DOI: 10.1111/ipd.

12148

Influence of professional experience on detection and

treatment decision of occlusal caries lesions in primary teeth

DIEGO GIROTTO BUSSANELI1, THALITA BOLDIERI1, MICHELE BAFFI DINIZ2, LUCIANA MONTI
LIMA RIVERA3, LOURDES SANTOS-PINTO1 & RITA DE CÁSSIA LOIOLA CORDEIRO1
1
Department of Pediatric Dentistry and Orthodontics, Araraquara School of Dentistry, UNESP-Univ Estadual Paulista,
Araraquara, SP, Brazil, 2Department of Pediatric Dentistry, School of Dentistry, UNICSUL – Cruzeiro do Sul University, São
Paulo, SP, Brazil, and 3Department of Pediatric Dentistry, School of Dentistry, USC – Sagrado Coracßão Univesity, Bauru, SP,
Brazil

International Journal of Paediatric Dentistry 2015; 25:
418–427
Aim. To evaluate the influence of examiner’s clin-
ical experience on detection and treatment deci-
sion of caries lesions in primary molars.
Design. Three experienced dentists (Group A) and
three undergraduate students (Group B) used the
International Caries Detection and Assessment
System (ICDAS) criteria and bitewing radiographs
(BW) to perform examinations twice in 77 pri-
mary molars that presented a sound or carious
occlusal surface. For the treatment decision (TD),
the examiners attributed scores, analyzing the
teeth in conjunction with the radiographs. The
presence and the depth of lesion were validated
histologically, and reproducibility was evaluated.
The sensitivity, specificity, accuracy, and area
under the ROC curve values were calculated for
ICDAS and BW. The associations between ICDAS,
BW, and TD were analyzed by means of contin-
gency tables.
Results. Interexaminer agreement for ICDAS, BW,
and TD were excellent for Group B and moderate
for Group A. The two groups presented similar
and satisfactory performance for caries lesion
detection using ICDAS and BW. In the treatment
decision, Group A was shown to have a less inva-
sive approach than Group B.
Conclusion. The examiner’s experience was not
determinant for the clinical and radiographic
detection of occlusal lesions in primary teeth but
influenced the treatment decision of initial
lesions.

and in vivo studies4–6 have proved that the

Introduction
The decline in the prevalence of dental caries
has motivated researchers to develop more
efficient methods for early detection of cari-
ous lesions, and consequently, contributing to
the preparation of an adequate treatment
plan. Although most frequently used, the
visual examination (VE) is based on subjec-
tive signs, such as surface color, hardness,
and texture, and presents high specificity and
low sensitivity1,2.
The International Caries Detection and Assess-
ment System (ICDAS) was developed to catego-
rize the different stages of the lesion, starting
with initial alterations in enamel through to
cavities in dentin3, contributing to increasing
sensitivity of the visual examination. In vitro
Correspondence to:
Rita de Cássia Loiola Cordeiro, Faculdade de Odontologia
de Araraquara – UNESP, Rua Humaitá, 1680, 14801-903,
Araraquara, SP, Brazil. E-mail: ritacord@foar.unesp.br
visual examination using the ICDAS criteria
presents good validity and reproducibility in
the evaluation of caries lesions in primary
teeth.
It has been suggested that professional
experience has no influence on the clinical
detection of caries lesions on the occlusal
surface7–10; however, it may contribute to
improving accuracy and reproducibility in the
radiographic examination11,12. Moreover,
experienced clinicians base their decisions on
past experiences, whereas less experienced
professionals use ‘manuals’ as guidance for
decision-making with regard to the diagnosis
and adequate treatment plan1,2,13.
The majority of studies that have evaluated
the influence of the examiner on caries lesion
detection have been conducted in permanent
teeth,8–11,14–16 and up to now, there is no
evidence of the role professional experience
may play in the treatment decision of occlusal
caries lesions in primary teeth. Starting with

