Community Dent Oral Epidemiol 2013; 41; e41–e52 Ó 2012 John Wiley & Sons A/S.

y & Sons A/S. Published by Blackwell Publishing Ltd

All rights reserved

International Caries Detection NB Pitts1 and KR Ekstrand2 on behalf of

the ICDAS Foundation
1
Dental Innovation and Translation Centre,

and Assessment System (ICDAS) Kings College London, UK, 2Section of

Cariology & Endodontics and Pediatric
Dentistry & Clinical Genetics, Department of

and its International Caries

Odontology, Faculty of Health Sciences,
University of Copenhagen, Denmark

Classification and Management

System (ICCMS) – methods for
staging of the caries process and
enabling dentists to manage
caries
NB Pitts, KR Ekstrand. International Caries Detection and Assessment System
(ICDAS) and its International Caries Classification and Management System
(ICCMS) – methods for staging of the caries process and enabling dentists to
manage caries. Community Dent Oral Epidemiol 2013; 41: e41–e52. © 2012 John
Wiley & Sons A/S. Published by Blackwell Publishing Ltd

Abstract – Objectives: The aim of this article is to provide an overview of the

International Caries Detection and Assessment System (ICDAS) and its
associated International Caries Classification and Management System
(ICCMS), explain the evolution of these systems over the past decade and
outline how they are being used for staging of the caries process in order to
enable dentists to manage caries appropriately. Methods: the article outlines and
references the key steps in development of these systems. Results: ICDAS
employs an evidence-based and preventively oriented approach, is a detection
and assessment system classifying stages of the caries process on the basis of
histological extent and activity, is designed for use in the four domains of
clinical practice, education, research and public health and provides all
stakeholders with a common language for staging caries. Over a decade ICDAS
has evolved to comprise a number of approved, compatible ‘formats’, supports
Key words: assessment; dental caries;
decision making at both individual and public health levels and has generated detection; diagnosis; management
the ICCMS to enable improved long-term caries outcomes. A range of further
developments are in train, to assist with information capture and making Nigel Pitts
FRSE BDS PhD FDS RCS (Eng) FDS RCS
clinical systems simpler and more practice friendly. Conclusion: ICDAS (Edin) FFGDP (UK) FFPH, Dental
provides flexible and increasingly internationally adopted methods for Innovation and Translation Centre (ITC)
classifying stages of the caries process and the activity status of lesions which Kings College London Dental Institute, Floor
can be incorporated into the ICCMS. The ICCMS provides options to enable 18, Tower Wing, Guy’s Hospital, Great Maze
Pond, London SE1 9RT, United Kingdom
dentists to integrate and synthesize tooth and patient information, including Tel.: +44 (0)20 7188 1164;
caries risk status, in order to plan, manage and review caries in clinical and Fax: +44 (0)20 7188 1159
public health practice. e-mail: nigel.pitts@kcl.ac.uk

