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Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 117-121

Diagnostic performance of the visual caries classification of International Caries Detection and Assessment System II versus conventional radiography for the detection of occlusal carious lesions in primary molars

Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Submission03-Feb-2019
Date of Acceptance26-Jun-2019
Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Sreekanth Kumar Mallineni
Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_11_19

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Objective: The aim of the present study was to evaluate the accuracy in the diagnosis of the occlusal caries lesion using the International Caries Detection and Assessment System II (ICDAS II) and conventional bitewing radiographs in primary molars. Materials and Methods: A total of 35 children was selected randomly and recruited for visual ICDAS II and conventional bitewing radiographic examination by two independent trained examiners. Two hundred and fifty-four teeth were examined at D1 (enamel caries lesions) and D3 (dentine caries lesions) thresholds. Results: Sensitivity and specificity at D1 for ICDAS II was 100%, whereas it was 2.97% and 100%, respectively, for bitewing radiographs. At D3 threshold, sensitivity and specificity of ICDAS II was 94.55% and 96.45%, whereas it was 60.0% and 98.99% respectively for bitewing radiographs. Conclusion: ICDAS II is better than conventional bitewing radiographs in detecting carious lesions that confined to enamel, and both are equally effective in the detection of dentinal carious lesions.

Keywords: Bitewing radiographs, International Caries Detection and Assessment System II, occlusal caries, sensitivity, specificity

How to cite this article:
Bhumireddy JR, Nirmala S V, Mallineni SK, Nuvvula S. Diagnostic performance of the visual caries classification of International Caries Detection and Assessment System II versus conventional radiography for the detection of occlusal carious lesions in primary molars. SRM J Res Dent Sci 2019;10:117-21

How to cite this URL:
Bhumireddy JR, Nirmala S V, Mallineni SK, Nuvvula S. Diagnostic performance of the visual caries classification of International Caries Detection and Assessment System II versus conventional radiography for the detection of occlusal carious lesions in primary molars. SRM J Res Dent Sci [serial online] 2019 [cited 2022 Oct 6];10:117-21. Available from:

  Introduction Top

Dental caries is a microbial disease process, and the clinician may always face a challenge during preliminary diagnosis of this disease.[1] Early diagnosis of developing carious lesion is very important, and clinical diagnosis of occlusal carious lesion is very much thought-provoking due to the intricate morphology of pits and fissures and presence of staining.[2] Early detection of an incipient and non-cavitated carious lesions is critical for performing preventive treatments.[2],[3] Visual examination is more resourceful for the diagnosis of cavitated rather than non-cavitated and incipient carious lesions.[1],[2],[3] However both visual and radiographic examinations are conventionally performed to detect the carious lesions.

More often, a dentist uses visuotactile and radiographic methods for caries detection in regular clinical practice. Among visuotactile methods, conventional decayed, missing, and filled teeth (dmft)/decayed, missing, and filled surface (dmfs) indices are used to identify carious lesions, and the main limitation of dmft/dmfs index is detection of caries only after obvious cavitations.[3],[4] In recent times, a new paradigm International Caries Detection and Assessment System II (ICDAS II) came into force, presenting promising results in the early detection of caries and its activity.[1],[2],[3] ICDAS was initially introduced with caries detection codes which were extensively reviewed with the addition of caries activity at ICDAS II WORKSHOP-2005.[5] Radiographs are commonly employed for caries detection.[6] Other methods which are useful in early caries detection do not fit into routine clinical practice, since they are expensive. Nevertheless, a great deal of research is required to support commonly used caries detection methods.

The existing literature related to the field of radiographic caries diagnosis was carried out on permanent teeth by various methods; nonetheless, there are few caries detection studies on primary dentition.[2] Dental caries in the primary teeth forms a potential risk to their successors and arch integrity in the permanent dentition.[4] A statement of fact on oral health by the World Health Organization states that 60%–90% of schoolchildren are affected by dental caries leading to pain and discomfort.[7] There is an immediate need for further research in the field of caries diagnosis on primary dentition because they have less mineral content, thickness of enamel and dentin that poses risk of rapid caries progression, and early involvement of the pulp.[8] Occlusal caries detection and determination of carious lesion extension is crucial for appropriate management of dental caries. The change in caries pattern with the use of fluorides has presented challenges in diagnosing the extension of lesion.[9] Early detection of carious lesion and its extension can guide dental graduate students and practitioners to plan for early prevention, appropriate management, and interception of disease process. Therefore, the aim of the present study was to determine the clinical performance of ICDAS II in the detection of occlusal caries in primary teeth compared to conventional bitewing radiography.