418 © 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

the presupposition that the structural differ-
ences between primary and permanent teeth
may directly affect the process of evolution of
the lesion, and consequently make it difficult
for the professional to make the treatment
decision, the aim of this study was to evalu-
ate the influence of the examiner’s clinical
experience on the detection and treatment
decision of occlusal caries lesions in primary
molars.
Materials and methods
Study participants
Three faculty members from the Department
of Paediatric Dentistry (Group A), with at
least 10 years of experience in clinical prac-
tice and previous experience with ICDAS cri-
teria, and three students (Group B) in the
second year of the Dentistry Course of the
Araraquara Dental School–UNESP, Brazil,
participated in the study.
After theoretical lectures about the clinical
criteria for the detection and evaluation of
caries lesions, each student underwent online
training about the use of the ICDAS criteria
(www.icdas.org/icdas-e-learning-course). This
training, with a duration of 90 min, presents
each of the ICDAS criteria in a detailed man-
ner and offers an interactive exercise after
presentation of the theoretical content. After-
ward, practical laboratory training was con-
ducted, in which the students analyzed 15
extracted primary teeth that were not part of
the study sample, with subsequent analysis of
the results and group discussion. The average
unweighted kappa value for all examiners
was 0.81, indicating excellent interexaminer
agreement with a reference examiner. Group
A did not receive any type of training, as
these examiners had previous experience
with the use of ICDAS.
Sample
After receiving approval from the Research
Ethics Committee (Process Number 13/09), 77
recently extracted or exfoliated primary
molars were selected. These presented a sound
occlusal surface, or had signs suggesting the
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Detection and treatment of caries lesions 419
presence of caries lesion, such as white spots,
pigmentations, and cavities.
Before analyses, the teeth were cleaned
with a Robinson brush coupled to a low-
speed motor and prophylactic paste. The teeth
were individually stored in a 0.1% thymol
solution. After this, the teeth were numbered
and photographed under a stereomicroscopic
lens at 109 magnification (Olympus, SZ2-
ILST, Tokyo, Japan). An independent
researcher, who was not involved in the
examinations, selected one occlusal site per
tooth and recorded it as the ‘test site’ in pho-
tographs of the occlusal surface printed on
paper, in order to prevent selection bias and
to guide lesion location. Thus, sample selec-
tion was randomly performed.
The teeth were radiographed by the inter-
proximal technique, with the aid of a posi-
tioner, which allowed the images to be
standardized. Ultraspeed films (Kodak Insight,
22 9 35 mm, Kodak, Rochester, USA) and an
X-ray appliance (Spectro 70X, Dabi-Atlante,
Ribeirão Preto, Brazil) were used, operating at
70 kVp, 8 mA, and exposure time of 0.3 s. The
radiographs were processed in an automatic
processer (Dent-X 9000, Dent-X, Emsford,
USA) and mounted on posters identified for
later analysis.
Examination of the teeth
The examiners clinically evaluated each site
selected, independently. For this purpose, the
teeth were illuminated with a reflector, and
initially analyzed wet, then dried with a triple
syringe. Scores were attributed in accordance
with the ICDAS criteria17 as follows: (0) sound;
(1) first visual change in enamel; (2) distinct
visual change in enamel; (3) localized enamel
breakdown, without visible dentin or shad-
ows; (4) underlying dentin shadow; (5) distinct
cavity with visible dentin; and (6) extensive
cavity within visible dentin.
After this, the bitewing radiographs (BW)
were analyzed by the same examiners, with
the aid of a negatoscope (Imatec R€ ontgen-
technik, Switzerland) and a magnifying glass
(VRX-Fabinject, Taubate, São Paulo, Brazil)
and were classified according to Rodrigues