doi: 10.1111/cdoe.12025
e41
Pitts & Ekstrand
The aim of this article is to provide an overview of
the International Caries Detection and Assessment Sys-
tem – ICDAS (which classifies lesions on the basis
of their clinical visual appearance), and it is associ-
ated International Caries Classification and Manage-
ment System – ICCMS (which integrates ICDAS
tooth assessments with wider patient-level infor-
mation in order to plan, manage and review car-
ies). It also seeks to explain the evolution of these
systems over the past decade and outline how they
are being used for staging of the caries process in
order to enable dentists to manage caries appropri-
ately. The article represents the work of the Inter-
national Caries Detection and Assessment System
(ICDAS) Foundation Coordinating Committee (1),
a group of volunteer colleagues from many coun-
tries working together since May 2002.
The Concept of the ICDAS Foundation, since its
beginning in 2002, has been to lead to: ‘better qual-
ity information to inform decisions about appropri-
ate diagnosis, prognosis and clinical management
at both the individual and public health levels’ (2).
Because some have become familiar with the use of
ICDAS in just one of the four domains, the system
has been designed for (clinical practice, education,
research and public health); there is often some
confusion about the true breadth of its application
across dentistry. Others are not familiar with the
extent of evolution of the Systems over the last dec-
ade. This article seeks to overcome these problems
by giving a comprehensive overview as well as
identifying other sources of more in depth infor-
mation.
The essential feature of ICDAS is the subdivision
of stages of the continuum of dental caries into a
variable number of discrete and predicable catego-
ries based upon the histological extent of the lesion
within the tooth – as shown in Fig. 1.
Methods
Although much of the research and methodologi-
cal development of key elements of the ICDAS and
ICCMS systems preceded it, the start point for their
development was the ‘International Consensus
Workshop on Caries Clinical Trials’ held in Janu-
ary 2002 (3). This Workshop sought to review the
whole area of cariology and caries clinical trials
and seek consensus as to ‘agreeing where the evi-
dence leads’. As part of this process, a systematic
review of previous caries classification systems was
planned and undertaken (4). This review compiled
e42
details of the (many) previously published systems
for classifying caries in which the very variable
diagnostic criteria employed in many cases lacked
construct validity and also made direct comparison
of evidence from different studies impossible.
These findings were also contrasted against mod-
ern concepts of caries measurement (5) identifying
a continuum of caries. A key area of consensus to
emerge from the meeting was to separate out
specific definitions for three specific terms around
caries diagnosis which were confused in the litera-
ture. The consensus (3) was to refer to:
• lesion detection (which implies an objective
method of determining whether or not disease is
present)
• lesion assessment (which aims to characterize
or monitor a lesion, once it has been detected)
• caries diagnosis (which should imply a human
professional summation of all available data).
The need for further International consensus in
the areas of caries detection and assessment real-
ized at the Workshop led to the convening of the
first meeting of the International Caries Detection and
Assessment System Group in the spring of 2002. This
group sought to overcome as much of the confu-
sion around the evidence and the terminology (lik-
ened to trying to communicate within a Tower of
Babel) in this area as possible (2). Their work on
agreed definitions has led over a period of years to
the development of an agreed International ‘Glos-
sary’ of key terms (6), which has been published,
then adopted and distributed by the FDI World
Dental Federation and has also formed the founda-
tion of a compatible US publication (7).
The group elected to merge the many different
conventions and criteria that they were working
with at that time into a single unified system, built
on best evidence and available in flexible formats
which were termed the ICDAS methodology ward-
robe. The systems that were merged to create the
ICDAS (8, 9) included those by Pitts & Fyffe; Ismail
and co-workers; British Association for the Study
of Community Dentistry; Ekstrand, Ricketts and
Kidd; Indiana University systems and the Dundee
Selectable Threshold Method. These open criteria
for use on clean dry teeth and avoiding iatrogenic
damage with sharp probes/explorers were made
widely available via the ICDAS website where they
are still available and updated periodically (10, 11).
The ICDAS classification criteria, and associated
estimates of caries activity (12–14), are based upon
the histological extension of lesions spreading into
the tooth tissues (15–17).
 ICDAS / ICCMS - staging caries to enable caries management
ICDAS codes, based on the histological
extent of lesions, stage the caries continuum
Images provided courtesy of Dr Andrea Ferreira Zandona, University of Indiana
Fig. 1. ICDAS clinical visual codes, based on evidence of the histological extent of lesions, stage the caries continuum
The essential elements of the ICDAS caries detec-
tion codes have been shown in Fig. 1. The visual cri-
teria for the full series of sound and six caries codes
(from the first visual carious change in enamel seen
clinically only when the tooth is dry (code 1) to the
histologically more extensive distinct visual change
which is visible wet or dry (code 2), through steps to
the most severe stage, the extensive distinct cavity
with visible dentine) were built following careful
