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Clinical and Radiographic Diagnosis of Underlying Dark Shadow from Dentin

(ICDAS 4) in Permanent Molars

Article  in  Caries Research · May 2013

DOI: 10.1159/000350924 · Source: PubMed

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 Short Communication
Caries Res 2013;47:429–432
DOI: 10.1159/000350924
Clinical and Radiographic Diagnosis of
Underlying Dark Shadow from Dentin
(ICDAS 4) in Permanent Molars
N. Bertella a M. dos S. Moura a L.S. Alves a N. Damé-Teixeira a V. Fontanella b
M. Maltz a  
Departments of a Social and Preventive Dentistry and b Surgery and Orthopedics, Faculty of Odontology,
Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Key Words
Dental radiography · Diagnosis · Molar · Permanent
dentition
Abstract
This study investigated the radiographic pattern of underly-
ing dark shadow from dentin (ICDAS 4) in permanent molars
and assessed the association between enamel breakdown
and radiographic features. Ninety-five teeth (54 patients)
were clinically and radiographically assessed. The majority of
ICDAS 4 caries lesions presented enamel breakdown (n = 78,
82.1%) and no radiographic image (n = 64, 67.4%) or a radio-
lucent zone restricted to the enamel-dentin junction (n = 17,
17.9%). No association was found between enamel break-
down and radiographic features. This study suggests that a
radiographic examination is needed prior to the decision
making process for underlying dark shadows from dentin.
Copyright © 2013 S. Karger AG, Basel
Different diagnostic criteria to detect caries lesions
have been proposed to enhance accuracy, precision and
reproducibility of the clinical examination. The Interna-
© 2013 S. Karger AG, Basel
0008–6568/13/0475–0429$38.00/0
E-Mail karger@karger.com
www.karger.com/cre
Received: July 18, 2012
Accepted after version: March 12, 2013
Published online: May 25, 2013
tional Caries Detection and Assessment System (ICDAS)
classifies dental surfaces into 7 codes, ranging from 0
(sound surface) to 6 (extensive cavity with visible dentin).
According to ICDAS, underlying dark shadows from
dentin with or without enamel breakdown are classified
as code 4 [Ismail et al., 2007].
Previous studies assessing the relationship between
clinical and histological features of caries lesions classi-
fied according to the ICDAS showed a substantial in-
volvement of dentin in the histological analysis of dark
shadows [Ekstrand et al., 2007; Jablonski-Momeni et al.,
2008; Rodrigues et al., 2008; Diniz et al., 2009]. Neverthe-
less, it is known that the presence of mineral loss in dentin
by itself does not indicate the need for operative treat-
ment [Ekstrand et al., 2007]. In clinical practice, the deci-
sion making process is based on the combination of in-
formation obtained from the clinical and radiographic
examinations [Mejàre et al., 1999; Espelid et al., 2001].
There is no in vivo study assessing the relationship be-
tween clinical and radiographic features of dark shadows
from dentin. Therefore, the aim of this study was to in-
vestigate the radiographic pattern of ICDAS 4 caries le-
sions in permanent molars and to assess the association
between enamel breakdown and radiographic features.
Universidade Federal do Rio Grande do Sul
143.54.254.36 - 5/29/2013 1:51:26 PM
Marisa Maltz
Faculty of Dentistry, UFRGS, Department of Social and Preventive Dentistry
Ramiro Barcelos, 2492
Downloaded by:
Porto Alegre, RS, 90035-003 (Brazil)
E-Mail marisa.maltz @ gmail.com
 Subjects and Methods Table 1. Sample description

