International Caries Detection and Assessment System (ICDAS)

International Caries Detection andAssessment System (ICDAS)Dr. Ghada Elmasuri

01/05/23 1

Outlines of the presentation

Introduction Measuring Dental Caries

Review of caries assessment systems developed over the last decade.

International Caries Detection and Assessment System (ICDAS) Insights into the ICDASFuture of ICDASConclusions and Recommendations

01/05/23 2

Slides numbers: 70Estimated time: 40 minutes

Introduction An increasing concern more than a decade ago about

the quality and comparability of caries data assessed using the traditional measurement of caries.

Further, it has been shown that the diagnosis of caries at the cavitation level results in a significant underestimation of the actual caries experience in populations.

Pitts et al., 1988; Manji et al., 1989; Ismail et al 1992; Pitts, 1993;Machiulskiene et al., 1998; Nyvad et al., 1999; Pitts et al., 2004

01/05/23 3

Introduction

The International Caries Detection and Assessment System (ICDAS) has was developed based on a systematic review of the available clinical caries detection and assessment systems, to provide an international system for caries detection that would allow for comparison of data collected in different locations at different points in time, and to bring forward the current understanding of the process of initiation and progression of dental caries to the fields of epidemiological and clinical research.

Nyvad et al., 1999; Ekstrand et al., 1995; 1998; Pitts 2004 ; Ismail 2007

01/05/23 4

What is Dental Caries?

A localized post eruptive pathological process of external origin involving softening of the hard tooth tissue and proceeding to the formation of cavity.

01/05/23 5

Measuring Dental Caries

01/05/23 6

What is Measuring Dental Caries?

Measurement is a process of assigning values to characteristics according to a set of rules. This is facilitated through indices.

“A numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits, which is designed to permit and facilitate comparison with other populations classified by same criteria and methods.”

Russell A. L.

01/05/23 7

Why Measuring Dental Caries?

1. For epidemiological investigation in population groups

2. For public health programme planning and evaluation

3. For testing prevention and control procedures.

01/05/23 8

Prevalence of Dental caries is measured in terms of:

Percentage of persons affected Number of teeth attacked Number of tooth surface involved Number of discrete cavities Size and degree of severity of carious lesion

01/05/23 9

Ideal Requisites of an Index

1. CLARITY: The examiner should be able to remember the rules of the index clearly in his mind.

2. SIMPLICITY: The index should be simple and easy to apply so that there is no undue time lost during field examinations.

3. OBJECTIVITY: The criteria for the index should be objective and unambiguous, with mutually exclusive criteria.

4. VALIDITY: The index must measure what it is intended to measure.

01/05/23 10

Ideal Requisites of an Index

5. RELIABILITY: The index should measure consistently at different times and at variety of conditions.

6. QUANTIFIABILITY: The index should be amenable to statistical analysis.

7. SENSITIVITY: The index should be able to detect reasonably small shifts, in either direction in group condition.

8. ACCEPTABILITY: The use of index should not be painful or demeaning to the subject.

01/05/23 11

Review of caries assessmentsystems developed over the last decade

01/05/23 12

Black’s Classification System

Developed by G.V. Black in the early 1900s. Dental caries assessed based on the tooth type and the cavity location or tooth surfaces involved.

01/05/23 13

Black’s Classification System

Strength Simple and practical with long

history of use in general dental practice.

Shortcoming Does not record noncavitated

lesions leading to underestimation of caries experience.

01/05/23 14

The Decayed, Missing, Filled (DMF) index

Developed by Klein, Palmer and Knutson in 1938. World health organization has adopted this index in its oral

health assessment form for conducting national oral health surveys.

It has been used for more than 70 years as the key measure of caries experience in dental epidemiology.

Larmas 2010

01/05/23 15

The Decayed, Missing, Filled (DMF) index

When its applied only to tooth surfaces it is called the DMFS index, and scores per individual range from 0 to 128 or 148, depending on whether the third molars are included in the scoring.