et al.18 into as follows: (0) absence of radio-
420 D. G. Bussaneli et al.
lucency; (1) radiolucency in enamel; (2)
radiolucency in external half of the dentin;
and (3) radiolucency in internal half on the
dentin.
For treatment decision evaluations (TD),
the examiners attributed scores according to
Diniz et al.19 as follows: (0) no treatment;
(1) sealant application; (2) microabrasion and
sealant application; (3) invasive sealant with
spherical bur; (4a) restoration with resin
composite; and (4b) restoration with silver
amalgam.
All examinations were performed indepen-
dently on the same day. The teeth were ran-
domly numbered and reordered before each
evaluation to prevent bias. First, the examin-
ers performed the visual inspection and after
this, the radiographic examination. The
examiners were blinded during the examina-
tion of the radiographs, and they did not
have access to the test tooth. Then, they
made decisions about the treatment score
based on visual inspection associated with the
radiographic examination. For this procedure,
the ICDAS and the radiographic examination
(BW) scores for each tooth were available to
the examiner when making the treatment
decisions.
The examinations (ICDAS, BW, and TD)
were performed twice, with a 1-week interval,
by each examiner. The repeated measure-
ments were conducted in all teeth (n = 77).
Histological validation
For histological validation, the teeth were
longitudinally sectioned in the center of the
selected site, using a diamond disk with cool-
ing water, in a precision cutting machine
(ISOMET 1000, Buehler Ltd., Lake Bluff, IL,
USA), resulting in two sections corresponding
to the test site. The section that presented the
most severe lesion was analyzed under a ste-
reoscopic magnifying glass (SZX7, Olympus
Corporation, Tokyo, Japan) at 109 magnifica-
tion. The following criteria proposed by
Ekstrand et al.20 were used: (0) absence of
caries lesion; (1) caries lesion limited to the
outer half of enamel; (2) caries lesion involv-
ing the inner half of the enamel or external
third of dentin; (3) lesion limited to the
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
middle third of dentin; and (4) lesion involv-
ing the internal third of the dentin. Two
experienced examiners who had participated
in other evaluations in previous researches
examined each section of the teeth indepen-
dently. In cases of disagreement, a new
examination was performed and consensus
was reached after discussion.
Statistical analysis
The intra- and interexaminer reproducibilities
of ICDAS, BW, and TD were calculated, using
the unweighted kappa coefficient and classi-
fied as follows: >0.75 – good/excellent; 0.5 to
0.75 – moderate/good; 0.25 to 0.5 – weak/
moderate; and <0.25 – absence of correlation.
The sensitivity, specificity, accuracy, and
area under the ROC curve (Az) values were
calculated for ICDAS and BW, at two diag-
nostic thresholds. D1 – corresponding to all
lesions (ICDAS scores 0 = sound and 1, 2, 3,
4, 5, and 6 = carious; and BW scores 0 =
sound and 1, 2, and 3 = carious); and D3 –
corresponding to lesions in dentin (ICDAS
scores 0, 1, 2, and 3 = sound and 4, 5, and
6 = carious; and BW scores 0 and 1 = sound
and 2 and 3 = carious). The McNemar test
was used to verify the significance of the
results between Groups A and B. The level of
significance adopted was 5%.
The associations between ICDAS, BW, and
TD and between ICDAS codes and histological
scores were verified by means of contingency
tables.
Results
Of the 77 teeth in the sample, 28 (36.3%)
were shown to be sound (score 0), 25
(32.4%) had caries lesions limited to the
external half of enamel (score 1), 13 (16.8%)
had caries lesions up to the internal half of
the enamel, or external third of dentin (score
2), 8 (10.3%) had lesions in the middle third
of dentin (score 3), and 3 (3.8%) had caries
lesions in the internal third of dentin (score
4).
Table 1 shows the unweighted kappa coeffi-
cient values for intra- and interexaminer
reproducibility for ICDAS, BW, and TD.
 Detection and treatment of caries lesions 421