The study protocol was approved by the Federal University of Characteristic Statistic
Rio Grande do Sul Research Ethics Committee (register No.
19288). All participants and their parents or legal guardians pro- Gender, n
vided written informed consent. Male 12 (22)
Female 42 (78)
Sample Age, years
Fifty-four individuals were included in this study, totaling 95 Mean ± SD 14.2±4.2
teeth. Most individuals (n = 40, 74%) were selected from a cross- Range 11–30
sectional survey conducted in Porto Alegre, southern Brazil, ICDAS 4 caries lesion per individual
which included schoolchildren aged 12 years [Alves et al., 2012]. Mean ± SD 1.7±1.3
The remaining participants (n = 14, 26%) were gathered from the Range 1–8
dental clinics of the Federal University of Rio Grande do Sul. Radiographic image, n
Screening was performed by one examiner (L.S.A.). All selected Absent 64 (67.4)
teeth (n = 103) were reexamined by another dentist (M.S.M.) and Enamel-dentin junction 17 (17.9)
dubious cases were excluded (n = 8). Outer ½ of dentin 12 (12.6)
This sample of 95 teeth was considered sufficient to detect a Inner ½ of dentin 2 (2.1)
proportion of 90% of ICDAS 4 caries lesions with radiographic Clinical aspect, n
image achieving dentin [Ekstrand et al., 2007; Jablonski-Momeni Without enamel breakdown 17 (17.9)
et al., 2008; Rodrigues et al., 2008; Diniz et al., 2009], considering With enamel breakdown 78 (82.1)
a precision level of ±6% and a confidence level of 95%. Tooth, n
First molar 59 (62)
Eligibility Criteria Second molar 36 (38)
To be included in the study, individuals should present at least Arch, n
one permanent molar with an ICDAS 4 caries lesion at the occlusal Upper 39 (41)
surface. Occlusal-approximal dark shadows were excluded as well Lower 56 (59)
as those in which the radiographic visualization of the lesion was
impeded by buccal/lingual restorations or orthodontic bands. Values in parentheses are percentages. SD = Standard
deviation.
Data Collection
Clinical examinations were conducted at a dental unit, using
artificial light, a clinical mirror and probe, after dental prophy-
laxis with rotating tuffs and air drying (M.S.M.). Teeth classified
as ICDAS 4 caries lesions were visually assessed with regards to i.e. the same individual contributed with more than one tooth,
the presence or absence of localized enamel breakdown by an- odds ratios were obtained using generalized estimating equations
other examiner (N.B.). Digital bitewing radiographs was taken us- with a logistic link function. Due to the reduced number of obser-
ing film holders (Jon®, São Paulo, Brazil) with 0.6-second expo- vations in some radiographic categories, the outcome was dichot-
sure. Images were processed through the Vista Scan system (Dürr omized in two ways. Firstly, the outcome was defined as absent if
Dental®, Bietigheim-Bissingen, Germany). no radiographic image could be seen (score 0) and present if any
radiographic image was observed (scores 1, 2 and 3). Secondly, the
Reproducibility outcome was defined as absent if no radiographic image or an im-
All examiners were trained and calibrated by means of double age in the enamel-dentin junction was detected (scores 0 and 1)
examinations with a minimal time interval of 2 days. The following and present if a radiographic image in the outer or inner half of
unweighted Cohen’s kappa values were obtained: 0.80 (L.S.A.) and dentin was observed (scores 2 and 3). Statistical analyses were car-
0.78 (M.S.M.) for ICDAS 4 caries lesions diagnosis, and 0.71 for ried out using SPSS version 17.0.
enamel breakdown assessment (N.B.). All radiographs were exam-
ined twice and the unweighted Cohen’s kappa for radiographic
examination was 0.73 (V.F.).
Results
Data Analysis
Radiographic images were classified by a senior radiologist
(V.F.) into: 0, absent; 1, radiolucent image at the enamel-dentin The sample description is shown in table 1. Most of the
junction; 2, radiolucent image at the outer half of dentin, and 3, ra- individuals were female, with a mean age of 14.2 years.
diolucent image at the inner half of dentin, adapted from a previ- The number of ICDAS 4 caries lesion per individual var-
ously described code system [Mejàre et al., 2004]. The examiner was ied widely, ranging from 1 to 8.
blinded in regards to the clinical appearance of the occlusal surfaces.
A logistic regression model was used to assess the association In the clinical examination, most cases presented
between the presence of enamel breakdown and the presence/ enamel breakdown (n = 78, 82.1%). In the radiographic
analysis, the majority of teeth did not present a radiolu-
Universidade Federal do Rio Grande do Sul

depth of the radiolucent image. Considering the clustering of data,

143.54.254.36 - 5/29/2013 1:51:26 PM

430 Caries Res 2013;47:429–432 Bertella/Moura/Alves/Damé-Teixeira/

DOI: 10.1159/000350924 Fontanella/Maltz
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Table 2. Relationship between the clinical aspect and the radiographic image of the ICDAS 4 caries lesions