Cappelli and Mobley 2007 When written in lowercase letters, (dmft) is a variation

that is applied to expresses the number of affected teeth in the primary dentition, with scores ranging from 0 to 20 for children.

01/05/23 16

The Decayed, Missing, Filled (DMF) index The dmfs index expresses the number of affected surfaces in

primary dentition with a score range of 0 to 88 surfaces.

Strength; Simple to use; accepted at global level; long track record of use supported by literature; allows for meaningful comparison of caries situation in various

populations; recognized by majority of countries and ministries of health

01/05/23 17

Shortcomings of DMF Index

1. Researchers have noted a significant amount of inter-observer bias and variability.

A practitioner has to judge whether a minor lesion will develop into a major lesion over time, and whether a lesion in primary tooth can safely remain untreated for the life of the tooth.

LeSaffre et al., 2004

2. Inability of D component of DMF score to provide any indication as to the number of teeth at risk or data that is useful in estimating treatment needs.

01/05/23 18


4. It assesses only cavitated lesion extended into dentin and cannot be use to assess root caries.

5. The indices do not account for teeth lost for reasons other than decay (such as periodontal disease) and do not account for sealed teeth since sealants and other.

6. DMF index gives equal weight to missing, untreated decayed and well restored teeth.

Broadbent JM, Thomson 2005; Burt 1997

01/05/23 19


6. Underestimation of the prevalence and severity of caries, because it does not register the initial manifestation of caries like the white spot lesion.

Gonzales 19998. Cannot assess caries progression rate.9. DMF index is invalid in elderly population, as teeth can

be lost for reasons other than caries.Broadbent JM, Thomson 2005; Burt 1997

01/05/23 20

Nyvad Caries Diagnostic Criteria

Proposed by Nyvad in 1999. includes the initial manifestation of caries in the pre-

cavitated stages. This system differentiates between active and inactive caries

lesions at both the cavitated and non cavitated levels.

Nyvad et al., 1999

01/05/23 21

01/05/23 22


Strength

1. Can identify incipient caries lesion, hence can be used for planning prevention programmes.

2. Underestimation of prevalence and severity of caries with def index can be omitted as it measures only cavitation state.

3. Reduce the need of treatment on a long term basis because diagnosis of initial lesions can stop the progression of lesion.

01/05/23 23


The prevalence values with Nyvad´s caries diagnostic criteria were 97%, were higher than those obtained with the def index being 73%.

01/05/23 24

Shortcomings of Nyvad Caries Diagnostic Criteria

1. It is more difficult to make an exact diagnosis of a precavitated active lesion such as a white spot lesion over the occlusal surface than over the facial surface, because of the physiologic wear of the occlusal surface during mastication, these lesions can disappear.

These lesions can be underdiagnosed, progressing to frank cavitation.

01/05/23 25

Significant caries Index (SiC)

In 1981, WHO declared that “the global goal for oral health by the year 2000 should be that the DMFT for the 12-year-olds should not exceed 3”. Over a period of 20ys, nearly 70% of the countries in the world have achieved this goal, or being at borderline value.A detailed analysis of the caries situation in many countries showed a skewed distribution of caries prevalence and that a proportion of 12-year-olds still has high or even very high DMFT values even though a proportion is totally caries free.

01/05/23 26


Thus DMFT value does not accurately reflect this skewed distribution leading to incorrect conclusion that the caries situation for the whole population is controlled, while in reality, several individuals still have caries.

Bratthall in 2000 proposed SiC indix in order to bring attention to the individuals with the highest caries values in each population under investigation.

Bratthall 2000

01/05/23 27


While mean scores provide a good measure of population disease levels, it is important to also look at those who might be carrying a significant burden of the dental disease experience in the population.SiC indix is used together with DMF to highlight oral health inequalities more accurately among different population groups within the community in order to identify the need for special preventive oral health interventions.

