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Validity and reproducibility of ICDAS II in primary teeth

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 Original Paper
Caries Res 2009;43:442–448
DOI: 10.1159/000258551
Validity and Reproducibility of ICDAS II
in Primary Teeth
L. Shoaib a C. Deery b D.N.J. Ricketts c Z.J. Nugent d
a
Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia; b School of Clinical Dentistry, University of
Sheffield, Sheffield, and c Dundee Dental Hospital and School, University of Dundee, Dundee, UK; d CancerCare
Manitoba, Winnipeg, Man., Canada
Key Words
Caries, occlusal and approximal surfaces ⴢ International
Caries Detection and Assessment System ⴢ Primary teeth
Abstract
The aim of this in vitro study was to assess the validity and
reproducibility of the ICDAS II (International Caries Detec-
tion and Assessment System) criteria in primary teeth. Three
trained examiners independently examined 112 extracted
primary molars, ranging from clinically sound to cavitated,
set up in groups of 4 to mimic their anatomical positions. The
most advanced caries on the occlusal and approximal sur-
faces was recorded. Subsequently the teeth were serially
sectioned and histological validation was undertaken using
the Downer and Ekstrand-Ricketts-Kidd (ERK) scoring sys-
tems. For occlusal surfaces at the D1/ERK1 threshold, the
mean specificity was 90.0%, with a sensitivity of 75.4%. For
approximal surfaces, the specificity and sensitivity were 85.4
and 66.4%, respectively. For occlusal surfaces at ICDAS code
63 (ERK3 threshold), the mean specificity and sensitivity
were 87.0 and 78.1%, respectively. For approximal surfaces,
the equivalent values were 90.6 and 75.3%. At the D3 thresh-
old for occlusal surfaces, the mean specificity and sensitiv-
ity were 92.8 and 63.1%, and for approximal surfaces 94.2
and 58.3%, respectively. Mean intraexaminer reproducibility
(Cohen’s kappa) ranged from 0.78 to 0.81 at the ICDAS code
© 2009 S. Karger AG, Basel
0008–6568/09/0436–0442$26.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/cre
Received: March 19, 2009
Accepted after revision: September 24, 2009
Published online: November 12, 2009
61 cut-off and at the ICDAS code 63 cut-off from 0.74 to
0.76. Interexaminer reproducibility was lower, ranging from
0.68 to 0.70 at the ICDAS code 61 cut-off and from 0.66 to
0.73 at the ICDAS code 63 cut-off. In conclusion, the validity
and reproducibility of the ICDAS II criteria were acceptable
when applied to primary molar teeth.
Copyright © 2009 S. Karger AG, Basel
Traditionally caries has been diagnosed at the cavita-
tion stage or, more recently, at the stage when a lesion ex-
tends into dentine stage (D3 diagnostic threshold) [Pitts
and Fyffe, 1988]. Historically this is the point at which
most dentists have agreed that restoration is required.
However, the disease is present, diagnosable and revers-
ible long before this stage. The ability of examiners to
detect the initial stages of caries is well documented, with
work stretching back into the middle of the last century
[Backer Dirks et al., 1951; Marthaler, 1965].
Therefore, we have a situation where the disease may
not be detected, diagnosed, recorded or managed in the
most appropriate way. For example, the differences in di-
agnostic thresholds and criteria used impede comparison
between epidemiological surveys or research trials – the
areas of dentistry where one would expect the greatest
standardization [Pitts, 2004].
Prof. Chris Deery
School of Clinical Dentistry
19 Claremont Crescent
Sheffield S10 9TA (UK)
Tel. +44 114 271 7974, E-Mail c.deery @ sheffield.ac.uk
 The International Caries Detection and Assessment
System (ICDAS) was developed to provide clinicians, ep-
idemiologists and researchers with an evidence-based
system which would permit standardized caries detec-
tion and diagnosis in differing environments and situa-
tions [Pitts, 2004]. The ICDAS was, and continues to be,
based on systematic reviews [Bader et al., 2002; Ismail,
2004] and the integration of other caries detection and
diagnostic systems, which have used meticulous diagno-
sis to include noncavitated enamel lesions and staged the
disease process [Pitts and Fyffe, 1988; Ekstrand et al.,
1997, 1998; Deery et al., 2000; Fyffe et al., 2000; Chesters
et al., 2002; Ricketts et al., 2002]. Following a minor al-
teration in the criteria (table 1) the system is now known
as ICDAS II.
