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visual method of diagnosis can detect dentine caries with a sensitivity in excess of 0.6 and a specificity in excess of 0.8 in a sample of borderline lesions. In the Downer histology the enamel-dentine junction is taken as a diagnostic threshold to calculate diagnostic accuracy at the D3 level (code 2–3), whereas in the ERK histological system the enamel-dentine junction is not used and the histological threshold 2–3 corresponds to deeper dentine lesions (a threshold between outer third of dentine and middle third of dentine). Despite this, similar levels of sensitivity and specificity were obtained when the same ICDAS-II cut-off 2–3 was used. Using these ICDAS-II cut-offs and ERK histological threshold allowed comparison with previous work where higher sensitivity (0.92–0.97) and specificity (0.85–0.93) values were obtained [Ekstrand et al., 1997]. In the present study, when a higher ICDAS-II cut-off 3–4 was used, specificity values increased to a mean of 0.90 at the expense of sensitivity, which fell to a mean of 0.60. However, the level of overall accuracy (sensitivity plus specificity) was of the same order of magnitude as when ICDAS-II cut-off 2–3 was used. A review of studies that included the validation of diagnostic techniques against a histological gold standard [Ie and Verdonschot, 1994] showed that visual inspection performed comparatively poorly for occlusal caries diagnosis compared to electrical resistance measurements and fibre-optic transillumination. In addition to this, another systematic review of the literature has shown that for visual examination specificity is high but sensitivity is low [Bader et al., 2001]. In these two reviews meta-analyses have either not been carried out or the results should be regarded with caution because of the heterogeneity of the studies included. However, it would appear that in general, visual examination has been regarded as poor for caries detection. In contrast, this study has shown that by meticulously examining clean dry teeth sensitivity of a visual examination can be improved after a short training period. In summary, after a relatively short training period 3 examiners were able to achieve results using the ICDAS- II system that were comparable to that of the examiner carrying out the training. The ICDAS-II system demonstrated reproducibility and diagnostic accuracy for the detection of occlusal caries at varying stages of the disease process comparable to those published in previous studies using similar visual criteria. The moderate to strong relationship with histological extent also demonstrates its potential to monitor lesions with time. With the development of more extensive and advanced training packages and calibration exercises there may be scope to improve the reproducibility and accuracy further. In addition, such packages would allow further dissemination of ICDAS-II, allowing data from clinical studies in primary dental care, clinical trials and epidemiological surveys to have greater clarity and comparability for metaanalyses. References Bader JD, Shugars DA: A systematic review of the performance of a laser fluorescence device for detecting caries. J Am Dent Assoc 2004; 135: 1413–1426. Bader JD, Shugars DA, Bonito AJ: Systematic reviews of selected dental caries diagnostic and management methods. J Dent Educ 2001; 65: 960–968. Chesters RK, Pitts NB, Matuliene G, Kvedariene A, Huntington E, Bendinskaite R, Balciuniene I, Matheson JR, Nicholson JA, Gendvilyte A, Sabalaite R, Ramanauskiene J, Savage D, Mileriene J: An abbreviated caries clinical trial design validated over 24 months. J Dent Res 2002; 81: 637–640. Downer MC: Concurrent validity of an epidemiological diagnostic system for caries with the histological appearance of extracted teeth as validating criterion. Caries Res 1975; 9: 231–246. Downer MC: Validation of methods used in dental caries diagnosis. Int Dent J 1989; 39: 241– 246. Ekstrand KR, Kuzmina I, Bjørndal L, Thylstrup A: Relationship between external and histologic features of progressive stages of caries in the occlusal fossa. Caries Res 1995; 29: 243–250. Ekstrand KR, Ricketts DN, Kidd EA: Reproducibility and accuracy of three methods for assessment of demineralization depth on the occlusal surface: an in vitro examination. Caries Res 1997; 31: 224–231. Ekstrand KR, Ricketts DN, Kidd EA: Occlusal caries: pathology, diagnosis and logical management. Dent Update 2001; 28: 380–387. Ekstrand KR, Ricketts DN, Longbottom C, Pitts NB: Visual and tactile assessment of arrested initial enamel carious lesions: an in vivo pilot study. Caries Res 2005; 39: 173–177. 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Pitts N: ‘ICDAS’ – an international system for caries detection and assessment being developed to facilitate caries epidemiology, research and appropriate clinical management. Community Dent Health 2004; 21: 193–198. Reis A, Zach VL Jr, de Lima AC, de Lima Navarro MF, Grande RH: Occlusal caries detection: a comparison of DIAGNOdent and two conventional diagnostic methods. J Clin Dent 2004; 15: 76–82. Richards D: Outcomes, what outcomes? (Editorial). Evid Based Dent 2005; 6: 1. Ricketts DN, Ekstrand KR, Kidd EA, Larsen T: Relating visual and radiographic ranked scoring systems for occlusal caries detection to histological and microbiological evidence. Oper Dent 2002; 27: 231–237. Ricketts DN, Kidd EA, Smith BG, Wilson RF: Clinical and radiographic diagnosis of occlusal caries: a study in vitro. J Oral Rehabil 1995; 22: 15–20. Ricketts DN, Watson TF, Liepins PJ, Kidd EA: A comparison of two histological validating techniques for occlusal caries. J Dent 1998; 26: 89–96. Sheehy EC, Brailsford SR, Kidd EA, Beighton D, Zoitopoulos L: Comparison between visual examination and a laser fluorescence system for in vivo diagnosis of occlusal caries. Caries Res 2001; 35: 421–426. Souza-Zaroni WC, Ciccone JC, Souza-Gabriel AE, Ramos RP, Corona SAM, Palma-Dibb RG: Validity and reproducibility of different combinations of methods for occlusal caries detection: an in vitro comparison. Caries Res 2006; 40: 194–201. Stachniss V: Zur Hartschnitt-Technik nicht entkalkter Zähne und digitale makrofotografische Reproduktion histologischer Präparate. Research Report, Philipps University Marburg, 2005. WHO: Oral Health Surveys: Basic Methods, ed 4. Geneva, World Health Organization, 1997. Reproducibility/Accuracy of a Method for Caries Detection Caries Res 2008;42:79–87 87
Page 1 and 2: Original Paper Caries Res 2008;42:7
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