Bratthall 2000

01/05/23 28


SiC is calculated by sorting individuals according to their DMFT values, than one third of the population with the highest caries scores is selected and the mean DMFT for this subgroup is calculated. Strength:It can bring authorities attention to the need of preventive measures required for prevention/control of caries in these subgroups.

Bratthall 2000

01/05/23 29

Shortcomings of Significant caries Index (SiC)

1. It is just an extension of DMF index as it follows same criteria for assessing dental caries and thus the same limitations in assessing caries in a population as DMF index.

2. Is more of significance in population where caries prevalence is low and has a skewed distribution.

01/05/23 30

Specific Caries Index

Proposed by Acharya in 2006 to be used in conjunction with the DMFS index to provide qualitative and quantitative information about caries prevalence, location, type of caries lesion as well as untreated dental caries in an individual based on clinical examination.

Strength; The index has shown good reliability and validity in the study

conducted by original author but further search on various databases did not reveal any other study using this index.

01/05/23 31

Specific Caries Index

The SCI score for an individual is calculated by adding the individual tooth scores, scores for an individual can range from 0 to 192 (for 32 teeth).

01/05/23 32

Shortcomings of Specific Caries Index

1. It employs same caries detection criteria as DMF or DMFS;2. Inability of this index, if used alone, to capture

information useful for treatment planning.3. In cases of large lesions, which cover more than one

surface, only an assumption can be made regarding the originating lesion.

4. Number of proximal lesions be underestimated in absence of bitewing radiograph.

5. Lack of provision for assessing root caries.

01/05/23 33

PUFA (pulp-ulcer-fistula-abscess) index

Developed by Monse et al in 2010 to overcome DMF index failure to provide information on the clinical consequences of untreated dental caries, such as pulpal abscess, which may be more serious than the carious lesions themselves.

Monse et al 2010

01/05/23 34

01/05/23 35

PUFA (pulp-ulcer-fistula-abscess) index

Strength;1.Simple to record.2.Can be used for primary and permanent teeth alongside with DMF index.3.Can provide useful information for researches and authorities in many developing countries, where access to oral health services is limited and teeth are often left untreated or are extracted because of pain or discomfort.

01/05/23 36

Shortcomings of PUFA (pulp-ulcer-fistula-abscess) index

1. Stages of carious lesion progression in enamel are not being assessed.

2. Few subjects with score “u” (ulcer).3. Assessment of abscess and fistula can be combined into

one code.4. Reliability and validity of this index requires further

discussion and research.

01/05/23 37

Caries Assessment Spectrum and Treatment (CAST) Index

Developed by Frencken et al 2011, because of the need to find a reliable, pragmatic cohesive and easy to read reporting system.

Combines elements of the ICDAS II and PUFA indices, and the M- and F-components of the DMF index.

Strength; It covers the total dental caries spectrum – from no carious

lesion, through caries protection (sealant) and caries cure (restoration) to carious lesions in enamel and dentine, and the advanced stages of caries lesion progression in pulpal and tooth surrounding tissue.

Frencken et al 2011

01/05/23 38

01/05/23 39

Shortcomings CAST Index

1. It does not record active and inactive carious lesions. 2. The CAST index has not been validated, nor has its

reliability been tested. 3. It is also not suggested for use in clinical trials. 4. It does not provide data on treatment or preventive

measures required for each code.

01/05/23 40

The Problem Of Diagnosis ?Sensitivity Vs Specificity

Sensitivity: It is defined by the probability of the test giving a positive finding when disease is present.Specificity: It is the probability of a negative finding when disease is absent. The indications that are currently used of dental caries diagnosis gives sensitivities of 60% and a specificity of 85%. Leading to a profound effects on possible negligence of early pathological demineralization.