The systematic review by Bader et al. [2002] noted that
there was relatively little research on the validity of caries
detection and diagnosis in primary teeth, identifying
only five assessments of which two assessed visual diag-
nostic methods. In addition, there is little research on the
validity and reproducibility of the ICDAS criteria on sur-
faces other than occlusal ones [Ismail et al., 2007].
The aim of this in vitro study was to assess the valid-
ity and reproducibility of the ICDAS II criteria for the
detection and diagnosis of caries of the occlusal and ap-
proximal surfaces of primary molar teeth.
Materials and Methods
The occlusal and approximal surfaces of 112 extracted pri-
mary molars (52 first primary molars and 60 second primary mo-
lars) were examined by three clinicians. The teeth represented a
wide range of clinical appearances from apparently sound to cav-
itated dentine caries; extensively broken down teeth were exclud-
ed. The teeth had been extracted from the children in the preced-
ing months and written informed consent for use in research had
been obtained. None of the teeth had been exposed to fluoridated
water. The extracted teeth were stored in neutral buffered forma-
lin immediately after extraction and at no time allowed to dehy-
drate. Soft tissue debris was removed and each tooth surface was
thoroughly cleaned with hand instruments, pumice and water to
remove debris, plaque and stain. They were then stored in 0.12%
aqueous thymol. Subsequently, the teeth were mounted in groups
of four in pink impression putty (Coltene Lab Putty, Whaledent
AG, Switzerland). The teeth were as far as possible arranged to
mimic the intraoral anatomical position.
Examiner Training
Examiner 1 (C.D.) had experience of using meticulous diag-
nostic systems [Fyffe et al., 2000] and the ICDAS criteria. Exam-
iner 2 (L.S.), although an experienced clinician, was not familiar
with dental examinations under epidemiological or trial condi-
tions. Therefore, examiner 3 (D.R.), who had extensive previous
ICDAS II in Primary Teeth
Table 1. ICDAS II codes and criteria
Code Criterion
0 Sound tooth surface: no evidence of caries after 5 s air dry-
ing
1 First visual change in enamel: opacity or discoloration
(white or brown) is visible at the entrance to the pit or fis-
sure seen after prolonged air drying
2 Distinct visual change in enamel visible when wet, lesion
must be visible when dry
3 Localized enamel breakdown (without clinical visual
signs of dentinal involvement) seen when wet and after
prolonged drying
4 Underlying dark shadow from dentine
5 Distinct cavity with visible dentine
6 Extensive (more than half the surface) distinct cavity with
visible dentine
knowledge of the ICDAS criteria, conducted the training to stan-
dardize the three examiners [Ekstrand et al., 1997; Jablonski-Mo-
meni et al., 2008]. This consisted of an explanation of the criteria
and coding, followed by discussion and practice using 20 extract-
ed teeth, which were not part of this study.
Clinical Visual Examination
All the visual examinations were conducted under standard
conditions in dental surgery, with a dental light (KaVo, Biberach,
German) and 3:1 syringe to dry and wet the teeth as appropriate,
with access to a blunt probe (CPITN), as required by the criteria.
The three examiners used written criteria and examined the teeth
independently, blinded to the score of the other examiners (http://
www.icdas.org/; table 1) [Jablonski-Momeni et al., 2008]. The
teeth were kept wet during the examinations unless when active-
ly dried and 45 min was the interval between successive examina-
tions to permit rehydration. All examinations were repeated
blinded to previous scores after a period of at least 1 week, to al-
low assessment of intraexaminer reproducibility.
Validation
Teeth were removed individually from the putty. A groove was
placed in the mesial cervical area of each tooth and nail varnish
was applied to this mesial groove to aid identification of tooth
surfaces and therefore orientation after sectioning. Each tooth
was mounted in orthodontic resin (Orthoresin, Dentsply, UK)
into 112 individual blocks. Each mounted block was then serially
sectioned in a longitudinal mesio-distal plane with a water-cooled
diamond disc on a Buehler Precision Saw (Isomet 5000, Buehler
Ltd., USA). Each section was 250 ␮m thick. The sections were
separated from the block and numbered for examination.
Two experienced histological examiners (C.D. and D.R.) ex-