Table 1. Unweighted kappa coefficient for intra- and interexaminer reproducibility for International Caries Detection and
Assessment System (ICDAS), radiographic examination [bitewing radiographs (BW)], and treatment decision (TD).

Unweighted kappa coefficient

Examiners Reproducibility ICDAS BW TD

Group A Intraexaminer 0.75 0.76 0.78

Interexaminer 0.58 0.50 0.52
Group B Intraexaminer 0.80 0.76 0.74
Interexaminer 0.77 0.73 0.71

Intraexaminer agreement ranged between Tables 5 and 6 show the distribution of

0.74 and 0.80 for both groups. In interexam- treatment decision scores for Groups A and B,
iner agreement, higher values were observed respectively. Group B opted to perform some
for Group B (0.71–0.77), whereas Group A type of treatment in 70% of the cases with
presented lower values (0.50–0.58). initial lesions (ICDAS 1 and 2) and without
Table 2 shows the distribution of absolute the presence of radiolucency in BW (score 0),
frequencies for ICDAS scores and the corre- whereas Group A suggested treatment in
sponding histological score for all examinations 24% of the cases that were in the same situa-
of both groups, totalizing 924 assessments. tion. Even when some radiographic alteration
It could be observed an overestimation of the was observed (BW scores 1, 2, and 3) in ini-
ICDAS codes when compared with the histo- tial lesions, the results of Group A remained
logical score for the absence of caries lesion, more conservative, opting for interventions in
and caries lesion limited to the outer half of 26% of the cases, against 98.8% in Group B.
enamel; however, there was as underestima- For moderate lesions (ICDAS 3 and 4), in no
tion of the ICDAS codes when correlated case did Group B fail to propose some inter-
with the histological score for caries lesion vention. In the presence of extensive lesions
involving the inner half of the enamel or (ICDAS 5 and 6), the treatment chosen by
external third of dentin and lesion limited to both groups was resin composite when the
the middle third of dentin. radiographic image of the lesion extended up
The sensitivity, specificity, accuracy, and to the external half of dentin (Score 2), and
area under the ROC curve values for ICDAS amalgam when it was in the internal half of
and BW are shown in Tables 3 and 4, respec- dentin (Score 3).
tively. The visual ICDAS criterion showed
higher sensitivity values in D1 than in D3,
with statistically significant differences Table 2. Distribution of the absolute frequencies for
between the two groups of examiners International Caries Detection and Assessment System
(P < 0.05). The specificity values in D3 were (ICDAS) scores and the corresponding histological score for
all examinations of both groups.
statistically similar between the two groups
(P > 0.05) and higher than in D1, which pre- Histological scores
sented statistically significant difference
ICDAS scores 0 1 2 3 4 Total
(P < 0.05). The BW radiographic examination
showed moderate sensitivity in D3 and high 0 122 50 3 4 1 180
specificity, without statistically significant dif- 1 78 66 30 21 1 196
ference between the groups (P > 0.05). In D1, 2 92 144 31 43 2 312
3 27 29 19 28 0 103
Group B presented a higher sensitivity and 4 5 15 1 22 10 53
lower specificity value (P < 0.05). The accu- 5 0 7 0 1 21 29
racy and area under the ROC curve (Az) val- 6 12 1 0 1 37 51
Total 336 312 84 120 72 924
ues were statistically similar (P > 0.05) for the
two methods of detection in the two diagnos- Italic numbers indicate the ICDAS codes and the corresponding
tic thresholds. histological criteria according to Ekstrand et al.26

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
422 D. G. Bussaneli et al.

Table 3. Sensitivity, specificity, accuracy, and Az for International Caries Detection and Assessment System visual criteria at
D1 and D3 thresholds.

Sensitivity Specificity Accuracy Az

Examiners D1 D3 D1 D3 D1 D3 D1 D3

Group A 0.87a 0.42a 0.45a 0.95a 0.72a 0.84a 0.66a 0.69a

Group B 0.93b 0.54b 0.28b 0.93a 0.69a 0.85a 0.60a 0.74a

Different letters in the same column indicate statistically significant difference (McNemar test, P < 0.05 for sensitivity, specificity and
accuracy; nonparametric test, P < 0.05 for Az).

Table 4. Sensitivity, specificity, accuracy, and Az for radiographic examination (bitewing radiographs) at D1 and D3
thresholds.

Sensitivity Specificity Accuracy Az

Examiners D1 D3 D1 D3 D1 D3 D1 D3

Group A 0.57a 0.57a 0.70a 0.88a 0.61a 0.82a 0.63a 0.73a

Group B 0.71b 0.60a 0.41b 0.84a 0.61a 0.79a 0.55a 0.72a

Different letters in the same column indicate statistically significant difference (McNemar test, P < 0.05 for sensitivity, specificity and
accuracy; nonparametric test, P < 0.05 for Az).