Lussi 1991; Pitts 1995

01/05/23 41

The Problem Of Diagnosis ?Sensitivity Vs Specificity

01/05/23 42

Need for an Integrated SystemUnfortunately, in carious lesion detection, the scale of measurement differs with clinicians, researchers, techniques, and gadgets because a baseline or a gold standard is absent. Thus future of research, practice, and education in cariology requires the development of an integrated definition of dental caries and uniform measuring system designed in such a way to produce reliable/reproducible results.

01/05/23 43

International Caries Detectionand Assessment System

(ICDAS) – I and II

Developed in the year 2001 by the effort of large group of researchers, epidemiologists and restorative dentists to find a common caries assessment system based on of insights gained from a systematic review of the literature on clinical caries detection systems.

Ismail 2004

01/05/23 44



To lead to better quality information to inform decisions about the appropriate diagnosis, prognosis and clinical management of dental caries at both the individual and

public health levels.Pitts, 2004

01/05/23 45

International Caries Detection and Assessment System (ICDAS) – I and II

The ‘D’ in ICDAS stands for detection of dental caries by i. stage of the carious process;ii. topography (pit-and-fissure or smooth surfaces);iii. anatomy (crowns versus roots);iv. restoration or sealant status

The ‘A’ in ICDAS stands for assessment of the caries process by stage (non-cavitated or cavitated) and activity (active or arrested)

01/05/23 46

International Caries Detection and Assessment System

ICDAS I (2001) ICDAS II (2009)

Include (D) component for caries detection and (A) component for assessment of caries process (whether cavitated or non-cavitated and active or arrested caries). Root caries were not included due to lack of consensus and need for further discussions.

Modified by ICDAS coordinating committee in 2009 which describes both coronal caries and caries associated with restorations and sealants (CARS) and root caries.

01/05/23 47



There is insufficient” evidence on the validity of clinical diagnostic systems for root caries based on the National Institutes of Health (NIH) Consensus Development Conference on dental caries diagnosis and management.

Bader et al 2001 Root caries are frequently observed near the cemento-enamel

junction (CEJ), although lesions can appear anywhere on the root surface.

01/05/23 48


The color of the root lesions has been used as an indication of lesion activity.

Active lesions have been described as being; Yellowish or light brown in color, Darkly stained for arrested lesions.

However, color subsequently has been shown not to be a reliable indicator of caries activity.

Hellyer et al, 1999; Lynch and Beighton 1994

01/05/23 49

ICDAS/ A. Pits and fissuresB- Smooth surface (mesial and

distal)

01/05/23 50

CARIES ADJACENT TO RESTORATIONS AND SEALANTS (CARS) New in ICDAS II

01/05/23 51

C-Root Caries (New in ICDAS II)

01/05/23 52


ICDAS has a 2-digit coding system (X-Y).I.The first decision (code X; lesion detection) is to classify each tooth surface on whether it is sound, sealed, restored, crowned, or missing. II.The second decision (attributed to code Y; lesion assessment) that should be made for each tooth surface is the classification of the carious status on an ordinal scale.The ICDAS systems advocate the removal of plaque prior to the initial examination in order to accurately detect the lesion.

01/05/23 53

ICDAS two-digit coding method/ Decision I

01/05/23 54

ICDAS two-digit coding method/ Decision II

01/05/23 55

ICDAS two-digit coding method

ExampleA tooth restored with amalgam, which also exhibits an extensive distinct cavity with visible dentin will be coded 4 (for an amalgam restoration) and 6 (for a distinct cavity).

01/05/23 56

Wardrobe approach of ICDAS

To facilitate the use of ICDAS in different settings there is a range of validated tools to select from, much as you would select the

appropriate clothes from your wardrobe depending on what you were doing that day.

01/05/23 57

Wardrobe approach of ICDAS

This ‘wardrobe’ of validated tools allows users to select the best criteria and conventions for each specific application of the system.

Example; in a national study that aims to compare dental caries prevalence over time, the number and configuration of tooth surfaces may be selected to match previous surveys. Also, the stage of caries detection may be adjusted to match previous studies conducted in a country.

