Original Paper
Caries Res 2018;52:406–419 Received: August 6, 2017
DOI: 10.1159/000486429
The International Caries Detection
and Assessment System – ICDAS:
A Systematic Review
Kim Rud Ekstrand a Thais Gimenez b Fernanda R. Ferreira b Fausto M. Mendes b
Mariana M. Braga b  
a Department of Odontology, University of Copenhagen, Copenhagen, Denmark; b Department of Pediatric
Dentistry, School of Dentistry, University of São Paulo, São Paulo, Brazil
Keywords
Dental caries · Caries detection · Activity assessment ·
Visual inspection · ICDAS · Performance · Accuracy
Abstract
The aims of this study were: (1) to evaluate the overall repro-
ducibility and accuracy of the International Caries Detection
and Assessment System (ICDAS) for assessing coronal caries
lesions, and (2) to investigate the use of systems associated
with the ICDAS for activity assessment of coronal caries le-
sions. Specific search strategies were adopted to identify
studies published up to 2016. For the first objective, we se-
lected studies that assessed primary coronal caries lesions
using the ICDAS as a reference standard. A total of 54 studies
were included. Meta-analyses summarized the results con-
cerning reproducibility and accuracy (correlation with his-
tology, summary ROC curves [SROC], and diagnostic odds
ratio [DOR]). The latter 2 were expressed at D1/D3 levels. The
heterogeneity of the studies was also assessed. Reproduc-
ibility values (pooled) were >0.65. The ICDAS mostly present-
ed a good overall performance as most areas under SROC
were >0.75 at D1 and > 0.90 at D3; DOR ≥6. For the second
objective, we selected studies investigating activity assess-
© 2018 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/cre
Accepted after revision: December 20, 2017
Published online: March 8, 2018
ment associated with the ICDAS. The meta-analyses pooled
results based on the same methodology and parameters as
above. Longitudinal findings regarding caries progression
were described to estimate the validity of these systems. On
average, the systems for activity assessment of caries lesions
showed moderate values concerning reproducibility and
overall performance. Active caries lesions were more prone
to progress than inactive ones after 2 years. In conclusion,
the ICDAS presented a substantial level of reproducibility
and accuracy for assessing primary coronal caries lesions.
Additional systems associated with the ICDAS that classify
caries lesion activity can be useful as they are moderately
reproducible and accurate. © 2018 S. Karger AG, Basel
The ICDAS was devised between 2002 and 2004, based
on the following statements at 2 consensus conferences
held around the millennium [Bader et al., 2001; Pitts and
Stamm, 2004]: (a) that the reliability of the available caries
detection/diagnostic systems (at that time), including vi-
This paper is based on a presentation given at the ORCA Saturday
Afternoon Symposium “Critical Appraisal of Current Clinical Caries
Diagnostic Systems” in Athens on July 6, 2016.
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Univ. of California Santa Barbara
Kim Rud Ekstrand
Section of Cariology and Endodontics, Dental School of Copenhagen
University of Copenhagen, Nörre Alle 20
DK–2200 Copenhagen (Denmark)
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E-Mail kek @ sund.ku.dk
sual and visual-tactile criteria, was not strong, and (b) that
there were too many incompatible systems. A group of
caries “experts” were invited to a meeting in Dundee in
2002. The tasks were to devise a simple, logical, evidence-
based system for the detection and classification of caries
in dental education, clinical practice, dental research, and
dental public health in order to provide appropriate diag-
nosis, prognosis, and clinical management of dental car-
ies at both the individual and public health levels [Pitts,
2004, 2009].
Three groups were formed to report the literature
within clinical classification systems on coronal caries,
root caries, and caries adjacent to restorations. The expert
group dealing with coronal caries suggested using the
Ekstrand, Kidd, Ricketts system (ERK system) [Ekstrand
et al., 1997] because that system used histology as valida-
tion [Ekstrand et al., 1998; Cortes et al., 2000; Ricketts et
al., 2002], and activity assessment of caries lesions had
also been tried with the ERK system [Ekstrand et al.,
1998]. Eventually, the 5 scores in the original ERK-system
were extended to 7 scores in the International Caries De-
tection and Assessment System, abbreviated as ICDAS I
[Pitts, 2004].
The other 2 groups at the Dundee meeting devised
scoring systems for root caries lesions and caries adjacent
to restorations [ICDAS, 2017]. The latter eventually be-
came similar to that developed for coronal caries. The ex-
pert group also suggested that the ICDAS should be a
2-digit system where the first digit was the status of the
surface and the second score was the ICDAS caries status
of the surface [ICDAS, 2017].
In 2004, there was a consensus conference in Boston,
USA, where it was agreed that the original score 3 (shad-
owed lesion) and 4 (enamel cavitation) should swap plac-
es in the ICDAS scoring system, as shadowed lesions his-
tologically were a bit more mature (deeper) than enamel
cavitated lesions [Cortes et al., 2000, 2003]. Thus, the IC-
DAS II was devised [Ismail et al., 2007], which eventually
became understood as the ICDAS.
At a pre-ORCA congress in 2005 in Indianapolis, the
ICDAS Coordinating Committee discussed criteria for
activity assessment of the caries lesion [ICDAS, 2017].
Some of these criteria were afterwards combined and
named the ICDAS-LAA system. Both the original activity
assessment system as well as the ICDAS-LAA have been
evaluated [Ekstrand et al., 2007; Braga et al., 2010; Pio-
vesan et al., 2013; Guedes et al., 2014; Floriano et al.,
2015]. Finally, at the preORCA congress held in Den-
mark in 2007, an ICDAS radiographical system based on
7 scores was devised [Halfsteein et al. 2007] and the re-
The International Caries Detection and
Assessment System – ICDAS
producibility of the scoring system has been evaluated
clinically [Agustsdottir et al., 2010; Ferreira Zandona et
al., 2012].
Aims of the Present Study
The organizers of the Saturday afternoon symposiums in 2016
gave the authors the following working title: Aims, Advantages,
and Limitations of the International Caries Detection and Assess-
ment System – ICDAS.
To cover the advantages and limitations of the ICDAS and de-
termine its overall reliability and accuracy/validity, we carried out
a systematic review including a meta-analysis. Furthermore, we
aimed to synthesize published information about the ICDAS
linked to activity assessment systems in terms of reproducibility,
sensitivity/specificity, and predictive and construct validity.
The aims of this paper can be summarized as: (1) to evaluate the
overall reproducibility and accuracy of the ICDAS for assessing cor-
onal caries lesions, and (2) to investigate the use of systems associ-
ated with ICDAS for activity assessment of coronal caries lesions.
Materials and Methods
The systematic reviews in this paper follow the PRISMA guide-
lines [Moher et al., 2009]. This review comprised a subset anal-
ysis from an umbrella review registered in Prospero (2013/
CRD42013003718) and previously published [Gimenez et al., 2015].
Systematic Review: The Accuracy of the ICDAS in Detecting
Coronal Caries
Information Sources, Study Selection, and Eligibility Criteria
In the first review, the focus of attention was on answering the
following question: “how reproducible and accurate is the ICDAS
in assessing coronal caries lesions?”
Based on this, a search was performed until July 2016, using an
adaptation of a published search strategy [Gimenez et al., 2015]
(online suppl. Fig. S1; for all online suppl. material, see www.karg-
er.com/doi/10.1159/000486429). The PubMed, Embase, and Sco-
pus databases were searched to retrieve published studies. Also
OpenSIGLE and the annals of the IADR/AADR (International and
American Associations for Dental Research) and ORCA (Euro-
pean Organization for Caries Research) congresses were accessed
to retrieve unpublished literature. The references of included ar-
ticles were checked manually.
Titles and abstracts were initially assessed against the inclusion
criteria, which were: (1) available information regarding detecting
primary coronal caries lesions using visual inspection; (2) mate-
rial of primary and permanent human teeth, including either a
laboratory or clinical setting and all types of surfaces, and (3) writ-
ten in the English language, as performed for an umbrella review
[Gimenez et al., 2015]. Studies that did not specifically use the
ICDAS for caries detection or did not present a reference standard
were excluded from this review. Those studies not reporting the
used threshold or any data allowing an estimation of the perfor-
mance of the method were excluded. This was also the case for
conceptual papers and other reviews (not primary studies).
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Caries Res 2018;52:406–419 407
DOI: 10.1159/000486429
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 408
Intra-examiner reproducibility

