardised data collection in different settings and better
comparison between studies. The aim is to provide
better understanding of caries and its management within
the population and at an individual level [Pitts, 2004].
ICDAS was developed on the basis of insights gained
from a systematic review of the literature on clinical caries
detection systems [Ismail, 2004] and other sources
[Ekstrand et al., 1997, 2001, 2005; Fyffe et al., 2000a;
Chesters et al., 2002; Ricketts et al., 2002]. Use of the
ICDAS was intended to make subsequent studies more
useful for comparison, reviews or meta-analyses and thus
fulfil the requirements of evidence-based dentistry [Richards,
2005].
The aim of this in vitro study was to validate the
ICDAS-II system for caries detection in pits and fissures
using two histological classification systems used in previous
studies. In addition, the reproducibility of the
method was checked against a reference examiner who
was familiar with the ICDAS-II system as well as intraexaminer
reliability.
Materials and Methods
Sample Selection
One hundred unrestored molar (n = 85) and premolar teeth
(n = 15) were selected from a group of extracted teeth stored in
thymol. These were cleaned carefully with a rotating brush and
water and then stored in water.
Table 1. ICDAS-II criteria
ICDAS-II
code
Criteria
0 Sound tooth surface: no evidence of caries after prolonged
air drying (5 s)
1 First visual change in enamel: opacity or discoloration
(white or brown) is visible at the entrance to the pit or
fissure after prolonged air drying, which is not or hardly
seen on a wet surface
2 Distinct visual change in enamel: opacity or discoloration
distinctly visible at the entrance to the pit and fissure
when wet, lesion must still be visible when dry
3 Localized enamel breakdown due to caries with no visible
dentine or underlying shadow: opacity or discoloration
wider than the natural fissure/fossa when wet and
after prolonged air drying
4 Underlying dark shadow from dentine 8 localised
enamel breakdown
5 Distinct cavity with visible dentine: visual evidence of
demineralisation and dentine exposed
6 Extensive distinct cavity with visible dentine and more
than half of the surface involved
One to four easily re-located sites within the pit and fissure
system of each tooth were chosen as potential investigation sites
(total sites 181). Digital images of the occlusal surfaces were taken
with the teeth surrounded by a right-angled coordinate system,
which allowed accurate recording and identification of the investigation
sites ( fig. 1 ). Black and white copies of these, printed in
draft quality on plain paper, were used by the examiners during
this study and were only suitable for lesion location.
Training in ICDAS-II
Prior to the visual examination, the reference examiner
(D.N.J.R.) trained 3 other examiners (K.P., V.S. and A.J.-M.) in
the ICDAS-II classification system in a 2-hour session. The training
involved a 30-min lecture on the ICDAS-II system and the
importance of examining clean teeth when both wet and dry. The
details of each score were discussed and a series of images of the
occlusal surface and corresponding histological appearance were
shown to demonstrate that small and subtle changes at the entrance
to the fissure can correspond to marked histological
changes. Following this a series of approximately 20 projected,
magnified images of the occlusal surfaces of teeth with a range
of appearances were discussed and a consensus ICDAS-II score
assigned. This was followed by examination of approximately 20
extracted teeth that were not included in the main study, representing
all ICDAS-II scores. These teeth were initially examined
blind to other examiners, followed by discussion and a consensus
score given.
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Caries Res 2008;42:79–87
Jablonski-Momeni /Stachniss /Ricketts /
Heinzel-Gutenbrunner /Pieper