Pitts, 2004

01/05/23 58

Performance of ICDASPeer review papers

Search methods for identification of studiesGoogle, Google Scholar, the Cochrane Library MEDLINE and EMBASE electronic databases were searched.

01/05/23 59

Search Results

01/05/23 60

Performance of ICDASEvidence Based Results

Author& Location Objectives Findings

Ekstrand et al., 2007Dundee, Scotland and Copenhagen,

To test the reproducibility and accuracy of the ICDAS I and ICDAS II caries detection systems for coronal primary caries in vitro.

Both the ICDAS caries detection systems I and II are valid and reliable for detecting caries and predicting the depth of the lesion at any coronal surface.

01/05/23 61

Search Results

01/05/23 62


Author& Location Objectives Findings

Ismail et al., 2008US

Assessed the prevalence, severity of dental caries, using the International Caries Detection and Assessment System (ICDAS).

The use of ICDAS provided useful information on caries distribution including both cavitated (ICDAS 3-6) as well as the non cavitated carious lesion (ICDAS 1-2).

01/05/23 63

Search Results

01/05/23 64


Author& Location

Objectives MMethodology Findings

Shoaib et al., 2009Malaysia

To assess the validity and reproducibility of the ICDAS II criteria in primary teeth.

Three trained examiners independently examined 112 extracted primary molars (52 first primary molars and 60 second primary molars), ranging from clinically sound to cavitated using ICDAS II system.

The ICDAS II criteria are appropriate for use in theprimary dentition both for approximal and occlusal surfaces.

01/05/23 65

The ICDAS has been shown to be reproducible and accurate (Jablonski-Momeni et al., 2008) and to allow the detection and assessment of early lesions and longitudinal follow-up

(Burt et al., 2006; Ekstrand et al., 2007; Finlayson et al., 2007; Ismail et al., 2007, 2008; Sohn et al., 2007; Cook et al., 2008; Jablonski-Momeni et al., 2008; Varma et al., 2008).

Summary of evidences

01/05/23 66

Strength of ICDAS

1. Clinically reliable in permanent teeth and acceptable in primary teeth.

2. Designed to detect 6 stages of caries severity, varying from initial changes visible in enamel to frank cavitation in dentine.

3. Very suitable for use in clinical trials assessing the efficacy and/or effectiveness of caries control agents.

01/05/23 67

Shortcomings of ICDAS

1. Root caries assessment criteria has not been tested in any epidemiological or clinical studies.

2. Data obtained are unpragmatic, non-cohesive and difficult to read.

3. May lead to overestimation of seriousness of dental caries.4. Results are difficult to compare against the widely-used DMF

index.5. In very young children, some claim it is not practical to dry6. surfaces to assess for early enamel caries (others, however

have used it successfully for this age group).

01/05/23 68

ICDAS adaptation of the WHO “Stepwise” approach to the Surveillance of Non-Communicable Diseases for use with dental caries and oral health indicators.

FUTURE OF ICDAS

01/05/23 69

Pitts, 2009

WHO Stepwise approach to Surveillance (STEPS) is a simple, standardized method for collecting, analysing and disseminating data in WHO member countries.

By using the same standardized questions and protocols, all countries can use STEPS information not only for monitoring within-country trends, but also for making comparisons across countries. The approach encourages the collection of small amounts of useful information on a regular and continuing basis.

FUTURE OF ICDAS

01/05/23 70

This philosophy is entirely consistent with the wardrobe approach of ICDAS and its use would result in improved comparability of data collected nationally and internationally and thereby facilitates systematic reviews in the area. This foundation allows researchers and clinicians to choose the stage of disease and characteristics for assessment.

FUTURE OF ICDAS

01/05/23 71

The future of ICDAS depends on acceptance of the concepts of integration and utility within a caries detection and assessment system and to the fields of epidemiological and clinical research by the cariology community.