Primary teeth Permanent teeth

I2 (%) 65.1; 95% CI 10.8–90.8 I2 (%) 68.0; 95% CI 27.1–85.7

Chawla et al. [2012] 0.55 (0.35, 0.75) Neuhaus et al. [2015a] 0.41 (0.20, 0.62)
Freitas et al. [2016] 0.75 (0.67, 0.83) Achilleos et al. [(2013] 0.74 (0.23, 1.25)
Braga et al. [2009b] 0.95 (0.80, 1.10) Ozturk and Sinanoglu [2015] 0.71 (0.51, 0.91)
Bussaneli et al. [2015] 0.75 (0.40, 1.10) Neuhaus et al. [2015b]* 0.57 (0.33, 0.81)
Noaves et al. [2012] 0.76 (0.55, 0.96) Neuhaus et al. [2015b]*** 0.50 (0.26, 0.74)
Neuhaus et al. [2011] 0.73 (0.21, 1.25) Jallad et al. [2015] 0.88 (0.80, 0.96)
Ekstrand et al. [2011] 0.96 (0.83, 1.09) Diniz et al. [2011] 0.89 (0.86, 0.92)
Souza et al. [2013] 0.92 (0.72, 1.12) Gomez et al. [2013] 0.85 (0.56, 1.14)
Cotta et al. [2015] 0.84 (0.57, 1.11)

DOI: 10.1159/000486429
RE model 0.81 (0.71, 0.92) Rodrigues et al. [2008] 0.61 (0.29, 0.93)

Caries Res 2018;52:406–419

Jablonski-Momeni et al. [2008] 0.78 (0.49, 1.07)
–0.2 0 0.2 0.4 0.6 0.8 1.0 1.2 Diniz et al. [2009] 0.59 (0.31, 0.87)
IRR
Zandona et al. [2009]* 0.79 (0.70, 0.88)
Zandona et al. [2009]** 0.84 (0.75, 0.93)
Zandona et al. [2009]*** 0.81 (0.70, 0.92)
Ekstrand et al. [2011] 0.91 (0.78, 1.04)
Castilho et al. [2016] 0.60 (0.24, 0.96)
Ozkan et al. [2015] 0.76 (0.38, 1.14)
Ko et al. [2015] 0.96 (0.94, 0.96)
Ekstrand et al. [2007] 0.85 (0.65, 1.05)

RE model 0.78 (0.71, 0.85)

–0.2 0 0.2 0.4 0.6 0.8 1.0 1.2

IRR

Braga
Ekstrand/Gimenez/Ferreira/Mendes/
(For legend see next page.)
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 Interexaminer reproducibility

Primary teeth Permanent teeth

I2 (%) 87.6; 95% CI 71.8–95.0 I2 (%) 8.5; 95% CI 3.21–20.6

Chawla et al. [2012] 0.41 (0.35, 0.47) Neuhaus et al. [2015a] 0.64 (0.42, 0.86)
Teo et al. [2014] 0.84 (0.61, 1.07) Mitropoulos et al. [2010] 0.51 (0.36, 0.66)
Braga et al. [2010] 0.91 (0.69, 1.13) Parviainen et al. [2013] 0.47 (0.02, 0.92)

Assessment System – ICDAS

Braga et al. [2009b] 0.82 (0.62, 1.02) Achilleos et al. [2013] 0.73 (0.28, 1.18)
Braga et al. [2009a] 0.47 (0.31, 0.63) Ozturk et al. [2015] 0.37 (0.17, 0.57)
Bussaneli et al. [2015] 0.58 (0.17, 0.99) Jallad et al. [2015] 0.72 (0.63, 0.81)
Piovesan et al. [2013]# 0.84 (0.69, 1.00) Diniz et al. [2011] 0.81 (0.75, 0.87)