  Materials and Methods Top

This descriptive cross-sectional diagnostic study was conducted on children referred to the Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital. Informed consent was obtained from all patients before the study. The proposal of this study was approved by the Ethics Committee of the institute. Clinical examination of each tooth was performed under adequate lighting after cleaning the tooth surfaces by two examiners calibrated in a pilot study. The samples used in the pilot study were not included in the main study. The examination is carried out using a plain mouth mirror, round end probe (CPITN probe) under good illumination. Prior to the proceeding of the visual examination, examiner 1 has attended an e-learning program (audio-visual aid) at and then was trained according to training recommendations of ICDAS committee.[10] After achieving a consistent reproducibility (verified by a senior examiner 2 who was previously trained in ICDAS II), examiner 1 has carried out the study. Children of age 5–10 years, who attended the department of pedodontics and preventive dentistry and community-based school dental health program, were randomly selected for the study. Children with full set of primary or mixed dentition, children with increased caries risk, and children requiring diagnostic radiographs for primary molars were recruited in the study. Children of age <5 years; children with full set of permanent dentition, compromised systemic health, and uncooperative behavior; those with special health-care needs, dental emergencies, and developmental anomalies of teeth; and children of parents who did not give consent were excluded from the study. Informed consent and assent from the parents and the children, respectively, were obtained prior to the study. Approval of this study was obtained from the Institutional Ethics Committee of the institution. Occlusal surfaces of the maxillary and mandibular primary molars were examined after a thorough prophylaxis was carried out and the area to be examined was dried for 5 s.[10],[11] This was followed by a recording of the scores based on ICDAS II [Table 1]. Children for radiographic examination were selected based on the guidelines of the American Dental Association.[12] Conventional bitewing film radiographs were obtained with bitewing instrument. Both the child and the operator were covered with lead apron and thyroid collar during the radiographic process. Radiographic X-ray machine Satelec X-Mind X-Ray System (manufactured by Satelec India Pvt. Ltd, India) with beam-limiting device of 31 cm long and 6 cm diameter was used. Exposure recommendations of tube voltage 70 kVp, current 8 mA, and exposure time of 0.5 s were used to obtain film radiographs (Kodak E-speed film, size 0/size 1 according to the need). The obtained radiographic films were processed in automatic processing unit (Dental X-ray Film Processor-XP 05, Sunlight Dental, Guangzhou, Guangdong, China). Examination of the radiographs was done using standard illuminated radiographic viewing box in semi-dark room by both the examiners, and scores were given according to the radiographic criteria[12] [Table 1].
Table 1: Description of caries lesions based on the International Caries Detection and Assessment System II visual criteria[10]and radiographic criteria (modified from Dunkley and Ashley[11]) of caries detection based on the International Caries Detection and Assessment System II

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Reference standard

Validation of the findings was done by examination of pit and fissure after opening fissures as a part of the restorative procedure.[13],[14] The pit and fissure opening was carried out by a trained independent dentist who is not involved in the previous examinations. A fine carbide bur (Fissurotomy Micro NTF; SS White, Lakewood, NJ, USA) was used and observed for signs of caries, using the codes given by Heinrich-Weltzien et al.,[14] and fissure opening codes are as follows:

  1. B0 – No caries seen
  2. B1 – Caries detected, confined to enamel
  3. B2 – Caries detected, extended into dentin.

Two examiners (BJC and MSK) with different levels of experience were involved in the study for evolution. However, prior to the visual examination, examiners 1 and 2 have attended an e-learning program (audio-visual aid) at, and then, the examiners was trained according to training recommendations of the ICDAS committee.[8] Diagnostic performance was evaluated using parameters such as sensitivity, specificity, negative predictive value, positive predictive value, and accuracy at two different thresholds D1 (all caries lesions) and D3 (dentine caries lesions). Accuracy was defined as the percentage of correct diagnosis in all the samples (sound and decayed surfaces). For ICDAS and radiographic method, Score 1 represented the cutoff point for all the lesions (D1 threshold) and Score 2 for the lesions in dentine (D3 threshold). Intraclass correlation coefficient (ICC) with 95% confidence interval (CI) was used to determine the inter-examiner reproducibility initially by considering all the scores given based on ICDAS II and conventional radiographic methods. The McNemar test was employed to compare sensitivity, specificity, and accuracy values of the different methods. The inter-examiner reliability was calculated using Cohen's kappa test. The study design has been shown in flowchart [Figure 1]. All the descriptive statistical analyses were carried out using statistical software (IBM SPSS Statistics version 21.0, Chicago, IL, USA).
Figure 1: Flow diagram showing details of study design

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  Results Top

Forty children were available for the study, with a mean age of 8.08 years. Among them, five were excluded and only 35 children with 280 primary morals were available for the study. In this sample, 26 molars were excluded due to varying reasons (grossly decayed, root stumps, missing, and early loss). At the D1 threshold [lesions limited to enamel, [Figure 2], the ICDAS showed significantly higher sensitivity (100%) and accuracy (100%) than radiographic method (12.8%), while no significant differences were found in the specificity (100%). At D3 threshold [dentinal caries, [Figure 3], no significant differences were found for specificity when comparing ICDAS II and conventional radiographic evaluation, but ICDAS II showed higher sensitivity (94.55%). Kappa statistics and ICC values showed similar agreement with both the methods of caries diagnosis for both the examiners.
Figure 2: Comparison of diagnostic accuracy at dentinal carious lesions (D1) threshold based on the International Caries Detection and Assessment System II and conventional bitewings

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Figure 3: Comparison of diagnostic accuracy at dentinal carious lesions (D3) threshold based on the International Caries Detection and Assessment System II and conventional bitewings

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  Discussion Top

Visual and radiographic methods are still commonly employed for caries detection clinically in the regular dental practice. Although various new methods such as laser fluorescence and electric conductance have received paramount importance in the research, their use in the clinical practice has not been receiving much attention, especially in developing countries due to its high cost. Apart from lesion detection, knowing the extent of lesion in dental tissues is critical to the selection of restorative material and success of the treatment performed. Hence, all the current methods are testedin vitro but not in vivo, which is crucial for generalizability of research findings.[9] A recent systematic review reported that there is a need forin vivo studies regarding the accuracy of digital systems and conventional systems in terms of diagnostic precision of carious lesions.[15] Furthermore, the available literature regarding occlusal caries detection in primary teeth is sparse.[2] Therefore, the present study evaluated the accuracy of conventional bitewing radiographs and ICDAS II to uncover the extent of occlusal carious lesions in primary molars.

Considering the sensitivity and specificity, this study showed that ICDAS II was more promising than conventional radiographic method for enamel occlusal carious lesion detection in primary molars. This finding may be biased because of the operative reference standard, but still the roughness/cavitation of enamel surface perceived by tactile sensation of two examiners withCommunity periodontal index (CPI) probe, good sample from our population, and exclusion of lesions coded 1 or 2 are considered as factors that reduce the bias significantly. For dentinal caries lesions, conventional bitewing radiography had less sensitivity and good specificity compared to visual ICDAS II. Hence, conventional bitewing radiographs form good adjuncts to visual ICDAS II. These results are in agreement with a Brazilian study by Dias da Silva et al.;[8] however, the findings were from an in vitro study and the authors compared digital records with conventional and visual examination. A recent study by Bhumireddy et al[16] found ICDAS II equally effective as digital radiographs (DR) for the detection

of carious lesions involving dentin whereas ICDAS II showed better performance in detecting initial early caries lesions than (DR) in primary molars. The reference standard used in this study is operative evaluation along with ICDAS II and conventional radiographs, which is not a gold standard compared to the histological sectioning and observation of sections with transverse microradiography or polarized light microscope or stereomicroscope.[14] These methods are suitable only for in vitro studies and not for in vivo.[17] True validation of the caries detection methods measuring the lesion extent or stage should be done clinically where the real disease occurs.[18] Such validation may be tested with an operating microscope or surgical loupes as they can provide fine details of dental tissues. The distribution of the disease in the sample should reflect the distribution in the population for which the diagnostic method will be used.[19] If it does not, calculated values for sensitivity and specificity may be either underestimated or overestimated in the target population. Underestimation falls out when the sample contains too many “borderline” cases and overestimation, when too many “obvious” cases are included.[20],[21]