reviews of the literature (2), including earlier work
spread over a period of 60 years from authors,
including Backer Dirks; Marthaler; the WHO; Pitts
& Fyffe; Ismail; Ekstrand, Ricketts & Kidd; Fyffe &
co-workers and Nyvad. These stages of lesion
severity, shown for many years using an iceberg
metaphor, are shown on the detecting lesion extent
front face of the ICDAS cube in Fig. 2. This figure
also shows the point-in-time assessment of lesion
activity element and the monitoring of lesion behav-
iour over time element.
The ICDAS conventions were developed and
refined in a series of meetings of the coordinating
committee held over 2002–2004 in Dundee, Scot-
land; Michigan, USA; Indianapolis, USA and Born-
holm, Denmark, before an open peer-review
Workshop held in association with the Interna-
tional Association for Dental Research meeting in
Baltimore, USA in 2005. Following this meeting,
the sequence of codes 3 and 4 was swapped with
what became known as the ICDAS II criteria. Since
that time, there have been no further substantial
changes in the System, so the ‘II’ suffix has been
dropped from the name.
At all these workshops, the underlying preven-
tive ethos of the ICDAS system has been reinforced,
www.icdas.org
and the desire to facilitate a move from an opera-
tive/surgical approach to more nonoperative/pre-
ventive treatment of dental caries in clinical practice
has been stressed (18, 19) with the development and
publication of an ICDAS framework for caries man-
agement.
Over the last decade, the ICDAS system has been
built upon incrementally by the ICDAS Coordinat-
ing Committee via a further series of international
workshops, often held in partnership with a series
of International dental organizations. These
include the International Association for Dental
Research, the European Organization for Caries
Research, the Association for Dental Education in
Europe and the FDI World Dental Federation. Over
the 2008–12 period, these development meetings
have included:
• ICDAS Workshop at Bogota, Colombia - October
2008
• ICDAS Workshop at Temple University, USA –
April 2010
• ICDAS Symposium at Montpellier, France – July
2010
• ICDAS pre ORCA Workshop Kaunas, Lithuania
– July 2011
This work has developed the ICDAS preven-
tively oriented framework for patient-centred car-
ies management (19) into a more comprehensive
International Caries Classification and Manage-
ment System – the ICCMS (1, 20–24). This Caries
Management System seeks to improve decision
making and enable improved long-term caries out-
comes; it was trade marked by the ICDAS Founda-
tion (a charity) on advice in order to be able to
ensure that this open system remains free for use
e43
Pitts & Ekstrand
Fig. 2. The ICDAS cube – caries detection and assessment by determining lesion extent and activity, allowing monitor-
ing of behaviour over time.
by all and allow the linkage to evidence to be main-
tained by the ICDAS Coordinating Committee.
Results
The 2012 status of ICDAS system of classifying car-
ies lesions and the ICCMS system for extending
this into patient focussed, risk assessed caries man-
agement can best be summarized by the shared
‘vision statement’ agreed at the July 2011 ICDAS
Review held in Kaunas, Lithuania. This states that
‘the shared Vision for the International Caries
Detection and Assessment System – ICDAS is:
• ICDAS: employs an evidence-based and preven-
tively oriented approach
• ICDAS is: a detection & assessment system clas-
sifying stages of the caries process
• ICDAS is for: use in dental education, clinical
practice, research and public health
• ICDAS provides: all stakeholders with a com-
mon caries language
• ICDAS has evolved: to comprise a number of
approved, compatible ‘formats’
• ICDAS supports decision making: at both indi-
vidual & public health levels
• ICDAS has generated ICCMS to enable:
improved long-term caries outcomes’
The International Caries Classification and Man-
agement System – ICCMS deliberately incorporates
a range of options designed to accommodate the
needs of different users across the ICDAS domains
of clinical practice, dental education, research and
public health. These options are represented by the
e44
www.icdas.org
2012 ICDAS / ICCMS wardrobe, which is out-
lined in Fig. 3 and explained in more detail on the
ICDAS website (1) and in recent publications (22).
The wardrobe analogy is related to the ability to
choose from ICDAS / ICCMS whatever is most
appropriate in terms of methodology for the task at
hand, be it for clinical practice, dental education,
research or public health use.
Figure 3a shows the central options with the full
6 codes of caries system in the middle of the figure,
the merged codes (three stages of caries) option on
the left door and the binary, WHO Basic Methods-
like system of obvious dentine caries or ‘sound’
depicted on the right door. All of these options
related to the ‘D’ component of the DMF Index.
Should anyone need to calculate the DMF index at
either the Tooth or Surface level, this is readily
achievable – as depicted by the shelf at the top of
the Wardrobe. The PUFA Index, or a subset of it, is
also finding favour with a number of users interna-
tionally and can be used with the systems. Fig-
ure 3b shows the options of prevention-focussed
clinical care for individual patients in ICCMS Prac-
tice, standardized and evidence-based cariology
education for ICCMS Education, population and
clinical research on caries and caries management
in ICDAS & ICCMS Research and population-
focussed health promotion, prevention and needs
assessment in ICDAS & ICCMS Public Health.
The core clinical visual coding of ICDAS is
explained and illustrated in detail by a ninety-min-
ute e-learning programme developed to support
training in the use of ICDAS. This explains the IC-
 ICDAS / ICCMS - staging caries to enable caries management