amined each tooth section (occlusal and approximal surfaces) in-
dependently under magnification (!4) using a binocular micro-
Caries Res 2009;43:442–448 443
Table 2. Codes and criteria used in the histological examination Table 3. Caries lesion distribution in the sample using each of the
validation systems
Code Criterion
Code Downer ERK
Downer
distal occlusal mesial distal occlusal mesial
0 No enamel demineralization or a narrow surface zone of
opacity (edge phenomenon) 0 41 20 32 41 20 32
1 8 3 7 8 3 7
1 Enamel demineralization limited to the outer 50% of the
2 22 23 38 35 41 51
enamel layer
3 19 27 20 11 12 10
2 Demineralization involving the inner 50% of the enamel, 4 22 44 15 17 31 12
up to the enamel-dentine junction
Downer [1975]; Ekstrand et al. [1997]. n = 112 for mesial and
3 Demineralization involving the outer 50% of the dentine distal surfaces and 107 for occlusal surfaces.
4 Demineralization involving the inner 50% of the dentine
ERK
0 No enamel demineralization or a narrow surface zone of
opacity (edge phenomenon) ferred to as D1/ERK1. The ERK3 threshold is deeper than the D3,
as it includes only those dentine lesions extending beyond the
1 Enamel demineralization limited to the outer 50% of the outer third. Unweighted Cohen’s kappa values were calculated at
enamel layer two cut-offs – ICDAS code 61 and ICDAS code 63 – to examine
2 Demineralization involving between 50% of the enamel intraexaminer and interexaminer repeatability.
and outer third of the dentine
3 Demineralization involving the middle third of the den-
tine Results
4 Demineralization involving the inner third of the den-
tine On gross examination, 18 occlusal (16.8%), 16 mesial
(14.3%) and 25 distal (22.3%) surfaces had frank cavita-
Downer [1975]; Ekstrand et al. [1997]. tion. No tooth was lost during sectioning, so all 112 teeth
were available. However, during the histological exami-
nation, five restorations or fissure sealants were identi-
fied in or on occlusal surfaces and therefore these five
scope (Nikon Corp., Japan). Where the examiners disagreed the surfaces were excluded from further analysis. On average
sections were re-examined and agreement reached. Table 2 pre- 10 sections (range 6–15 sections) were produced per
sents the two histological scoring systems used [Downer, 1975;
Ekstrand et al., 1997]. The criteria proposed by Downer [1975] tooth.
were used because they permit comparison with previous work. The results of the histological examination revealed 20
These included the amelodentinal junction as an important land- occlusal (18.7%), 32 mesial (28.6%) and 41 distal (36.6%)
mark and division between caries severity codes. The Ekstrand- surfaces to be sound. Table 3 presents the full breakdown
Ricketts-Kidd (ERK) histological criteria [1997] were used as these of the caries lesion distribution in the sample for both
are the criteria proposed for use with the ICDAS II criteria.
The different scores for each section were compared and the validation systems. Because codes 0 and 1 have the same
worst score for each surface taken as the principal unit for statis- meaning in both the Downer and ERK systems (see
tical analysis. above), the prevalence for these codes is identical, but for
higher codes the prevalence differs because of the differ-
Statistical Analysis ent definitions (table 2).
The data were analyzed using SAS version 9.1 (SAS Institute
Inc., USA) to provide validity and reproducibility of data. The Table 4 presents the mean and range of the diagnostic
specificity, sensitivity, positive predictive value, negative predic- parameters for approximal and occlusal surfaces, at each
tive value, diagnostic accuracy and likelihood ratio were calcu- diagnostic threshold. On all occasions, the specificity
lated using the histological findings as the ‘gold standard’. For the was higher than the sensitivity. Using the ERK criteria
analysis using the Downer histological classification these pa- for validation, the mean specificity ranged from 85.5%
rameters were calculated at the D1 (enamel and dentine) and D3
(dentine) caries thresholds [Fyffe et al., 2000]. The corresponding (approximal surfaces: D1/ERK1 threshold) to 90.0% (oc-
ERK thresholds were ERK1 and ERK3. To make it clear that D1 is clusal surfaces: D1/ERK1 threshold). The mean sensitiv-
identical for both validation systems, this threshold will be re- ity ranged from 66.4% (approximal surfaces: D1/ERK1