Clinical aspect Radiographic image

absent EDJ outer ½ of inner ½ of total
dentin dentin
Dark shadow from dentin, n 13 (76.5) 1 (5.9) 2 (11.8) 1 (5.9) 17 (100)
Dark shadow from dentin with enamel breakdown, n 51 (65.4) 16 (20.5) 10 (12.8) 1 (1.3) 78 (100)
Total 64 (67.4) 17 (17.9) 12 (12.6) 2 (2.1) 95 (100)

Values in parentheses are percentages. EDJ = Enamel-dentin junction.

cent image (n = 64, 67.4%) or presented a radiolucent

Color version available online

image restricted to the enamel-dentin junction (n = 17,
17.9%).
Table  2 describes the relationship between enamel
breakdown and the radiographic image. The majority of
ICDAS 4 caries lesion (n = 51, 65.4%) presented no radio-
graphic image despite the presence of enamel breakdown.
Logistic regression analysis showed no association be-
tween enamel breakdown and radiographic features, irre- a
spective of the cutoff used (p > 0.05). Examples of ICDAS
4 caries lesions included in the study are shown in figure 1.

Discussion

The majority of ICDAS 4 caries lesions evaluated in

this study presented no radiographic image or a radiolu-
cent zone restricted to the enamel-dentin junction, de-
spite the presence of clinically evident dark shadow from
dentin. Furthermore, no association was observed be-
tween the presence of enamel breakdown and presence/
depth of the radiolucent image.
Recent in vitro studies have correlated the clinical
and histological characteristics of dark shadows from
dentin; however, these studies included reduced sample
sizes, ranging from 3 to 9 teeth [Ekstrand et al., 2007;
Jablonski-Momeni et al., 2008; Rodrigues et al., 2008;
Diniz et al., 2009]. By summing those samples, 25 teeth
were classified as having ICDAS 4 caries lesion, and
most of them presented involvement of deep dentin
(88%). It is known that the histological examination is
the gold standard to assess the extent to which a tissue
is affected by disease [Mitropoulos et al., 2010]; how-
ever, it is not an available tool in clinical practice. On
the other hand, radiographic examination is the method
of choice to assess caries depth [van Amerongen et al.,
1992; Ekstrand et al., 1997]. In the present in vivo study,
b
Fig. 1. Examples of ICDAS 4 caries lesions included in the study.
a Tooth 46, dark shadow from dentin with enamel breakdown
and no radiolucent zone. b Tooth 36, dark shadow from dentin
with enamel breakdown, radiolucent zone at the outer half of
dentin.
a sample of 95 teeth with dark shadow from dentin was
assessed, and 85.3% did not present a radiolucent image
(67.4%) or presented a radiolucent image restricted to
the enamel-dentin junction (17.9%). Ekstrand et al.
[1997] showed that the radiographic examination is an
excellent predictor of soft, demineralized dentin, thus
suggesting the existence of a radiographic detection
similar to the demineralization area observed histologi-
cally when the caries lesion achieves deep dentin. The
disagreement between the present study and the afore-
mentioned in vitro studies may be attributed to issues
Universidade Federal do Rio Grande do Sul
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Underlying Dark Shadow from Dentin in Caries Res 2013;47:429–432 431

Permanent Molars DOI: 10.1159/000350924
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related to sample size and sample selection criteria.
These studies included a reduced number of teeth with
ICDAS 4 caries lesions, which may not be representa-
tive of the conditions usually found in clinical practice.
It is possible that teeth included in these in vitro stud-
ies were those with deep caries lesions leading to tooth
extraction.
In conclusion, the present study showed that the clin-
ical classification of a caries lesion as ICDAS 4, regard-
less of the presence of cavitation, was not associated with
radiographic lesion depth. These results suggest that a
radiographic examination is needed prior to the deci-
sion making process for such lesions.
Declaration of Interest
We declare that we have no proprietary, financial, professional
or other personal interest of any nature or kind in any product,
service, and/or company that could be construed as influencing the
position presented in, or the review of this manuscript.

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432 Caries Res 2013;47:429–432 Bertella/Moura/Alves/Damé-Teixeira/

DOI: 10.1159/000350924 Fontanella/Maltz
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