The reproducibility results for ICDAS

Discussion
The visual ICDAS criteria system was used in
this study because it is a caries lesion codifica-
tion tool that allows recording and standardi-
zation of the data collected. The dental
students (Group B) who participated in this
study did not have any previous clinical expe-
rience and neither with the ICDAS codes.
They received extensive training in the use
of these criteria, with lectures, interactive
e-learning tools, and laboratory training. The
students were in the second year of the den-
tistry program, and at the time of the investi-
gation, the operative dentistry course was
being conducted with lectures only, and no
care of patients. Furthermore, it should be
emphasized that the pediatric dentistry course
is only conducted in the fifth year of the pro-
gram. Thus, the students had no previous
contact with children or with dental caries in
primary teeth. Diniz et al.21 proved the effec-
tiveness of this training when they verified
the influence of this tool on the detection of
occlusal caries lesions in permanent teeth, by
a group of students, and observed a signifi-
cant increase in the specificity and reproduc-
ibility values, improving the performance of
students’ capacity to detect caries lesions.
showed good intraexaminer agreement for
both groups, good interexaminer agreement
for Group B, and moderate interexaminer
agreement for Group A. The literature pre-
sents discrepant results in the reproducibility
values for the use of the ICDAS criteria in the
visual examination. Diniz et al.19 found good
results in intra- and interexaminer reproduc-
ibility for in vitro occlusal caries lesion detec-
tion in permanent teeth. Rodrigues et al.18
found moderate agreement values in the in
vitro evaluation of permanent teeth, per-
formed by examiners with vast clinical expe-
rience and previous knowledge. Jablonski-
Momeni et al.22, in an in vitro study, found
results ranging from 0.32 to 0.61 for interex-
aminer reproducibility and from 0.54 to 0.65
for intraexaminer reproducibility in the exam-
ination performed by two doctoral students
with previous training. In the present study,
the examiners evaluated primary teeth that
were mostly sound, stained, or presented
early lesions. This fact could explain and
strengthen the high reproducibility values
obtained for the ICDAS criteria for both
groups of examiners, showing that the criteria
seem to be promising for careful description
of the characteristics of the tooth surface.

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Detection and treatment of caries lesions 423

Table 5. Distribution of the absolute frequencies for the
treatment decision scores within the International Caries
Detection and Assessment System (ICDAS) and bitewing
radiographs (BW), considering all the examinations for
Group A.
Table 6. Distribution of the absolute frequencies for the
treatment decision scores within the International Caries
Detection and Assessment System (ICDAS) and bitewing
radiographs (BW), considering all the examinations for
Group B.

Treatment decision Treatment decision

ICDAS BW 0 1 2 3 4a 4b ICDAS BW 0 1 2 3 4a 4b

0 0 105 0 0 50 1
1 8 1 13 2
2 2
3 3
1 0 42 1 1 1 1 0 18 35
1 48 2 1 1 1 31 6
2 1 2 2
3 3 3 3
2 0 58 3 17 9 2 0 9 22 6
1 33 4 6 2 1 1 56 19 15 1 2
2 3 3 12 2 1 19 5
3 3
3 0 4 1 2 3 0 3
1 3 2 9 2 1 7 11 10 3
2 4 8 9 2 12 6 2
3 2 3 3
4 0 4 0 3 3
1 1 1 7 2
2 10 2 8 3
3 4 2 3 1 6 3
5 0 5 0 2 4
1 1
2 5 2 4
3 3 8 3 4 2
6 0 6 0
1 1
2 2 5
3 24 3 10 16

Zandona et al.8, when comparing three
groups of examiners with different levels of
clinical experience (faculty, undergraduate,
and graduate students), concluded that this
previous experience did not contribute to
learning about use of the ICDAS criteria and
attributed the good performance of the stu-
dents to the clarity of the criteria in question.
Similar to our results, Souza-Zaroni et al.9
obtained higher reproducibility values for stu-
dents than for professionals in the visual
examination of the occlusal surface, using
clinical criteria in accordance with lesion
depth. The authors attributed the low values
to the different levels of experience and
knowledge acquired and pointed out that as
they were subjective examinations, they may
be influenced by various factors. In view of
our findings, we may suggest that the better
interexaminer agreement values of the stu-
dents were due to their similar education and
the ICDAS training session. Eight senior den-
tal students from our research group had pre-
viously participated in another study using
the ICDAS criteria; however, in permanent
teeth, similar reproducibility values to those
of the present study were found after they
had gone through the ICDAS e-learning pro-
gram21. Although the use of visual systems
appears to be logical, the moderate interex-
aminer reproducibility value for Group A
could be explained by the differences in the
acquisition of knowledge among the examin-
ers. We agree with Gimenez et al.16 when
they considered that more experienced pro-
fessionals are accustomed to using their past
clinical experience to make diagnoses and
may therefore be more resistant to learning
descriptive methods. The authors observed
that this experience did not interfere signifi-