444 Caries Res 2009;43:442–448 Shoaib /Deery /Ricketts /Nugent

Table 4. Diagnostic parameters for occlusal (n = 107) and approximal surfaces (n = 224)

Surface Diagnostic Specificity Sensitivity PVP PVN DV Likelihood

threshold % % % % % ratio

Occlusal D1/ERK1 90.0 (90.0–90.0) 75.4 (68.6–81.6) 97.0 (96.7–97.3) 46.4 (40.0–52.9) 78.1 (72.6–83.2) 7.54 (6.9–8.2)
D3 92.8 (87.0–97.8) 63.1 (55.0–72.1) 92.6 (88.0–97.1) 66.0 (62.5–70.2) 75.9 (73.6–78.5) 13.5 (5.5–25.0)
ERK3 87.0 (78.1–93.8) 77.9 (71.4–83.7) 81.0 (72.0–88.2) 84.8 (83.3–87.7) 83.4 (80.4–85.0) 7.5 (3.8–11.4)
Approxi- D1 85.4 (82.2–89.0) 66.4 (53.0–78.1) 90.5 (90.1–90.9) 56.2 (47.8–64.5) 72.6 (47.8–64.5) 4.6 (4.4–4.8)
mal D3 94.2 (92.6–95.3) 58.3 (51.3–67.1) 83.8 (82.3–86.0) 81.9 (79.1–84.6) 81.9 (79.9–83.9) 10.2 (9.0–12.0)
ERK3 90.5 (86.8–92.5) 75.3 (68.0–78.0) 69.7 (62.9–74.0) 92.2 (91.0–93.2) 86.8 (84.8–88.4) 8.3 (5.9–9.9)

Means with ranges in parentheses. PVP = Predictive value positive; PVN = predictive value negative; DV = diagnostic accuracy.