The International Caries Detection and

Piovesan et al. [2013]## 0.57 (0.36, 0.77) Cotta et al. [2015] 0.60 (0.26, 0.94)
Piovesan et al. [2013]### 0.78 (0.39, 1.17) Rodrigues et al. [2013] 0.61 (0.43, 0.79)
Novaes et al. [2009] 0.62 (0.52, 0.72) Rodrigues et al. [2008] 0.51 (0.17, 0.85)
Novaes et al. [2012] 0.63 (0.38, 0.88) Jablonski-Momeni et al. [2008] 0.82 (0.64, 1.00)
Neuhaus et al. [2011] 0.35 (–0.26, 0.96) Diniz et al. [2009] 0.51 (0.22, 0.80)
Ekstrand et al. [2011] 0.87 (0.70, 1.04) Ekstrand et al. [2011] 0.86 (0.72, 1.00)
Souza et al. [2013] 0.55 (0.44, 0.66) Ozkan et al. [2015] 0.63 (0.18, 1.09)
Shoaib et al. [2009]### 0.68 (0.65, 0.71) Ekstrand et al. [2007] 0.82 (0.60, 1.04)
Shoaib et al. [2009]## 0.70 (0.64, 0.76)
Soviero et al. [2012] 0.93 (0.70, 1.16) RE model 0.67 (0.58, 0.75)
–0.2 0 0.2 0.4 0.6 0.8 1.0 1.2
IRR
RE model 0.68 (0.60, 0.76)
–0.2 0 0.2 0.4 0.6 0.8 1.0 1.2
IRR

Fig. 1. Forest plots for meta-analysis and heterogeneity analysis of intra- and inter-examiner reproducibility when ICDAS was used for assessing caries lesion severity.

DOI: 10.1159/000486429
Caries Res 2018;52:406–419
IRR, intra- or inter-rater reproducibility. Examiners: * experienced; ** intermediate (+training); *** novice. Surfaces: # approximal; ## smooth; ### occlusal.

409
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 Study selection was performed independently by 2 reviewers
(T.G. and M.M.B.). Disagreements were resolved by discussion
with a third researcher (K.R.E.). For studies with the same data set,
only the study considered the most complete was included in this
review. If the same study evaluated the accuracy of different sub-
groups, the data were recorded as different studies.
Data Collection Process
We searched papers for intra- and inter-examiner reproduc-
ibility data of the ICDAS including quantitative intra- or inter-
rater reliability coefficients (intra-RR or inter-RR). When more
than 1 examiner was involved, the mean values of the coefficients
were used. If the study presented any estimation of variance, they
were also registered. If not, the standard error was estimated using
a graphical model [Hanley, 1987].
We also collected the absolute numbers of true positives, false
positive, true negatives, and false negatives or data to calculate
these figures. If the study had evaluated the performance of the
method with more than 1 examiner, we used the values of the first
examiner. If examiners with different levels of training participat-
ed, data from the first examiner per category of training were col-
lected and each category was considered as an independent set of
data. Data about the correlation between the ICDAS scores and the
histological validation were also collected.
Summary Measures and Synthesis of Results
Subgroups concerning the type of teeth and study setting were
considered for all analyses. For the meta-analyses of intra-RR and
inter-RR, random-effects models were fitted using the R package
metafor (GNU General Public License version 2) [Viechtbauer,
2010]. Separate analyses were conducted for intra-RR and inter-RR
data. When more than 1 IRR value was collected from the article as
reproducibility measurements, we preferred the following order of
IRR coefficients to be used in these analyses: weighted Kappa, un-
weighted Kappa, and intraclass correlation coefficient. Coefficients
were pooled according to the methodology of a previously pub-
lished study [Bornmann et al., 2010]. Concerning the correlation
coefficients between the ICDAS and histology, pooled coefficients
and their 95% confidence intervals are summarized in forest plots.
For accuracy, statistical analyses were performed for the sub-
groups above and also the thresholds (D1 or D3). At D1 threshold,
all lesions were considered as carious. At D3, only more advanced
caries lesions were included. Thus, surfaces considered as carious for
these analyses were those lesions into dentine when lesion depth was
assessed, or cavitated lesions when surface integrity was considered.
Statistical pooling of sensitivity, specificity, positive likelihood
(sensitivity/1 – specificity) and negative likelihood (1 – sensitivity/
specificity), and diagnostic odds ratio [DOR = (TP/FP)/(FN/TN)]
was carried out using the DERSimonian Laid method (random ef-
fects meta-analyses model). We summarized these analyses in re-
ceiver operating characteristics curves (SROC) and tested the het-
erogeneity among the included studies using the Cochran Q and I2
tests. Sensitivity analyses were performed to check the influence of
studies with approximal caries lesions on the pooled estimates. All
these analyses were performed in MetaDisc 1.4 software (Unidad de
Bioestadistica Clinica del Hospital Ramón y Caja, Madrid, Spain).
Publication bias was assessed by checking the asymmetry of
funnel plots visually and using regression analysis performed in R
package metafor. Alternatively, for accuracy, we used funnel plots
of natural logarithm (ln) DOR versus 1/√effective sample size
410 Caries Res 2018;52:406–419
DOI: 10.1159/000486429
[CRD, 2009]. The trim and fill method was used to adjust the
pooled estimates, when necessary (R package meta, version 4.8-2)
[Schwarzer, 2007].
Systematic Review: Activity Assessment Associated with the
ICDAS
Information Sources, Study Selection, and Eligibility Criteria
For the second review, the focus of attention was to collect in-
formation about the systems associated with the ICDAS for activ-
ity assessment of coronal caries lesions and, when possible, to ex-
press their performance in terms of reproducibility and accuracy.
Following the question: “How has the activity assessment been
performed when the ICDAS is used?” another search was per-
formed in PubMed until January 2017 to summarize the evidence
about activity assessment using the ICDAS (online suppl. Fig. S1).
We screened studies that combined any type of activity assess-
ment and the visual examination performed by the ICDAS, how-
ever exclusively on coronal caries. Articles that did not report data
about performance of the activity assessment or only reported in
vitro experiments were excluded. The same strategy described in the
previous section was used for duplicates. The selection of studies
was also performed by 2 independent reviewers (F.R.F. and M.M.B.)
and the same strategies were used for solving disagreements.
Data Collection Process and Synthesis of Results
We summarized the studies that used the activity assessment
associated with the ICDAS and their purposes. When aiming to
validate the method, we also registered how it was performed. For
longitudinal studies, findings regarding caries progression related
to the activity status of caries lesions were collected. When report-
ing data about performance, we carried out data collection and
analyses similarly to in the first section.
For the accuracy of activity assessment systems, sound surfaces
were not included in these analyses. Pooled results were presented
for all merged systems since they evaluated similar characteristics.
Risk of Bias of Individual Studies
Two reviewers (M.M.B. and T.G.) were responsible for risk of
bias assessment in the reviews reported above. The QUADAS-2
was used to assess the potential risk of bias of included test accu-
racy studies in both reviews. According to 4 domains (sample se-
lection, index test, reference standard, or timing and flow), the
studies were classified as low, high, or unclear risk of bias.
For longitudinal studies, the Newcastle-Ottawa quality assess-
ment scale was used to classify the risk of bias in 3 different do-
mains: selection, comparability, and outcome. This system identi-
fies the risk of bias using stars. If most of the stars were awarded
for the domain, the study was classified as having a low risk of bias
considering this aspect.
Results
Systematic Review: The Accuracy of the ICDAS in
Detecting Coronal Caries
Synthesis of Results
A total of 54 studies from 46 papers fulfilled the re-
quirements for enrolment (online suppl. Fig. S2). Most of
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Braga
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 Laboratory studies
SROC curve SROC curve
1.0
n studies = 16 n studies = 24
0.9
AUC(SE) = 0.8695 (0.0170) AUC(SE) = 0.8892
0.8 Pooled Sen = 0.785 (0.0297)
(0.759–0.810) Pooled Sen = 0,870
Pooled Spe = 0.786 (0.854–0.884)
0.7
(0.751–0.817) Pooled Spe = 0.725
(REM) pooled LR+ = 3.579 (0.682–0.766)
0.6 (2.128–6.020) (REM) pooled LR+ = 3.187
Sensitivity