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
424 D. G. Bussaneli et al.
cantly in the examiners’ performance in the
use of the ICDAS criteria.
The intraexaminer reproducibility values for
BW examinations for Groups A and B were
similar, whereas the interexaminer values
were discrepant, being 0.73 for Group B and
0.50 for Group A. Diniz et al.23 found low
intraexaminer reproducibility values in exam-
inations performed by students and profes-
sionals, pointing out that five factors may be
responsible for the difference in results: age,
training, skill, preferences, and experience,
whereas, Firestone et al.14 suggested that indi-
vidual skill associated with adequate didactic
instruction would equate the performance of
students to the capacity of a clinician experi-
enced in radiographic diagnosis.
In this study, the intraexaminer agreement
values for TD were good for both groups
(0.78 and 0.74), however, the interexaminer
agreement values were moderate for Group A
(0.52) and good for Group B (0.71). We
believe that this disagreement on TD between
the professionals may be justified by the fact
that during the course of their profession,
they acquired their own clinical treatment
concepts based on their past experience. This
did not occur with Group B, made up of stu-
dents who had a similar academic education
and no clinical experience.
International Caries Detection and Assess-
ment System presented statistically different
sensitivity values between the groups, being
higher for Group B in both D1 and D3. Group
B presented a lower specificity value in D1.
We believe that this result may be justified by
the sample used in this study, which was
made up of senile primary teeth with natural
pigmentations in the region of fossae and fis-
sures. This may have contributed to all the
pigmentations being classified as caries lesions,
and influencing the specificity values in D1.
Our results are in agreement with those of
Diniz et al.21 when they observed that the stu-
dents had difficulty in distinguishing between
enamel defects, areas of fluorosis, or pigmen-
tations of carious lesions in permanent teeth,
presenting sensitivity values of 0.36. Previous
studies11,16 have pointed out that during diag-
nosis, students are more inclined to classify
any alteration in enamel as caries.
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
In the D3 threshold, higher specificity val-
ues were observed for ICDAS without statisti-
cal differences between the groups, a fact
justified by the high prevalence of sound
teeth, or those with caries lesions in the outer
half of enamel (70%). Bengtson et al.7 found
different results from ours, with lower speci-
ficity values for students when compared
with specialists, and attributed this to experi-
enced dentists having greater capability of
clinical discernment. Souza-Zaroni et al.9 also
found results that diverged from ours, with
sensitivity values of 0.52 for students and
0.61 for professionals, and specificity values
of 0.93 for students and 0.69 for profession-
als, suggesting that experienced examiners
made more precise diagnoses with regard to
the presence of lesions. As far as the radio-
graphic examination was concerned, this
showed higher sensitivity values for Group B
and higher specificity values for Group A in
D1. The high specificity values found in D3
are in agreement with the findings of previ-
ous studies11,15,23.
In this investigation, the sample distribu-
tion was not homogeneous, with a low
prevalence of moderate and advanced caries
lesions in dentin, which might have influ-
enced the results of the ICDAS and BW
performance in both groups of examiners,
especially in terms of sensitivity at the D3
threshold. Thus, it is impossible to deter-
mine the real impact of these examinations
on advanced dentin lesions on the occlusal
surfaces of primary molars. Cross-tabulation
indicated that several teeth classified as hav-
ing a lesion limited to the middle third of
dentin in the histological validation were
wrongly classified as ICDAS codes 0, 1, and
2, which also might have influenced the
performance results.
Our results pointed out that professional
experience did not influence the visual and
radiographic capacity for detecting occlusal
caries lesions in primary teeth, as the accu-
racy and area under the ROC curve (Az)
values showed no statistically significant dif-
ference between the groups (P > 0.05), in
both D1 and D3. The lack of students’ experi-
ence was more relevant for questions related
to the application of clinical knowledge at the