The distribution of the enamel and dentin lesions in our study was 94 and 110, respectively, and 254 teeth were evaluated.. Hence, the disease distribution in our sample represents the real nature, unlike the extracted teeth sampled inin vitro studies which may contain more obvious lesions. An exact limitation of the present study was that this was not a random sample of patients scored by independent examiners, and the sample was hospital based from the outpatient department of pedodontics and preventive dentistry as well as those attending from the school dental health program. This may have some examiner bias, although every effort was made to be consistent with ICDASS II scores. Given the limitations of this convenience sample, these results can only serve to make conclusions about conventional bitewings and ICDASS II, but one can presume that it is not likely to be different from other reported findings. Further, it is possible that some examiner bias may have occurred, as the examiners were not with the same experience. Considering these limitations, other prospective researchers could use these data as a reference in similar clinical scenarios.

  Conclusion Top

ICDAS II is as effective as conventional bitewing radiography for detection of occlusal caries involving dentin. ICDAS II is better at detecting initial enamel caries lesions than the conventional radiographic method. Moreover, conventional radiographs are not always reliable to detect incipient lesions in primary molars.


We thank all the children and their parents for their participation in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gomez J, Tellez M, Pretty IA, Ellwood RP, Ismail AI. Non-cavitated carious lesions detection methods: A systematic review. Community Dent Oral Epidemiol 2013;41:54-66.  Back to cited text no. 1
Bader JD, Shugars DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic and management methods. J Dent Educ 2001;65:960-8.  Back to cited text no. 2
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Mallineni SK, Yiu C K. A retrospective review of outcomes of dental treatment performed for special needs patients under general anaesthesia: 2-year follow-up. Sci World J 2014: 748353. doi:10.1155/2014/748353.  Back to cited text no. 4
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: Anin vitro study. Int J Dent 2012;2012:371595.  Back to cited text no. 5
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;37:399-404.  Back to cited text no. 6
Oral Health Fact Sheet No 318; April, 2012. Available from: [Last accessed on 2016 Sep 21].  Back to cited text no. 7
Dias da Silva PR, Martins Marques M, Steagall W Jr., Medeiros Mendes F, Lascala CA. Accuracy of direct digital radiography for detecting occlusal caries in primary teeth compared with conventional radiography and visual inspection: Anin vitro study. Dentomaxillofac Radiol 2010;39:362-7.  Back to cited text no. 8
Pretty IA. Caries detection and diagnosis: Novel technologies. J Dent 2006;34:727-39.  Back to cited text no. 9
International Caries Detection and Assessment System Coordinating Committee Appendix, Criteria Manual. International Caries Detection and Assessment System (ICDAS II) Revised in December and July 2009 Bogota, Colombia and Budapest, Hungary; Workshop held in Baltimore, Maryland, March 12th-14th 2005, Updated Bogota; 8-11 December, 2008. Available from: [Last accessed on 2016 Sep 21].  Back to cited text no. 10
Dunkley S, Ashley P. Use of a ranked scoring system to detect occlusal caries in primary molars. Int J Paediatr Dent 2007;17:267-73.   Back to cited text no. 11
American Dental Association Council on Scientific Affairs. The use of dental radiographs: Update and recommendations. J Am Dent Assoc 2006;137:1304-12.  Back to cited text no. 12
Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H. The international caries detection and assessment system (ICDAS): An integrated system for measuring dental caries. Community Dent Oral Epidemiol 2007;35:170-8.  Back to cited text no. 13
Heinrich-Weltzien R, Weerheijm KL, Kühnisch J, Oehme T, Stösser L. Clinical evaluation of visual, radiographic, and laser fluorescence methods for detection of occlusal caries. ASDC J Dent Child 2002;69:127-32.  Back to cited text no. 14
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

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