www.icdas.org

ICDAS and the International Caries Classification and Management System - ICCMS™

B
ICCMS™ Practice

Prevention-focussed
Clinical Care for
individual patients

ICDAS & ICCMS™ ICDAS & ICCMS™

Research Public Health
Population and Clinical Population focussed Health
Research on caries and Promotion, Prevention and
caries management Needs Assessment

ICCMS™ Education

Standardized and EBD

Cariology Education www.icdas.org

Fig. 3. The ICDAS wardrobe 2012 – (a) How the full 6-caries code format is compatible with the merged codes recording
option, the Basic reporting option and DMF – PUFA indices (b) How the wardrobe can be used in each of the four
ICDAS – ICCMS domains of Practice, Research, Education and Public Health.

DAS examination protocol and reviews the coding
system and is available free for download in
English, Spanish, German and Portuguese from the
ICDAS Foundation website’s E-Learning page (25).
A PowerPoint Training Pack (comprising 52 slides)
entitled ICDAS Criteria For Detecting Coronal Car-
ies was developed after the Baltimore IADR work-
shop in 2005 and is available from the ICDAS
Foundation Website, downloads page (26).
To assess the international adoption and incre-
mental development of the ICDAS/ICCMS sys-
tems to date, a review of the publications referring
to ‘ICDAS in the literature’ is useful. This listing is
available on the ICDAS website (27) and, in May
2012, it indicated some 88 peer-reviewed publica-
tions, six Books/Chapters and 45 examples of
other types of publication. The first authors
listed in these publications came from some 19
Countries.
Another International group to both use and
promote the ICDAS systems is the Alliance for a
Cavity-Free Future, ACFF. This group of worldwide
leaders from the dental and public health profes-
sions have joined together to create a global Alli-
ance promoting integrated clinical and public
health action in order to stop caries initiation and

e45
Pitts & Ekstrand
progression to move towards a ‘Cavity-Free
Future’ for all age groups (28). The Alliance has
agreed a Declaration, and with oral health industry
support has produced a free and open web-based
resource (with incremental updates being intro-
duced) in order to facilitate the comprehensive
prevention and management of caries for commu-
nities, groups and individuals and is catalysing a
global social movement to ‘Stop Caries NOW for a
Cavity-Free Future’. It promotes awareness of the
full continuum of dental caries and uses ICDAS
methodology, particularly in supporting develop-
ments in dental education. In order to take forward
action on a local level, Alliance ‘Chapters’ have
been formed in Colombia, Mexico, Brazil, Venezuela
and China with more Countries preparing to join.
The Chapters are working with Dental Schools in
their own regions.
So, it can be seen that ICDAS employs an evi-
dence-based and preventively oriented approach; is
a detection and assessment system classifying stages
of the caries process on the basis of histological
extent and activity; has been designed for use in the
four domains of clinical practice, education, research
and public health; provides all stakeholders with a
common language for staging caries; and is being
used in an increasing number of countries over time.
Discussion
Over the last decade, ICDAS has evolved to com-
prise a number of approved, compatible user-
selectable ‘formats’ which all support decision
making at both individual and public health levels
and has generated the ICCMS to enable improved
long-term caries outcomes. Recent progress in the
four ICDAS domains of clinical practice, education,
research and public health are discussed below.
ICDAS / ICCMS in Clinical practice
It is important to stress that while clinical visual
detection and assessment of lesions on clean dry
teeth represents the clinical foundation for assess-
ing caries status at the individual level, the clini-
cian also needs to use (19) ‘Lesion Detection Aids’,
such as radiographs and/or other adjuncts to
detection. A recent review has highlighted that ‘the
electrical methods and laser fluorescence could be
useful adjuncts to visual-tactile and radiographic
examinations, especially on occlusal surfaces in
permanent and primary molars, although existing
evidence was graded as limited’ (29). Lesion activ-
e46
ity assessment (14) is also clinically very important
for treatment planning, particularly in deciding
when continuing preventive treatment options are
appropriate (19).
The logic of using caries criteria to underpin a
dental Care Pathway as part of a comprehensive,
risk-based, Oral Health Assessment is not new (30,
31) but has been refined and with ICDAS criteria
tested for feasibility in a General Dental Practice
setting in the UK (32) and across Europe (33).
Recently, the ICDAS method has been outlined in
guidance to General Dental Practitioners as part of
the Scottish Dental Clinical Effectiveness Pro-
gramme’s documentation on Oral Health Assess-
ment and Review (34). This Guidance is being
picked up and used by dental authorities in a num-
ber of countries, from Denmark to New Zealand.
In developing ICCMS Practice – to provide Pre-
vention-focussed Clinical Care for individual
patients – the participants at the 2010 ICCMS
development workshops in Temple and Montpel-
lier agreed the following Guiding Principles:
• Prevention* as a priority, surgical intervention
only used as a last resort (*both primary and
secondary)
• Where surgery is indicated, use minimal
removal of tooth tissue
• Cavity size and selection of material are gov-
erned by preservation of tooth tissue destruction
and healthy patient outcomes.
They also underlined the importance of includ-
ing the full ‘spectrum’ of caries severity across the
caries continuum (22) from health and wellness at
one end, including initial stage caries and then
moderate and extensive lesions (whether on a scale
divided into 3 or 6 elements) all the way through
to recording pain and sepsis at the other extreme.
The ICDAS caries management system has
evolved from the original ICDAS ‘Framework’ set
out in the Karger Monograph of 2009 (20), which
has been extensively used in Japan – working well
for both patients and dentists as well as being
financially viable (35). The development of the IC-
CMS is summarized in Fig. 4. This system is being
refined further with simpler and more practice-
friendly methods of delivery. There is an ICDAS
Book currently being finalized which is entitled
‘Clinical Management of Dental Caries: How to
plan and deliver rational, evidence-based caries
care’ which should make these choices clearer; this
publication should be available in 2013.
The upper half of Fig. 4 demonstrates the expli-
cit link between this System and overall goals to
 ICDAS / ICCMS - staging caries to enable caries management