(REM) pooled LR– = 0.244 (2.271–4.472)

0.5 (0.157–0.380) (REM) poole
(REM) pooled DOR = LR– = 0.147 (0.092–0.296)
0.4 16.115 (10.707–24.256) (REM) pooled DOR =
Heterogeneity Q (SE) = 26.467 (13.686–51.182)
24.06 (d.f. = 15), p = 0.064 Heterogeneity Q (SE) =
0.3 Inconsistency I2 = 37.6% 90.09 (d.f. = 23) p < 0.001
Estimate of between-study Inconsistency I2 = 74.5%
0.2 variance τ = 0.2447 Estimate of between-
study variance τ = 1.7641
0.1

0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
1 – specificity 1 – specificity
Primary teeth

Permanent teeth
Clinical studies
SROC curve SROC curve
1.0

n studies = 6 n studies = 4
0.9
AUC(SE) = 0.7908 AUC(SE) = 0.7820
0.8 (0.0297) (0.0420)
Pooled Sen = 0.553 Pooled Sen = 0.563
0.7 (0.521–0.585) (0.523–0.602)
Pooled Spe = 0.861 Pooled Spe = 0.966
(0.831–0.888) (0.958–0.973)
0.6
(REM) pooled LR+ = 2.647 (REM) pooled LR+ = 2.889
Sensitivity

(2.103–3.332) (0.594–14.060)
0.5
(REM) pooled LR– = 0.407 (REM) pooled LR– = 0.438
(0.261–0.635) (0.242–0.792)
0.4 (REM) pooled DOR = (REM) pooled DOR =
6.118 (3.988–9.384) 7.522 (1.519–37.255)
0.3 Heterogeneity Q (SE) = Heterogeneity Q (SE) =
8.33 (d.f. = 5) p = 0.139 20.55 (d.f. = 3) p < 0.001
Inconsistency I2 = 40.0% Inconsistency I2 = 85.4%
0.2
Estimate of between- Estimate of between-
study variance τ = 0.1045 study variance τ = 2.1578
0.1

0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
1 – specificity 1 – specificity

Fig. 2. Summary ROC diagrams for meta-analysis and heterogeneity analysis of ICDAS accuracy on assessing
any caries lesions at the D1 threshold – number of studies, area under the ROC curves, pooled sensitivity (Sen),
specificity (Spe), DOR, positive and negative likelihood ratios (LR), results for the Cochran Q test for heteroge-
neity, I2 and τ coefficient variances between studies.

the studies were laboratory studies (77%) conducted on Summary Measurements

permanent teeth (60%). A wide variety of examiner train- Thirty-two studies assessed the inter-RR and 28 stud-
ing/qualification was observed among the studies. Half of ies the intra-RR. Only a few of the studies were performed
the studies were performed with experienced examiners in a clinical setting and we therefore opted for a graphic
and approximately 40% were intermediately experienced summary, independently of setting (Fig.  1). The mean
but trained for the purposes of the study. The vast major- IRR values were all ≥0.67. The intra-RR tended to be
ity of studies (approx. 75%) concerned occlusal surfaces slightly higher than the inter-RR. The levels of heteroge-
(online suppl. Table S1). neity (I2) significantly varied among the subgroups
(Fig. 1).
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The International Caries Detection and Caries Res 2018;52:406–419 411