time of proposing an adequate treatment,
than in the diagnostic capacity itself. That is,
students were capable of correctly detecting
the caries lesions; however, they showed
doubts at the time of proposing treatment.
The treatment decision must be based on
the clinical and radiographic findings and on
pre-acquired knowledge about operative tech-
niques and restorative materials. In our study,
in general, the most frequent option observed
in Group A was to follow-up the evolution of
the lesion, without immediate intervention
(66% against 18% of Group B), whereas for
Group B, the most frequent option was the
indication of sealant (38% of cases). These
results are in disagreement with Diniz et al.19
who observed that when the ICDAS exami-
nation presented scores 1 and 2, without
radiographic signs, the most frequent TD
among the professionals was sealing with or
without previous cavity preparation (invasive
sealant or microabrasion). We believe that
this disagreement with the above-mentioned
authors is due to the fact that we used exfoli-
ated primary teeth, and therefore, considered
senile, in which the pigmentations observed
were not interpreted by the professionals of
Group A as lesions that needed treatment.
The above-mentioned authors used perma-
nent teeth, in which the pigmentations
observed could suggest the need for mini-
mally invasive treatment.
The results of this investigation also led us
to believe that the manner in which the pro-
fessionals with different levels of experience
reached the diagnosis may have had an influ-
ence on the TD, whereas clinicians with little
experience use hypothetic-deductive reason-
ing and experienced clinicians use cognitive
pathways, based on their previous experi-
ence13,16,24. Thus, according to the previously
cited authors, clinicians who are not experi-
enced explore the history and physical find-
ings in a logical manner and reunite the
information obtained to establish the diagno-
sis, whereas, experienced clinicians make
observations and interpretations in an intui-
tive manner as soon as they come into con-
tact with the patient, using visual pathways
and verbal and nonverbal communication
in this process. In addition to this, in our
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Detection and treatment of caries lesions 425
methodology, the treatment decision scores
do not in fact offer options for a noninvasive
approach, such as for example, fluoridated
varnish application. These criteria were based
on the study of Diniz et al.19, who found sim-
ilar results in permanent teeth.
Considering initial lesions (ICDAS scores 1
and 2) without the presence of radiographic
signs, Group B proposed some type of inter-
vention in approximately 70% of the cases,
whereas Group A opted for treating only 24%
of the surfaces that presented these condi-
tions. When the presence of some radio-
graphic sign associated with these initial
criteria was considered, the difference in con-
duct adopted by the groups became even
more accentuated, with Group A opting for
some type of intervention in 26% of the cases
and Group B in 98% of the cases. This allows
us to infer that the radiographic examination
was determinant at the time when the stu-
dents had to establish a treatment option,
whereas in Group A, the professionals rather
based the option on the clinical characteristics
of the lesion. Once again, this finding may
perhaps be justified by the students’ limited
knowledge as regards dental caries treatment,
as the restorative dentistry concepts have not
yet been transmitted to them. For this reason,
students may consider that any sign of caries
lesion must be restored, assuming that treat-
ment is synonymous with restoration25.
Generally speaking, this investigation
showed that experienced clinicians adopt dif-
ferent modes of conduct for the treatment of
caries lesions; however, this professional
experience was not determinant for the
detection of caries using the ICDAS and
radiographic criteria. Moreover, the profes-
sionals opted for more conservative treatment
than the students for the treatment of occlu-
sal caries in primary teeth.
Nowadays, students and professionals must
understand that caries lesion is the result of a
complex process and that initial lesions in
enamel may be paralyzed using nonoperative
therapies, by means of tooth remineralization
with fluoridated products, control of diet, and
biofilm removal, setting aside the old para-
digm that every caries lesion must be restored.
Finally, based on the findings, we may affirm
426 D. G. Bussaneli et al.
that the examiners’ experience was not deter-
minant for the clinical and radiographic detec-
tion of occlusal lesions in primary teeth, but it
did interfere in the process of treatment plan-
ning of initial lesions, in which the students
were more inclined to perform interventions
in this type of lesion.
Why this paper is important to paediatric dentists
• The professional experience does not directly influ-
ence the capacity of visual and radiographic detection
of caries lesions in primary teeth.
• Dentists with little experience tend to perform more
invasive treatments in primary teeth, or in some cases
even intervene in teeth that do not need any treat-
ment.
• Because, it warns less experienced clinicians to con-
sider opting for more conservative treatments in initial
lesions in primary teeth.
Conflict of interest
The authors declare no conflict of interest.
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© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd