J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1 10

Invited Review
Address for correspondence:
Dr. Shivakumar KM, Assistant Professor, Department of Public
Health Dentistry, Faculty of Dentistry, Sharad Pawar Dental
College and Hospital, Datta Meghe Institute of Medical Sciences
University, Sawangi (Meghe), Wardha 442 004, Maharashtra,
India. E-mail: shivakumarkm@rediffmail.com
Date of submission: 15.02.2009
Review completed: 23.03.2009
DOI: 10.4103/0972-0707.53335
International Caries Detection and Assessment
System: A new paradigm in detection of dental caries
KM Shivakumar, Sumanth Prasad, GN Chandu
1
Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences University,
Sawangi (Meghe), Wardha 442 004, Maharashtra,
1
Department of Public Health Dentistry, College of Dental Sciences,
Davangere - 577004, Karnataka, India
A b s t r a c t
A new emphasis on caries measurement and management is required for the dental community. The dental professionals need
new approaches in caries detection, its assessment, and management. The future of research, practice, and education in Cariol-
ogy requires the development of an integrated definition of dental caries, and uniform systems for measuring the caries process.
Keeping this in view, the International Caries Detection and Assessment System (ICDAS) has presented a new paradigm for the
measurement of dental caries, which was developed from the systematic reviews of literature on the clinical caries detection
system and other sources. The ICDAS can serve as a basis and benchmark for clinical and epidemiological research and inform
dental undergraduate and postgraduate teaching in Cariology. The ICDAS system was developed to bring forward the current
understanding of the process of initiation and progression of dental caries to the fields of epidemiological and clinical research.
Keywords: Dental caries; ICDAS; research.
INTRODUCTION
The International Caries Detection and Assessment
System (ICDAS) presents a new technique for the
measurement of dental caries developed from the
systematic reviews of literature on the clinical caries
detection system and other sources.
[1,2]
All these
reviews found that the new caries detection criteria
measured different stages of the caries process. The
review also found that there was a difference between
different criteria for dental caries detection and there
were many inconsistencies among the research criteria
for measuring the caries.
All these systematic reviews suggested that there was
an urgent need to answer the following questions:
1) What stage of the caries process should be
measured?
2) What are the definitions for each selected stage?
3) What is the best clinical approach to detect each
stage on different tooth surfaces?
4) What protocols of examiners training can provide
the highest degree of examiner reliability?
The ICDAS can serve as a basis and benchmark for
clinical and epidemiological research and inform dental
undergraduate and postgraduate teaching in Cariology.
The members of the coordinating committee of ICDAS
have attempted several times to include the largest
input of the cariology community in the process of
developing integrated criteria. There were various
concepts debated on the field of Cariology, in the
1980s. The new emphasis on caries measurement and
management may indicate that the dental community
worldwide has started to recognize that we need
new approaches in caries detection, assessment, and
management.
[3]
The development of new technologies
and applications has the potential to supplement
clinical caries detection, but these assessments
will have to be clinically meaningful by providing
measurements over and above the rattle of the arrested
initial and subclinical lesions.
[4]
ICDAS: The committee
The ICDAS activities have been carried out under the
supervision of and on behalf of an unfunded, informal,
and an adhoc and voluntary committee, which was
assembled in an attempt to advance some of the key
recommendations in the area of caries detection and
assessment criteria. After the first meeting in Dundee,
Scotland, an invitation was mailed to cariologists from
11 J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1
Europe and USA, to attend a development workshop
in Ann Arbor, Michigan.
[3]

ICDAS: The philosophy
The philosophy on which this truly collaborative
initiative is based on one where the methodology
from the caries epidemiology meets the one from
the caries clinical trials and practice, and the whole is
conducted according to the values of Evidence Based
Dentistry (EBD). The principles of the ICDAS committee
are: integration, scientific validation, and utility of the
criteria in different research and practice settings.
[3]
ICDAS: Developmental meetings
Before the ICDAS II workshop, four development
meetings were held - Dundee, Scotland in April 2002;
Ann Arbor, Michigan in August 2002; Indianapolis,
Indiana in May 2003; and Bornholm, Denmark in April
2004. An overview of the development of the ICDAS,
Denmark meeting (2004), is shown in Figure 1.
The ICDAS II workshop was held in Baltimore, USA
in 2005, to share the progress in the ICDAS criteria
and seek the input of a wider international expertise.
Invitations were mailed to a large group of experts
and those who accepted the invitation convened to
review, revise as necessary, and agree upon the ICDAS
II version of the criteria. The invitations were mailed
to over 60 cariologists and researchers in the field.
[3]
ICDAS: The concepts
A wardrobe of validated tools should allow users to
select the best criteria and conventions for a specific
use. The concept is that the system will be an open one
maintained on the World Wide Web and subject to peer
review. Users of the system will have to: specifically
acknowledge the version of the system they employ
and specify the parts of the ICDAS wardrobe that
are being used.
CORONAL PRIMARY CARIES
DETECTION CRITERIA
Principles used to develop the criteria for
coronal primary caries
Dental caries is a dynamic process with cycles of
ICDAS
International Caries Detection & Assessment System
Core ICDAS Criteria 2004
For use on coronal and root surfaces, as well as caries adjacent to restorations and sealants
These unifying, predominantly visual, criteria code a range of the characteristics of clean, dry
teeth in a consistent way that promotes the valid comparison of results between studies,
settings & locations
ICDAS criteria record both enamel and dentine caries and explore the measurement of caries
activity in all of the domains below
Education
Epidemiology /
Public Health
Clinical
Research
Clinical
Practice
ICDAS Clinical Visual Criteria
The ICDAS Detection codes are in use now and are recommended
The ICDAS Assessment codes are part of a developing research agenda
The ICDAS System provides an evidence based framework to validate and explore the impact of existing and
new-technology aids to caries diagnosis
Figure 1: An overview of the development of the ICDAS
Shivakumar, et al.: ICDAS
J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1 12
demineralization followed by remineralization. It is
hard to categorize a complex disease like dental caries
into a scale because the process is continuous and
can be measured. Clinically, we rely on visual signs
that represent manifestations of a relatively advanced
caries process.
[3]
The ICDAS measures the surface changes and potential
histological depth of the carious lesions by relying
on surface characteristics. The primary requirement
for applying the ICDAS system is the examination
of clean and dry teeth. The ICDAS examination is
visually aided by a ball-ended explorer that is used
to remove any remaining plaque and debris and to
check for surface contour, minor cavitation or sealants.
It is highly advisable that the teeth are cleaned with
a toothbrush or a prophylaxis head/cup before the
clinical examination. The use of a sharp explorer is not
necessary because it does not add to the accuracy of
the detection and it may damage the enamel surface
covering the early carious lesions.
[5]

The ICDAS detection codes for coronal caries range
from 0 to 6 depending on the severity of the lesion.
There are minor variations between the visual signs
associated with each code depending on a number of
factors, including the surface characteristics; whether
there are adjacent teeth present and also whether
or not the caries are associated with a restoration or
sealant. Therefore, a detailed description of each of the
codes is given under the following headings, to assist in
the training of examiners in the use of ICDAS: Pits and
fissures; smooth surface (mesial or distal); free smooth
surfaces and caries associated with restorations and
sealants (CARS).
[6]
However, the basis of the codes is
essentially the same throughout:
Code Description
0 Sound
1 First visual change in enamel (seen only after prolonged air
drying or restricted to the confines of a pit or fissure)
2 Distinct visual change in enamel
3 Localized enamel breakdown (without clinical visual signs of
dentinal involvement)
4 Underlying dark shadow from dentin
5 Distinct cavity with visible dentin
6 Extensive distinct cavity with visible dentin
A. Pits and fssure caries
[6]

Code 0: Sound tooth surface: There should be no
evidence of caries. Surfaces with developmental
defects such as enamel hyperplasia, fluorosis, tooth
wear (attrition, abrasion, and erosion), and extrinsic
or intrinsic stains will be recorded as sound. The
examiner should also score as sound, a surface with
multiple stained fissures if such a condition is seen
in other pits and fissures.
Code 1: First visual change in enamel: When seen wet
there is no evidence of any change in color attributable
to carious activity, but after prolonged air drying,
a carious opacity or discoloration (white or brown
lesion) is visible, which is not consistent with the
clinical appearance of sound enamel, or when there is
a change of color due to caries it is not consistent with
the clinical appearance of sound enamel and is limited
to the confines of the pit and fissure area (whether seen
wet or dry). The appearance of these carious areas is
not consistent with that of stained pits and fissures as
defined in code 0.
Code 2: Distinct visual change in enamel: The tooth must
be viewed wet. When wet there is a carious opacity
(white spot lesion) and/or brown carious discoloration
that is wider than the natural fissure/fossa, which is
not consistent with the clinical appearance of sound
enamel.