threshold) to 77.9% (occlusal surfaces: ERK3 threshold). Table 5. Intraexaminer and interexaminer reproducibility (Co-
The lowest specificity and sensitivity for any examiner hen’s kappa) at the occlusal and approximal surfaces
were 78.1% (occlusal surfaces: ERK3 threshold) and 53.0%
(approximal surfaces: D1/ERK1 threshold), respectively. ICDAS Surface Intraexaminer Interexaminer
code cut-off
At the D3 threshold, the specificity tended to be higher
and the sensitivity lower than when using the ERK3 ≥1 occlusal 0.78 (0.74–0.84) 0.68 (0.65–0.71)
threshold. ≥3 0.76 (0.71–0.82) 0.73 (0.79–0.78)
Table 5 presents the intraexaminer and interexaminer ≥1 approximal 0.81 (0.74–0.85) 0.70 (0.61–0.76)
reproducibilities (Cohen’s kappa). The mean intraexam- ≥3 0.74 (0.66–0.87) 0.66 (0.52–0.79)
iner reproducibility ranged from 0.74 (ICDAS code 63
cut-off) to 0.81 (ICDAS code 61 cut-off) for both occlu- Means with ranges in parentheses.
sal and approximal surfaces. For the mean interexaminer
reproducibility, the kappa values ranged from 0.66 (ap-
proximal surfaces: ICDAS code 63 cut-off) to 0.73 (oc-
clusal surfaces: ICDAS code 63 cut-off). ease of use and reliability. However, in reality this is dif-
ficult to achieve and therefore it is accepted that for caries
detection and diagnosis, where the prevalence is low and
Discussion progression slow, a high specificity is required at the ex-
pense of sensitivity [Downer, 1989]. Therefore, the values
The majority of trials assessing the validity and repro- for sensitivity and specificity reported for the ICDAS II
ducibility of caries detection have focussed on the occlu- criteria in this study are in keeping with the correct rela-
sal surfaces of permanent teeth [Bader et al., 2002]. The tionship of these parameters.
present study is the first to examine the validity and re- Table 6 summarizes eight studies which examined the
producibility of the ICDAS II criteria for caries detection detection and diagnosis of caries of the occlusal surface
and diagnosis in primary teeth and to include approxi- of primary molars. As can be seen from this table, the
mal smooth surfaces. sensitivity and specificity found in this study are at least
The sample size of over 100 primary molar teeth is comparable, whether at the D1/ERK1, D3 or ERK3 thresh-
comparable to those of previous studies [Ketley and Holt, olds. Differences can in part be explained by variations
1993; Ashley, 2000; Attrill and Ashley, 2001; Lussi and in methodology, such as differences in the set-up of the
Francescut, 2003; Dunkley and Ashley, 2007]. The distri- teeth, criteria either for examination or histological vali-
bution of disease stages was also appropriate for an inves- dation, or exclusion or inclusion criteria used for sample
tigation incorporating a meticulous diagnostic system selection. For example the study by Rocha et al. [2003]
and was in line with previous work. was novel in that the examinations were conducted in
An ideal diagnostic method should offer high specific- vivo and the validation carried out after exfoliation or
ity and sensitivity, as well as other characteristics such as extraction of the teeth.

ICDAS II in Primary Teeth Caries Res 2009;43:442–448 445

Table 6. Summary of results of studies using visual ranked diagnostic criteria to detect and diagnose occlusal caries in primary molar
teeth

Study Sample of Criteria Diagnostic Diagnostic cut-off criteria Specificity Sensitivity

primary molars threshold % %

Ketley and 100 Adapted from Downer D3 Breakdown of the walls of the fissure with 100 45
Holt [1975] with addition of an break in enamel or shadow or opacity
[1993] early enamel caries visual beneath enamel <1.5 mm across fissure
code
Ashley 58 Ekstrand et al. [1997] D1 Opacity or discoloration hardly visible on 95 78
[2000] the wet surface but distinctly visible after air
dryinga
D3 Localized enamel breakdown in opaque or 100 73
discolored enamel and/or greyish
discoloration from the underlying dentineb
Attrill and 58 Ekstrand et al. [1997] D1 a 79–86 60–70
Ashley [2001]
D3 b 57–63 89–93
Lussi and 95 Excluded the first stages of D2 After 4 s of drying examiner had to decide 68 54
Francescut enamel caries that caries reached inner enamel
[2003]
D3 After 4 s of drying examiner had to decide 98 35
that caries reached dentine
Rocha et al. 30 (50 sites) Ekstrand et al. [1997] Enamel caries a 85 82
[2003]
Inner half b 100 61
enamel and
dentine caries
Bengtson 50 (87 sites) Excluded the first stages of D2 Advanced enamel caries 76 58
et al. [2005] enamel caries
D3 Dentine caries 91 31
Mendes 79 (110 sites) Ekstrand et al. [1997] D1 Thin stain visible or white opacity distinctly 87 52
et al. [2006] visible after air drying
D3 b 42 92
Dunkley and 60 Ekstrand et al. [1997] D1 a 100 61
Ashley [2007]
D3 b 76 87

a or b indicate repeat of the same criteria.

