Reliability and validity of ICDAS II coding for occlusal caries using magnification: an in-vitro study


  • Sathyanarayanan R. Conservative Dentistry and Endodontics, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Puducherry, India
  • Carounanidy Usha Conservative Dentistry and Endodontics, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Puducherry, India
  • Sudhagar R. Conservative Dentistry and Endodontics, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Puducherry, India



ICDAS–II coding, Occlusal caries, Visual examination, Histological examination


Background: Pit and fissure caries presents diagnostic challenges due to its anatomical complexity and fluoride exposure. ICDAS II is a coding system for caries detection using clinical visual inspection. It identifies carious lesions by the change in colour, texture and surface integrity. Magnification might facilitate better detection of the lesions by enhancing the visual acuity. Thus, the objective of this study is to compare the reliability and validity of ICDAS II in detection of occlusal caries, with and without magnification, by using histological standard.

Methods: This single blinded, randomized study included 334 unrestored extracted human premolars and molars. Two examiners independently scored pit and fissure caries status using ICDAS II criteria without magnification and later under 6 x magnification using surgical microscope. The samples were sectioned and lesions were scored using the ERK histological criteria, under Stereo microscope. The scores of the examiners were correlated with the histological scoring. Kappa statistics and Spearman correlation coefficients were performed. Optimal sensitivity, specificity of visual and enhanced visual examination was calculated by Receiver Operating Characteristic Curve (ROC). Likelihood ratios (LR) were also calculated.

Results: The kappa values for Inter examiner reproducibility of visual and enhanced visual examination under microscope were 0.638-0.694 and for histological examination it was 0.979. Intra examiner reproducibility for visual and enhanced visual examination was 0.665 – 0.594. There was a strong relationship between visual, enhanced visual and histological examinations. Spearman’s correlation coefficient of ICDAS-II visual and enhanced visual examination for each examiner, to ERK histological scores was 0.869-0.848. The sensitivity and LR+ for visual and enhanced visual examination was decreased as the ICDAS score was increased and specificity and LR- increased with increased ICDAS score.

Conclusions: Reliability and validity of ICDAS scoring in detecting occlusal caries under magnification did not differ from clinical visual inspection. 


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Longbottom CL, Huysmans MC, Pitts NB, Fontana M. Glossary of key terms. Monogr Oral Sci. 2009;21:209-16.

Kidd EA, Fejerskov O. The control of disease progression: Non-operative treatment. In: Fejerskov O, Kidd E, Nyvad B, Baelum V, editors. Dental caries: The disease and its clinical management. 2nd ed. San Francisco, US: Blackwell Munksgaard Ltd; 2008: 252–255.

Neuhaus KW, Ellwood R, Lussi A, Pitts NB. Traditional lesion detection aids. Monogr Oral Sci. 2009;21:42-51.

Neuhaus KW, Longbottom C, Ellwood R, Lussi A. Novel lesion detection aids. Monogr Oral Sci. 2009;21:52-62.

Pitts NB, Stamm JW. International Consensus Workshop on Caries Clinical Trials (ICW-CCT)--final consensus statements: agreeing where the evidence leads. J Dent Res. 2004;83:125-8.

Ismail A, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, Pitts NB. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007;35(3):170-8.

Ismail A. Rationale and Evidence for the International Caries Detection and Assessment System. ICDAS Coordination Committee; 2005: 1–67.

Jablonski-Momeni A, Stachniss V, Ricketts DN, Heinzel-Gutenbrunner M, Pieper K. Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro. Caries Res. 2008;42(2):79-87.

Jablonski-Momeni A, Ricketts DN, Heinzel-Gutenbrunner M, Stoll R, Stachniss V, Pieper K. Impact of Scoring Single or Multiple Occlusal Lesions on Estimates of Diagnostic Accuracy of the Visual ICDAS-II System. Int J Dent. 2009;798283:1-7.

Jablonski-Momeni A, Ricketts DN, Weber K, Ziomek O, Heinzel-Gutenbrunner M, Schipper HM, Stoll R, Pieper K. Effect of different time intervals between examinations on the reproducibility of ICDAS-II for occlusal caries. Caries Res. 2010;44(3):267-71.