Code 3: Localized enamel breakdown due to caries with no
visible dentin or underlying shadow: The tooth viewed wet
may have a clear carious opacity (white spot lesion)
and/or brown carious discoloration that is wider than
the natural fissure/fossa, which is not consistent with
the clinical appearance of sound enamel. Once dried,
there is carious loss of tooth structure at the entrance
to, or within the pit or fissure/fossa. This will be seen
visually as evidence of demineralization at the entrance
to or within the fissure or pit, and although the pit or
fissure may appear substantially and unnaturally wider
than normal, the dentin is not visible in the walls or
base of the cavity/discontinuity.
If in doubt, or to confirm the visual assessment, the
WHO/CPI/PSR probe can be used gently across the tooth
surface, to confirm the presence of a cavity apparently
confined to the enamel. This is achieved by sliding the
ball end along the suspect pit or fissure and a limited
discontinuity is detected if the ball drops into the
surface of the enamel cavity/discontinuity.
Code 4: An underlying dark shadow from dentin with or
without localized enamel breakdown: This lesion appears
as a shadow of discolored dentin visible through an
apparently intact enamel surface, which may or may
Shivakumar, et al.: ICDAS
13 J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1
not show signs of localized breakdown. The shadow
appearance is often seen more easily when the tooth is
wet. The darkened area is an intrinsic shadow that may
appear gray, blue or brown. The shadow must clearly
represent caries that started on the tooth surface being
evaluated. If in the opinion of the examiner, the carious
lesion started on an adjacent surface and there was no
evidence of any caries on the surface being scored,
then the surface should be coded 0. Codes 3 and 4,
histologically may vary in depth with one being deeper
than the other and vice versa.
Code 5: Distinct cavity with visible dentin: Cavitation in
opaque or discolored enamel, exposing the dentin
beneath. The tooth viewed wet may have darkening
of the dentin visible through the enamel. Once dried,
there is visual evidence of loss of tooth structure at
the entrance to or within the pit or fissure - frank
cavitation. There is visual evidence of demineralization
(opaque (white), brown or dark brown walls) at the
entrance to or within the pit or fissure and in the
examiners judgment, the dentin is exposed.
The WHO/CPI/PSR probe can be used to confirm the
presence of a cavity, apparently in the dentin. This is
achieved by sliding the ball end along the suspect pit
or fissure and a dentin cavity is detected if the ball
enters the opening of the cavity and in the opinion of
the examiner the base is in dentin. (In pits or fissures
the thickness of the enamel is between 0.5 and 1.0 mm.
Note the deep pulpal dentin should not be probed)
Code 6: Extensive distinct cavity with visible dentin: There is
obvious loss of tooth structure, the cavity is both deep
and wide, and the dentin is clearly visible on the walls
and at the base. An extensive cavity involves at least
half of a tooth surface or possibly reaches the pulp.
B. Smooth surface caries
[6]

This requires visual inspection from the occlusal,
buccal, and lingual directions.
Code 0: Sound tooth surface: There should be no evidence
of caries. Surfaces with developmental defects such as
enamel hyperplasia, fluorosis, tooth wear (attrition,
abrasion and erosion), and extrinsic or intrinsic stains
will be recorded as sound.
Code 1: First visual change in enamel: When seen wet there
is no evidence of any change in color attributable to
carious activity, but after prolonged air drying a carious
opacity (white or brown lesion) is visible that is not
consistent with the clinical appearance of sound enamel.
This will be seen from the buccal or lingual surface.
Code 2: Distinct visual change in enamel when viewed wet:
There is a carious opacity or discoloration (white or
brown lesion) that is not consistent with the clinical
appearance of sound enamel. This lesion may be
seen directly when viewed from the buccal or lingual
direction. In addition, when viewed from the occlusal
direction, this opacity or discoloration may be seen
as a shadow confined to enamel, seen through the
marginal ridge.
Code 3: Initial breakdown in enamel due to caries with no
visible dentin: Once dried for approximately five seconds
there is distinct loss of enamel integrity, viewed from
the buccal or lingual direction. If in doubt, or to
confirm the visual assessment, the CPI probe can be
used gently across the surface to confirm the loss of
surface integrity.
Code 4: Underlying dark shadow from dentin with or
without localized enamel breakdown: This lesion appears
as a shadow of discolored dentin visible through an
apparently intact marginal ridge, buccal or lingual walls
of enamel. This appearance is often seen more easily
when the tooth is wet. The darkened area is an intrinsic
shadow which may appear as gray, blue or brown.