Assessment System – ICDAS DOI: 10.1159/000486429
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 Laboratory studies
SROC curve SROC curve
1.0
n studies = 16
0.9 n studies = 22
AUC(SE) = 0.9171
0.8 (0.0278) AUC(SE) = 0.9219 (0.0220)
Pooled Sen = 0.704 Pooled Sen = 0.730
(0.661–0.744) (0.696–0.762)
0.7
Pooled Spe = 0.876 Pooled Spe = 0.872
(0.856–0.894) (0.853–0.890)
0.6 (REM) pooled LR+ = 7.582 (REM) pooled LR+ = 5.957
Sensitivity

(4.423–12.999) (3.862–9.188)
0.5 (REM) pooled LR– =0.339 (REM) pooled LR– = 0.253
(0.235–0.488) (0.138–0.464)
0.4 (REM) pooled DOR = (REM) pooled DOR =
33.866 (13.165–87.115) 26.937 (13.701–52.959)
0.3 Heterogeneity Q (SE) = Heterogeneity Q (SE) =
92.31 (d.f. = 15) p < 0.001 98.27 (d.f. = 21), p < 0.001
Inconsistency I2 = 83.7% Inconsistency I2 = 78.6%
0.2 Estimate of between- Estimate of between-study
study variance τ2 = 2.9472 variance τ2 = 1.8415
0.1

0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1

Permanent teeth
1 – specificity 1 – specificity
Primary teeth

Clinical studies
SROC curve SROC curve
1.0
n studies = 6
0.9 n studies = 5*
AUC(SE) = 0.9246
0.8 (0.0384) AUC(SE) = 0.6763 (0.0792)
Pooled Sen = 0.598 Pooled Sen = 0.545 (0.475–
(0.504–0.688) 0.614)
0.7 Pooled Spe = 0.971 Pooled Spe = 0.972
(0.962–0.978) (0.965–0.977)
0.6 (REM) pooled (REM) pooled LR+ = 6.419
LR+ = 11.478 (3,763– (1.744–23.619)
Sensitivity

0.5 35.009) (REM) pooled LR– = 0.513

(REM) pooled LR– = 0.401 (0.443–0.594)
(0.217–0.738) (REM) pooled DOR =
0.4
(REM) pooled DOR = 16.286 ( 3.275–80.990)
59.627 (14.361–247.58)
0.3 Heterogeneity Q (SE) = Heterogeneity Q (SE) =
17.13 (d.f. = 5), p = 0.004 30.68 (d.f. = 4) p < 0.001
0.2 Inconsistency I2 = 70.8% Inconsistency I2 = 87.0%
Estimate of between- Estimate of between-study
study variance τ2 = 2.1709 variance τ2 = 2.4894
0.1

0
0 0.2 0.4 0.6 0.8 1 0 0.2 0.4 0.6 0.8 1
1 – specificity 1 – specificity

Fig. 3. Summary ROC diagrams for meta-analysis and heterogeneity analysis of ICDAS accuracy on assessing
more advanced caries lesions (cavitated caries lesions or those lesions histologically into dentine/at the D3 thresh-
old – number of studies, area under the ROC curves, pooled sensitivity (Sen), specificity (Spe), DOR, positive and
negative likelihood ratios (LR), results for the Cochran Q test for heterogeneity, I2 and τ coefficient variances
between studies. * One study was omitted in the pooled analysis because of a false-positive value = 0, Spe = 1.

The pooled Spearman correlation between the ICDAS
scores and histology was 0.78 for primary teeth (95% CI
0.73–0.84; n = 5) and 0.68 for the permanent teeth (95%
CI 0.58–0.78; n = 12). As very few studies were performed
in vivo, we presented the global pooled results.
The areas under the ROC curves were all substantial
(≥0.75), apart from permanent teeth in clinical studies,
where the area under the ROC curve was 0.67 (Fig. 2, 3).
The pooled specificities were also all high (>0.70). In con-
trast, the pooled sensitivities values were lower in the clin-
ical studies (0.55–0.60), but higher in the laboratory stud-
ies (>0.70). Pooled likelihood ratios (LR+) were above the
value 1 (2.65–11.48) and LR data ranged from 0.15 to
0.51. The DOR values were very high (6.1–59.6; Fig. 2, 3).
Values of SROC, sensitivity and specificity were simi-
lar between D1 and D3 levels for laboratorial studies
(Fig. 2, 3). At the D1 threshold, slightly higher SROC val-
ues were found for laboratorial conditions. We also no-
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 Sensitivity (95% CI)
SROC curve Freitas et al. [2016] 0.53 (0.41–0.64)
1.0 Cotta et al. [2015] 0.79 (0.49–0.95)
Braga et al. [2010] 0.79 (0.49–0.95)
0.9 Ekstrand et al. [2007] 0.84 (0.74–0.90)

0.8
Pooled sensitivity = 0.70 (0.63–0.77)
0.7 χ2 = 20.66: d.f. = 3 (p = 0.0001)
Inconsistency I2 = 85.5%
0 0.2 0.4 0.6 0.8 1.0
0.6
Sensitivity
Sensitivity

0.5

0.4

0.3
Specificity (95% CI)
0.2 Freitas et al. [2016] 0.64 (0.45–0.80)
Cotta et al. [2015] 0.40 (0.24–0.58)
Braga et al. [2010] 0.17 (0.02–0.48)
0.1
Ekstrand et al. [2007] 0.81 (0.64–0.93)

0 0.2 0.4 0.6 0.8 1.0

Pooled specificity = 0.56 (0.47–0.66)
1 – specificity
χ2 = 21.44: d.f. = 3 (p = 0.0001)
Inconsistency I2 = 86.0%
n studies = 4 0 0.2 0.4 0.6 0.8 1.0
Specificity
AUC(SE) = 0.7519 (0.1217)
(REM) pooled LR+= 1.596 (0.844–3.018)
(REM) pooled LR– = 0.508 (0.213–1.216)
(REM) pooled DOR = 3.274 (0.776–13.807)
Heterogeneity Q (SE) = 16.32 (d.f. = 2) p = 0.001
Inconsistency I2 = 81.6%
Estimate of between-study variance τ2 <0.001