In general, as was noted by Dunkley and Ashley [2007],
those studies that used a ranked diagnostic system such
as that proposed by Ekstrand et al. [1997], which is the
basis of the ICDAS II criteria, had higher values for diag-
nostic parameters.
The results of the present study can also be compared
with those for occlusal surfaces in permanent molars
using the same or similar ranked meticulous diagnostic
systems. At the ERK3 threshold, the specificity and sen-
sitivity are lower than the 92–97% and 85–93%, respec-
tively, reported by Ekstrand et al. [1997]. At both the
D1/ERK1 and ERK3 thresholds, the sensitivity and spec-
ificity are similar to those reported for permanent mo-
lars using the ICDAS II criteria [Jablonski-Momeni et
al., 2008]. In both these studies, predetermined sites
rather than surfaces were examined. This approach is
likely to inflate the results both in terms of validity and
reproducibility. Although acceptable as a means of vali-
dating a proposed caries detection and diagnostic sys-
tem, it does not replicate the real world situation, be it
epidemiology or clinical practice, where a surface is as-
sessed or treated rather than a site. In the present study,
the most advanced lesions on a surface were scored; this
more closely mimicked the clinical or epidemiological
situation.

446 Caries Res 2009;43:442–448 Shoaib /Deery /Ricketts /Nugent

 There are no studies with which to directly compare
the results for caries detection and diagnosis on approxi-
mal surfaces. The values for specificity are similar to
those found for occlusal surfaces, with a lower value for
sensitivity at the D1 threshold (66.4% compared to 75.4%).
This is probably due to the difficulty in viewing noncav-
itated enamel lesions approximally. The sensitivity at the
ERK3 threshold (75.5%) for approximal surfaces was sim-
ilar to that for occlusal surfaces (77.9%), suggesting that
more advanced lesions can be visually identified more
easily.
Despite the attempt to mimic gingival tissues with
pink impression putty and to reproduce the anatomical
positions of the teeth, it is almost certain that access
would have been easier in this in vitro simulation than in
real life and this may have inflated the approximal sensi-
tivity figures, particularly at the D1/ERK1 threshold. This
view is supported by the results of an in vivo study using
clinical examination of the approximal surfaces of pri-
mary molars following temporary tooth separation as the
validation (specificity of 95% and sensitivity of 20–21%)
[Novaes et al., 2009]. At the cavitation threshold, the
same study reported a sensitivity and specificity of 30 and
100%, respectively. There are no in vitro studies on the
visual diagnosis of approximal caries in primary teeth to
allow direct comparison with other studies. The present
study demonstrated a much higher value for sensitivity
(66.4 and 67.7% at the D1 and D3 diagnostic thresholds)
than an in vitro study using radiographs rather than his-
tology as validation, which found sensitivity values of
19.0 and 18.0, respectively, at the two thresholds [Fyffe et
al., 2000]. These latter levels of sensitivity are low and
might reflect the use of radiographs as the validation,
which was recognized by these authors as ‘imperfect’, due
to radiographs having low sensitivity. Thus when used as
the validation, radiographs result in a decreased sensitiv-
ity and an inflated specificity. The specificity values of 91
and 98%, at D1 and D3 respectively reported in this study
[Fyffe et al., 2000], would seem to support this sugges-
tions.
All mean kappa values for reproducibility were 10.6
(table 5), which can be regarded as acceptable. Only one
individual assessment for one pair of examiners (interex-
aminer reproducibility for approximal caries) achieved a
level below this standard.
In summary, as reported for permanent teeth [Jablon-
ski-Momeni et al., 2008] with relatively short training ex-
aminers achieved results comparable to the examiner
who carried out the training and levels comparable to
other reported studies. The results of this study indicated
that the ICDAS II criteria are appropriate for use in the
primary dentition both for approximal and occlusal sur-
faces.
Acknowledgements
We would like to thank Val Wilson for her assistance with
preparation of the histological specimens. Part of this study was
undertaken at Edinburgh Dental Institute, UK, while L.S. was a
postgraduate student there; we would like to thank them for their
support.

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