Code 5: Distinct cavity with visible dentin: Cavitation in
opaque or discolored enamel (white or brown) with
exposed dentin in the examiners judgment. If in
doubt, or to confirm the visual assessment a CPI probe
is used to confirm the presence of a cavity apparent in
dentin. This is achieved by sliding the ball end along
the surface and a dentin cavity is detected if the ball
enters the opening of the cavity and in the opinion of
the examiner the base is in dentin.
Code 6: Extensive distinct cavity with visible dentin: Obvious
loss of tooth structure, the extensive cavity may be deep
or wide and dentin is clearly visible on both the walls
and at the base. The marginal ridge may or may not be
present. An extensive cavity involves at least half of a
tooth surface or possibly reaching the pulp.
CARIES ADJACENT TO RESTORATIONS
AND SEALANTS (CARS)
When a restoration is placed in a tooth, the adjacent
Shivakumar, et al.: ICDAS
J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1 14
tooth tissue, which is vulnerable to caries, can be
considered in two planes. Secondary caries has
classically been described as occurring in two ways: an
outer lesion and a wall lesion. The chemical and
histological processes involved in outer lesions are
the same as primary caries.
[7]
Principles used to develop the criteria for
CARS
Since outer carious lesions adjacent to restorations
are thought to be analogous with primary caries, the
broad principles applied to the criteria for primary
caries are also applied to CARS where relevant.
However, it should be noted that the scientific basis for
doing so has not been established and the literature in
the area of secondary caries is far more limited than
that for primary coronal caries.
[3]
Caries associated with restoration and sealant
codes
[6]
Code 0: Sound tooth surface with restoration or sealant
Code 1: First visual change in enamel
Code 2: Distinct visual change in enamel/dentin adjacent
to a restoration/sealant margin
Code 3: Carious defects of < 0.5 mm, with signs of
code 2
Code 4: Marginal caries in enamel/dentin/cementum
adjacent to restoration/sealant, with underlying dark
shadow from dentin
Code 5: Distinct cavity adjacent to restoration/sealant
Code 6: Extensive distinct cavity with visible dentin
ICDAS two-digit coding method
A two-number coding system is suggested to identify
restorations/sealants with the first digit, followed
by the appropriate caries code, for example, a tooth
restored with amalgam, which also exhibits an
extensive distinct cavity with visible dentin will be
coded 4 (for an amalgam restoration) and 6 (for a
distinct cavity); an unrestored tooth with a distinct
cavity would be 06. The suggested restoration/sealant
coding system is as follows:
[6]
0 = Sound, that is, surface not restored or sealed (use
with the codes for primary caries)
1 = Sealant, partial
2 = Sealant, full
3 = Tooth colored restoration
4 = Amalgam restoration
5 = Stainless steel crown
6 = Porcelain or gold or PFM crown or veneer
7 = Lost or broken restoration
8 = Temporary restoration
9 = Used for the following conditions
96 = Tooth surface cannot be examined: surface
excluded
97 = Tooth missing because of caries (tooth surfaces
will be coded 97)
98 = Tooth missing for reasons other than caries (all
tooth surfaces will be coded 98)
99 = Unerupted (tooth surfaces coded 99)
ROOT CARIES
According to the National Institutes of Health (NIH)
Consensus Development Conference on dental caries
diagnosis and management, it was concluded that there
was "insufficient" evidence on the validity of clinical
diagnostic systems for root caries.
[8]
Root caries are
frequently observed near the cemento-enamel junction
(CEJ), although lesions can appear anywhere on the root
surface. The color of the root lesions has been used
as an indication of lesion activity. Active lesions have
been described as being yellowish or light brown in
color, whereas, arrested lesions appear darkly stained.
However, color subsequently has been shown not to
be a reliable indicator of caries activity.
[9,10]
Codes for the detection and classifcation of
carious lesions on the root surfaces
[6]
One score will be assigned per root surface. The facial,
mesial, distal, and lingual root surfaces of each tooth
should be classified as follows:
Code E: If the root surface cannot be visualized directly
as a result of gingival recession or by gentle air-drying,
then it is excluded. Surfaces covered entirely by
calculus can be excluded or, preferably, the calculus
can be removed prior to determining the status of
the surface.