Fig. 4. Meta-analysis of ICDAS+LAA accuracy on assessing caries lesion activity (left: summary ROC diagram;
right: forest plots for meta-analysis using sensitivity and specificity of the method).

ticed a trend of lower pooled sensitivities for clinical stud-
ies; however, these were associated with higher specificity
values (Fig. 2). For clinical studies, a slightly lower pooled
sensitivity was observed at the D3 level. For more ad-
vanced caries lesions, a very high pooled specificity
(>0.90) was observed for primary teeth, while a very low
pooled specificity was found for permanent teeth (Fig. 3).
A wide variety of results was observed, especially among
studies using permanent teeth (Fig. 3).
Looking to the SROC, we observed some very discrep-
ant points, which represent some of the studies per-
formed with approximal lesions (Fig. 2, 3). When exclud-
ing the studies with approximal surfaces from the sample
(sensitivity analysis), the DOR was increased by 20% for
laboratory studies concerning permanent teeth at the D1
threshold. For clinical studies, the exclusion of this type
of surface resulted in a significantly higher sensitivity
(0.88; 95% CI 0.81–0.93), AUC (0.90; 95% CI 0.83–0.97),
and DOR (14.860; 95% CI 6.756–32.670) at D1 concern-
ing primary teeth. At the D3 threshold, for the same set-
ting, only sensitivity was increased (0.86; 95% CI 0.76–
0.94).
Apart from clinical studies conducted with primary
teeth, moderate to high levels of heterogeneity (I2) were
observed among the studies (Fig. 4, 5).
Systematic Review: Activity Assessment Associated
with the ICDAS
Synthesis of Results
Thirty-six studies were retrieved in this search (online
suppl. Fig. S3). Out of 11 included studies, 9 were cross-
sectional and 2 were longitudinal studies (online suppl.
Table S2). Five studies validated a system to be used in
caries activity assessment in conjunction with the ICDAS.
One additional study showed data compatible with a pre-
dictive validation of activity assessment of caries lesions
[Ferreira Zandona et al., 2012]. Four studies were inter-
ested in the relationship between the ICDAS and activity
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Clinical studies
Flow/timing
Reference standard
Index test
Patient selection
a 0 10 20 30 40 50 60 70 80 90 100 %
■ High ■ Uncertain ■ Low
Laboratory studies
Flow/timing
Reference standard
Index test
Patient selection
b 0 10 20 30 40 50 60 70 80 90 100 %
Fig. 5. Risk of bias within included studies when investigating the
accuracy of ICDAS: laboratory studies (a) and clinical studies (b).
assessment and other indices or other clinical patterns
(online suppl. Table S2).
Eight studies used the ICDAS and LAA for activity as-
sessment of caries lesions (online suppl. Table S2). Other
studies considered similar characteristics as LAA (color,
luster, and texture), but did not use the point system pro-
posed by Ekstrand et al. [2007]. Seven studies were per-
formed with permanent teeth (63%). Six studies included
all tooth surfaces (55%), while 4 focused specifically on
specific surfaces (online suppl. Table S2).
Summary Measurements
Reproducibility and Accuracy. Systems showed mod-
erate to substantial values of pooled intra-RR (0.7; 95% CI
0.60–0.79) and inter-RR (0.65; 95% CI: 0.41–0.80). Lower
reproducibilities seemed to be more frequent in those
cases in which all surfaces were considered for analyses
instead of specific surfaces and/or more examiners were
involved. High levels of heterogeneity were observed
(I2 > 80%).
Four studies tested the accuracy of systems for caries
lesion activity assessment (online suppl. Table S3; Fig. 4).
The studies used a kind of criterion validity (concurrent
validity) inferring the pH in the plaque covering the le-
sion by using an appropriate impression material
[Ekstrand et al., 2007] or using methyl red, a solution
414 Caries Res 2018;52:406–419
DOI: 10.1159/000486429
known to change its color around a pH of 5.5 [Mac-
Gregor, 1962; Ekstrand et al., 1998].
A moderate overall performance was observed (see
area under SROC, Fig. 4). The pooled DOR was greater
than 1, and the pooled LRs were slightly closer to 1 (Fig. 4).
The pooled specificity tended to be lower than the pooled
sensitivity (Fig. 4). A high level of heterogeneity among
the studies was observed (Fig. 4).
Assessment of Lesion Progression over a Period of Time.
Two studies performed verified caries progression after 2
years [Ferreira Zandona et al., 2012; Guedes et al., 2014]
(online suppl. Table S4).
Significantly more active noncavitated caries lesions
progressed to frank cavitation in 2 years compared to the
inactive ones in primary teeth (online suppl. Table S4).
Differences in caries progression rates between active and
inactive cavitated caries lesions were still stronger in both
studies (online suppl. Table S4).
Risk of Bias of Individual Studies (Both Reviews). The
main source of risk of bias within the included studies for
testing accuracy of the ICDAS was related to sample se-
lection (Fig. 5; online suppl. Table S5). This observation
was true both for accuracy in assessing caries lesion sever-
ity and activity. Most clinical studies testing the ICDAS
for assessing lesion severity in permanent teeth (5 from 6
studies) presented the potential of bias when the sample
was selected, including specifically teeth indicated to be
extracted or restored. The same was observed in studies
with primary teeth, but less often (3 from 6 studies). Near-
ly 50% of studies also presented a high or unclear risk of
bias regarding the reference standard (Fig. 5; online sup-
pl. Table S5). The longitudinal studies presented a low
risk of bias considering all 3 domains evaluated (see on-
line suppl. Table S5).
Publication Bias (Both Reviews)
Through funnel plots analyses (online suppl. Fig. S3),
we identified the occurrence of publication bias when test-
ing the accuracy (DOR) in clinical studies involving pri-
mary teeth (p < 0.001) and the correlation with histology
(p < 0.001). After the adjustment of pooled estimates, slight
differences could be observed (see online suppl. Fig. S3).
Discussion
An enormous interest in the ICDAS has been regis-
tered since it was released in 2003–2004. A simple search
for ICDAS in PubMed conducted in January 2017 result-
ed in 264 hits.
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 The collected data about reproducibility came from
those studies that also examined the accuracy of the
ICDAS and indicated that both the intra- and inter-repro-
ducibility of the ICDAS were substantial (Fig. 1). A few
additional studies only focusing on the reproducibility of
the ICDAS could have been included using other selection
criteria. If these studies had been included, probably
slightly different figures would have been observed. How-