FUTURE OF ICDAS

01/05/23 72

Application of ICDAS

01/05/23 73

These recommendations have been formulated following the ICDAS II workshop in Baltimore (USA) for improvement in caries diagnosis using ICDAS;

1. Investigate different methods for effectively cleaning and drying of teeth and their impact on the usability of ICDAS.

2. Develop and test new explorers to allow for the detections of surface roughness or “tackiness” of root surfaces without causing damage to the surface.

3. Define the appropriate time required to dry teeth to identify the first visible signs of dental caries.

FUTURE OF ICDAS

01/05/23 74

Additionally, a need for the following supporting resources was identified in the workshop:

1. A library of images to depict the different codes and conditions related to ICDAS.

2. Statistical protocols for analysis of reliability data as well as for analysis of the ICDAS system in clinical and epidemiological studies.

3. Standardized protocols and online simulations to train examiners to use ICDAS.

FUTURE OF ICDAS

01/05/23 75

References World Health Organization. Oral health surveys– basic methods. 4. ed. Geneva: World

Health Organization; 1997. Klein H, Palmer C. Studies on dental caries vs. familial resemblance in the caries

experience of siblings. Pub Hlth Rep. 1938;53:1353-64. Larmas M. Has dental caries prevalence some connection with caries index values in

adults? Caries Res. 2010;44(1):81-4. Cappelli DP, Mobley CC. Prevention in Clinical Oral Health Care. Philadelphia, Pa:

Mosby Elsevier; 2007. LeSaffre E, Mwalili SM, Declerk D. Analysis of caries experience taking inter-observer

bias into account. J Dent Res. 2004;83(12):951-5. Broadbent JM, Thomson WM. For debate: problems with the DMF index pertinent to

dental caries data analysis. Community Oral Dent Epidemiol. 2005;33(6):400-9. Burt BA. How useful are cross-sectional data from surveys of dental caries?

Community Dent Oral Epidemiol. 1997 Feb;25(1):36-41.

01/05/23 76

References Gonzales, María Clara y col.Caries Dental. Guías de Práctica Clínica Basada en la

Evidencia ISS-ACFO 1999. Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system

differentiating between active and inactive caries lesions. Caries Research. 1999;33:252-260

Bratthall D, Introducing the Significant Caries Index together with a proposal for a new global oral health goal for 12-year-olds. Int Dent J 2000, 50: 378-384.

Mehta, Abhishek. "Comprehensive review of caries assessment systems developed over the last decade." RSBO (Online) 9.3 (2012): 316-321.

Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Palenstein Helderman W. PUFA– An index of clinical consequences of untreated dental caries. Community Dent Oral Epidemiol. 2010;38:77-82.

Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007;35:170-8.

01/05/23 77

References Ismail AI. Visual and visuo-tactile detection of dental caries. J Dent Res.

2004;83:C56-66. Bader JD, Shugars DA, Bonito AJ. Systematic review of selected dental caries

diagnostic and management methods. J Dent Educ. 2001;65:960–8. [PubMed] Hellyer PH, Beighton D, Heath MR, Lynch EJ. Root caries in older people

attending a general practice in East Sussex. Br Dent J. 1990;169:201–6. [PubMed] Lynch E, Beighton D. A comparison of primary root caries lesions classified

according to color. Caries Res. 1994;28:233–9. Ahlawat.P Comprehensive Implementation of the International Caries

Detection and Assessment System (ICDAS) in a Dental School and University Oral Health Centre: A Stepwise Framework Dent. J. 2014, 2, 41-51.

Pitts NB. Modern Concepts of Caries Measurement. J Dent Res 83(Spec Iss C):C43-C47, 2004.

ICDAS Coordinating Committee. Rationale and Evidence for the International Caries Detection and Assessment System (ICDAS II) in http://www.icdas.org/uploads/Rationale%20and%20Evidence%20ICDAS%20II%20September%2011-1.pdf

01/05/23 78

International Caries Detection and Assessment System (ICDAS)

Healthcare

Transcript of International Caries Detection and Assessment System (ICDAS)