Code 0: The root surface does not exhibit any unusual
discoloration that distinguishes it from the surrounding
or adjacent root areas, nor does it exhibit a surface
defect either at the CEJ or wholly on the root surface.
The root surface may have a natural anatomical
contour or the root surface may exhibit a definite loss
Shivakumar, et al.: ICDAS
15 J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1
of surface continuity or an anatomical contour that is
not consistent with the dental caries process.
Code 1: There is a clearly demarcated area on the
root surface or at the CEJ that is discolored (light/
dark brown, black) but there is no cavitation (loss of
anatomical contour < 0.5 mm) present.
Code 2: There is a clearly demarcated area on the root
surface or at the CEJ that is discolored (light/dark
brown, black) and there is cavitation (loss of anatomical
contour 0.5 mm) present.
THE FUTURE OF ICDAS
Researchers and clinicians have chosen the stage
of disease and characteristics for assessment of
carious lesions. Figure 2 shows the adaptation of
WHO stepwise approach to the surveillance of
noncommunicable diseases for use with oral health
indicators. The STEPS approach allows a logical
organization of different and often disparate indicators
used, into a series of core indicators that can be used
at STEP 1, 2 or 3, depending on the circumstances
and local needs, preferences. and resources. This
philosophy is entirely consistent with the wardrobe
approach of ICDAS and its use would result in the
improved comparability of data collected nationally
and internationally, thereby, facilitating systematic
reviews in the area.
[3,11]
The future of ICDAS depends
on the acceptance of the concepts of integration
and utility within a caries detection and assessment
system.
[11]
ACKNOWLEDGMENTS
We are very thankful to Registrar, Sri Raviji Meghe, DMIMS
University, Dr. AJ Pakhan, Dean, and Dr. RM Borle, Vice-Dean,
of the Sharad Pawar Dental College and Hospital, Datta
Meghe Institute of Medical Sciences University, Sawangi (M)
Wardha, India, for providing all the support and cooperation
in writing this manuscript.
REFERENCES
1. Chesters RK, Pitts NB, Matuliene G, Kvedariene A, Huntington E,
Bendinskaite R, et al. An abbreviated caries clinical trial design
validated over 24 months. J Dent Res 2002;81:637-40.
2. Ekstrand KR, Kuzmina I, Bjorndal L, Thyrlstrup A. Relationship
between external and histologic features of progressive stages
Figure 2: Adaptation of the WHOs stepwise approach to the surveillance of noncommunicable diseases for use with oral health
indicators. [Courtesy from: Pitts NB ICDAS - an international system for caries detection and assessment being developed to facilitate caries
epidemiology, research and appropriate clinical management. Community Dental Health 2004;21:193-198.]
Shivakumar, et al.: ICDAS
J Conserv Dent | Jan-Mar 2009 | Vol 12 | Issue 1 16
of caries in the occlusal fossa. Caries Res 1995;29:243-50.
3. Amid I Ismail. Rationale and Evidence for the International
Caries Detection and Assessment System. ICDAS Coordination
Committee. September 2005. p. 1-67.
4. Pitts NB, Stamm J. International Consensus Workshop on Caries
Clinical Trials (ICW-CCT) final consensus statements: Agreeing
where the evidence leads. J Dent Res 2004;83:125-8.
5. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the
effect of probing in occlusal surfaces. Caries Res 1987;21:363-74.
6. Criteria Manual: International Caries Detection and Assessment
System (ICDAS II). International Caries Detection and Assessment
System (ICDAS) Coordinating Committee. Workshop held in
Baltimore, Maryland: 12
th
- 14
th
March 2005.
7. Kidd EA, Beighton D. Prediction of secondary caries around
tooth-colored restorations: A clinical and microbiological study.
J Dent Res 1996;75:1942-6.
8. Bader JD, Shugars DA, Bonito AJ. Systematic review of selected
dental caries diagnostic and management methods. J Dent Educ
2001;65:960-8.
9. Hellyer PH, Beighton D, Heath MR, Lynch EJ. Root caries in
older people attending a general practice in East Sussex. Br
Dent J 1990;169:201-6.
10. Lynch E, Beighton D. A comparison of primary root caries lesions
classified according to color. Caries Res 1994;28:233-9.
11. Pitts NB. ICDAS - an international system for caries detection and
assessment being developed to facilitate caries epidemiology,
research and appropriate clinical management. Community Dent
Health 2004;21:193-8.
Source of Support: Nil, Confict of Interest: None declared.
Shivakumar, et al.: ICDAS
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