ever, we do not believe this option could have changed the
actual trend observed. Additionally, as only English stud-
ies were included, we could point out another limitation
of this review. On the other hand, systematic reviews seem
not to have been impacted when non-English studies were
included [Juni et al., 2002; Moher et al., 2003].
Although some studies do not optimally follow the
fundamental conditions for using the ICDAS (e.g., the
training of the examiner, cleaning and drying conditions)
[Topping et al., 2009], a substantial positive correlation
between the ICDAS and histology was observed (rs ≥
0.68). Many studies are performed on occlusal surfaces,
but examinations on extracted teeth where the approxi-
mal lesions can be classified also show a significant rela-
tionship between the ICDAS scores and the lesion depth
[Ekstrand et al., 2011; Piovesan et al., 2013]. On the other
hand, when excluding approximal lesions from analyses
because they by nature are difficult to see, considerable
changes were observed in a clinical setting. However, we
would probably have an error type 2 if meta-regression
was used to show this because of the small number of
studies. This is why we only presented the data by sensi-
tivity analysis.
The SROC curves pooled in the meta-analysis use
thresholds to present the results, permitting an overall ap-
preciation of method performance by means of DOR,
combining sensitivity and specificity [Glas et al., 2003].
Pooled DOR values were very high in all subgroups. LRs
indicated a slight to large increase on posttest probability
of the disease [McGee, 2002], depending on the threshold
and subgroup analyzed. These findings emphasize the ro-
bustness of the ICDAS system for assessing caries lesion
severity.
One factor that could have an influence on the correla-
tion with histology and performance is that the spectrum
of sample disease does not always reflect the disease in the
population. This variation in disease prevalence may af-
fect estimates of diagnostic performance [Whiting, 2004].
In fact, samples are usually chosen based on suspicious
sites (probably more difficult to detect) and certainly a
larger proportion of such lesions are included than are
found in the real world. Additionally, especially for per-
The International Caries Detection and
Assessment System – ICDAS
manent teeth, mostly teeth presenting special conditions
were extracted for histological validation, being consid-
ered a high risk of bias in clinical studies. On the other
hand, when other validation methods (such as expert
consensus) were used in these studies, we could also in-
troduce a partial verification, and consequently a confir-
mation bias.
Another factor that may influence the accuracy is the
choice of the reference system and the use of thresholds.
Different validation methods have been used (online
suppl. Table S1). It may be very difficult to decide visu-
ally if a noncavitated lesion is deep in the enamel or just
into the dentine, which suggests it may be best to use
enamel lesion or dentine lesion limited to the outer third
versus deeper dentine lesion as the threshold [Ekstrand et
al., 2007, 2011]. This threshold may boost the accuracy of
the system, but is relevant for managing the lesion, as sur-
gical intervention should mainly be restricted to lesions
deeper than the outer third of the dentine [Ismail et al.,
2015]. The variety of reference systems could be one ad-
ditional explanation for the high level of heterogeneity
observed among the studies.
Different examiners’ expertise and types of training
can be another source of heterogeneity. Less experienced
examiners tended to be less accurate in detecting caries
when using visual inspection [Gimenez et al., 2015].
However, including all kinds of examiners in our analyses
provides the verification that the system can be used suc-
cessfully in caries lesion severity assessment even for non-
researchers.
Studies which could approximate the results to the
clinic situation are limited when testing the accuracy of
the caries detection method because of issues regarding
the reference methods used for validation. Moreover,
they are not free of bias [Gimenez et al., 2015]. Clinical
studies showed a slight reduction in the examiners’ over-
all performance using the ICDAS (Fig.  2, 3), probably
caused by difficulties when examining under natural con-
ditions. On the other hand, this finding is associated with
a high specificity, which could be beneficial and avoid un-
necessary surgical treatment in practice.
One can debate the clinical significance of these stud-
ies on accuracy. It is important to highlight that the
ICDAS has a high correlation with histology. It is also
strongly associated with caries progression [Ferreira Zan-
dona et al., 2012; Guedes et al., 2014, 2016] and conse-
quently could be strongly related to clinical decision mak-
ing. The level of bias in the individual studies included in
this review certainly varies, and consequently their poten-
tial for clinical extrapolation. These aspects reflect the
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methodological heterogeneity present among data used
in this paper. The authors would like to encourage the
inclusion of a consecutive sample, minimizing the selec-
tion and spectrum bias, approximating the real condition
we tend to find in clinical practice with the sample. Com-
plete validation of the sample, noninfluenced by “test ex-
aminations” is also recommended when accuracy is the
issue. In the case of activity assessment, predictive valida-
tion is desirable for guidance in designing further labora-
tory and clinical studies presenting low risk of bias (as
shown in online suppl. Table S5).
For the activity assessment of caries lesions, the avail-
able evidence is still limited. In general, 2 systems have
been added to the original ICDAS. Both take into consid-
eration similar clinical features. One uses a combination
of predictors where the final assessment basically is sub-
jectively based as suggested by other indices which con-
templates the activity assessment of caries lesions [Nyvad
et al., 1999; Kuhnisch et al., 2009]. The other system uses
points predefined to the individual predictors (ICDAS-
LAA) and the final assessment is based on adding up the
points against a threshold. Thus, using the ICDAS-LAA
would reduce the subjectivity in the assessment, which
could be a promising advantage.
The studies for validating the methods for activity as-
sessment of caries lesions are still mainly based on pH in/
at the lesion. In such a design, only concurrent validity of
the system can be expressed. Moderate values of sensitiv-
ity and specificity have been shown, pointing out some
shortcomings to be improved. As pooled DOR is signifi-