Trevisan TC, Andrade MC De, Presoto CD, De OB, Júnior O, Andrade MF, et al. Hidden caries: A critical review. Sci J Dentistry. 2015;2:33–6.

Christensen GJ. Magnification in dentistry. Useful tool or another gimmick? J Am Dent Assoc. 2003;134(12):1647-50.

Friedman M, Mora AF, Schmidt R. Microscope-assisted precision dentistry. Compend Contin Educ Dent. 1999;20(8):723-8.

Forgie AH, Pine CM, Pitts NB. The use of magnification in a preventive approach to caries detection. Quintessence Int. 2002;33(1):13-6.

Zafersoy-Akarslan Z, Erten H, Uzun O, Semiz M. Reproducibility and agreement of clinical diagnosis of occlusal caries using unaided visual examination and operating microscope. J Can Dent Assoc. 2009;75(6):455.

Haak R, Wicht MJ, Hellmich M, Gossmann A, Noack MJ. The validity of proximal caries detection using magnifying visual aids. Caries Res. 2002;36(4):249-55.

Peker I, Toraman Alkurt M, Bala O, Altunkaynak B. The efficiency of operating microscope compared with unaided visual examination, conventional and digital intraoral radiography for proximal caries detection. Int J Dent. 2009;9:1-6.

Sisodia N, Manjunath MK. Impact of Low Level Magnification on Incipient Occlusal Caries Diagnosis and Treatment Decision Making. J Clin Diagn Res. 2014;8(8):32-5.

Mitropoulos P, Rahiotis C, Kakaboura A, Vougiouklakis G. The Impact of Magnification on Occlusal Caries Diagnosis with Implementation of the ICDAS II Criteria. Caries Res. 2012;46:82–6.

Ari T, Ari N. The Performance of ICDAS-II Using Low Powered Magnification with Light Emitting Diode Headlight and Alternating Current Impedance Spectroscopy Device for Detection of Occlusal Caries on Primary Molars. ISRN Dent. 2013;2013:276070.

Jablonski-Momeni A, Stucke J, Steinberg T, Heinzel-Gutenbrunner M. Use of ICDAS-II, Fluorescence-Based Methods, and Radiography in Detection and Treatment Decision of Occlusal Caries Lesions: An In Vitro Study. Int J Dent. 2012:371595;1-8.

Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility and accuracy of three methods for assessment of demineralization depth on the occlusal surface: an in vitro examination. Caries Res. 1997;31:224–31.

Viera AJ, Garrett JM. Understanding Inter-observer Agreement: The Kappa Statistic. Fam Med. 2005;37(5):360-3.

Rodrigues JA, Hug I, Diniz MB, Lussi A. Performance of fluorescence methods, radiographic examination and ICDAS II on occlusal surfaces in vitro. Caries Res. 2008;42(4):297-304.

Le YL, Verdonschot EH. Performance of diagnostic systems in occlusal caries detection compared. Comm Dent and Oral Epidemiol. 1994;22:187–91.

Diniz MB, Rodrigues JA, Hug I, Cordeiro Rde C, Lussi A. Reproducibility and accuracy of the ICDAS-II for occlusal caries detection. Community Dent Oral Epidemiol. 2009;37(5):399-404.

Gimenez T, Bittar DG, Piovesan C, Guglielmi CA, Fujimoto KY, Matos R, et al. Influence of examiner experience on clinical performance of visual inspection in detecting and assessing the activity status of caries lesions. Oper Dent. 2013;38(6):583-90.

Bussaneli DG, Boldieri T, Diniz MB, Rivera LM, Santos-Pinto L, Cordeiro Rde C. Influence of professional experience on detection and treatment decision of occlusal caries lesions in primary teeth. Int J Paediatr Dent. 2015;25(6):418-27.

Jallad M, Zero D, Eckert G, Zandona AF. In vitro detection of occlusal caries on permanent teeth by a visual, light-induced fluorescence and photothermal radiometry and modulated luminescence methods. Caries Res. 2015;49(5):523-30.

Carounanidy U, Sathyanarayanan R. Dental caries: A complete changeover (Part II)- Changeover in the diagnosis and prognosis. J Conserv Dent. 2009;12:87-100.






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