cantly higher than 1, the test can give additional informa-
tion about the disease [McGee, 2002]. However, LRs sug-
gested a slight impact on posttest probability [Henderson
et al., 2012].
These findings could also be affected by the method
used in validation. Previous results suggested that the
methyl red dye underestimates the activity status of caries
lesions [Braga et al., 2010]. In addition, when comparing
LAA with other systems (whether using the ICDAS in as-
sociation or not), different studies suggested it can over-
estimate the activity status and/or need for management
[Braga et al., 2010; Tikhonova et al., 2014; Floriano et al.,
2015; Oliveira et al., 2015]. However, none of these stud-
ies prospectively confirmed these findings. Additionally,
we observed a high variability in design of the few includ-
ed studies (see online suppl. Table S3).
Certainly, predictive validation would be the ideal
strategy for checking the ability to correctly assess the car-
ies status of the lesions [Baelum, 2006], since we can
check if future events are in accordance with the expected
416 Caries Res 2018;52:406–419
DOI: 10.1159/000486429
ones. However, it takes more time and effort. Few longi-
tudinal studies focused on how active lesions detected us-
ing the ICDAS at baseline behaved after a couple of years
[Ferreira Zandona et al., 2012; Guedes et al., 2014].
In general, despite low progression rates, active caries
lesions classified using the ICDAS had a higher risk of
progression than inactive ones [Ferreira Zandoná et al.,
2012; Guedes et al., 2014], indicating the predictive valid-
ity of the activity assessment system. Therefore, the low
positive predictive value found so far may not necessarily
be related to the scoring system alone, but also related to
caries progression in the studied sample. In addition, the
findings related to activity assessment using the ICDAS
could not be generalized for all types of surfaces [Guedes
et al., 2014], nor all the ICDAS scores [Ferreira Zandona
et al., 2012]. On the other hand, we should state that sub-
group analyses were considered for that.
Lesion severity assessed with the ICDAS has been
shown to be a strong predictor of lesion progression to
cavitation [Ferreira Zandoná et al., 2012; Guedes et al.,
2014]. However, the activity can be an important param-
eter to be evaluated in conjunction to the severity in cer-
tain circumstances, for example occlusal noncavitated le-
sions (especially the ICDAS score 2) or cavitated lesions
clinically into enamel (ICDAS score 3). Additionally, ac-
tive caries lesions were found more frequently in children
with high caries experience, evidencing also the construct
validity of this system [Guedes et al., 2014]. Further pro-
spective studies are desirable to guarantee stronger levels
of evidence for caries activity assessment.
Since diagnostic accuracy studies might not demand
previous registration, systematic reviews of these studies
could inflate the test accuracy if only positive results were
published [Song et al., 2002]. However, publication bias
was only identified in a few analyses in our systematic re-
view. Using the trim and fill analysis, we tried to overview
possible unbiased results by simulating possible unpub-
lished results [Duval and Tweedie, 2000]. Actually, we
cannot affirm whether the funnel plot asymmetry is only
caused by publication bias, or also by the inherent vari-
ability among the studies [Duval and Tweedie, 2000].
However, we used this approach to investigate how our
findings could be influenced by this bias, trying to adjust
for it. Mainly the larger studies tended to show a higher
correlation to histology. On the other hand, using these
adjustments, results seem not in general to be affected as
the confidence intervals of adjusted and unadjusted esti-
mates are overlapping.
To answer the question about advantages of the
ICDAS, based on the available evidence we feel that it is
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fair to state that the ICDAS is a robust caries scoring sys-
tem to assess the severity of coronal caries lesions. Even
though there are some limitations concerning activity as-
sessment of the lesions, the ICDAS showed both predic-
tive and construct validity. The main limitation is that
there are no or very few studies concerning the ICDAS
and caries adjacent to restorations, as well as the ICDAS
and root caries.
The training in the ICDAS is burdensome; on the oth-
er hand, it requires dentists and dental hygienists to add
several predictors together before the final activity assess-
ment can be performed. In this sense, the visual appear-
ances of the lesion (ICDAS scores), the location of the
lesion (in plaque stagnation areas or not in plaque stagna-
tion areas), as well as the tactile feeling of the lesions are
the best predictors [Ekstrand et al., 2007]. Due to its sub-
stantial association between the external signs of caries
and the internal changes in the underlying tissue [Ekstrand
et al., 2007], the ICDAS can be used as an educational tool
for undergraduates.
Implications for Research
Clinical studies presenting a low risk of bias should be
encouraged, especially paying attention to sample acqui-
sition to minimize sample spectrum bias, and offers a
greater approximation to the real clinical situation. In ad-
dition, the web page of ICDAS (http://www.icdas.org)
and the monography [Pitts, 2009] are mandatory for de-
tailed knowledge.
Acknowledgements
This study was partially funded by a grant from Brazil (FAPESP
2012/17888-1 and 2014/00271-7), CNPq (400736/2014-4), Capes.
The authors acknowledge feedback from Prof. Nigel Pitts,
Kings College, London, during the development of this paper.
Disclosure Statement
K.R.E. has participated in the development of ICDAS. The au-
thors declare no financial conflict of interests.

Implications for Clinical Practice

The ICDAS presented a substantial level of reproduc-
ibility and accuracy for assessing primary coronal caries
lesions. Thus, the ICDAS is a robust caries detection sys-
tem in most of the conditions tested, encouraging its use
in clinical practice. Additional systems associated with
the ICDAS, which classify caries lesion activity, can be
useful as they are moderately reproducible and accurate.
Author Contributions
K.R.E. contributed to conception and design, acquisition of the
study, analysis and interpretation of data and drafted the manu-
script. T.G., F.R.F., and F.M.M. contributed to the data acquistion
and analysis of the data. M.M.B. contributed to acquisition, analy-
sis, interpretation of data and drafted the manuscript. All authors
critically revised the manuscript, had final responsibility for the
decision to submit, and approved the submitted version.

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