The International Caries Classification and Management System

™
(ICDAS’s ICCMS ) including e-Learning, software and data aspects
Goal: to improve oral health through the
With parallel implementation of a new paradigm for managing In concert
“Upstream” dental caries and its consequences, one that is based with other
Common Risk on our current knowledge of the disease process and improvements
Factor its prevention, so as to deliver optimal oral and thus in Oral and
Approach general health and well being to all peoples General
Activities (FDI Global Caries Initiative) Health

Monitoring & Review

Can be delivered as a cycle using

Caries Management Pathways
(CMPs)
Clinical
Initial treatments
(non-surgical
patient Detection, & surgical)
assessments Synthesis
activity and with
[Histories & and
appropriate prevention
data collection] decision -
risk
making
assessment

Monitoring & Review

Fig. 4. Schematic overview of the International Caries Classification and Management System (ICDAS’s ICCMS).

Clarification of histologically compatible R

choices for caries reporting
e
s
Lesions into e
pulp a
+ Clinically detectable
r
lesions in dentine c
h
+ Clinically detectable
‘cavities’ limited to enamel
G
r Binary & P
+ Clinically detectable enamel lesions
a Obvious Dentine Caries = II

with ‘intact’ surfaces No Obvious Dentine Caries = I

d
i ICDAS & P
+ Clinically detectable only with
n
Simplified format
(3 -levels)
additional diagnostic aids
g
ICDAS & PUFA
+ Sub-clinical initial lesionsDetection Codes
(+/–) = activity status
in a dynamic state of progression/regression

Extension of both ICDAS Iceberg and scale options

with addition of more research levels below & between 0-6

Fig. 5. Illustration of how the iceberg of caries severity maps onto the histologically compatible choices of the ICDAS
wardrobe and areas for further cariology research (Note P signifies a simplified recording of the PUFA Index).

improve health and oral health while at the same
time playing a part in reducing health inequalities
(21). Linkage with the Goal of the FDI World Den-
tal Federation Global Caries Initiative and with
parallel ‘upstream’ prevention linking to the com-
mon risk factor approach should help to achieve
health improvement. However, it is also impor-
tant that when an individual patient interacts with
dental teams in primary care that prevention and
long-term health maintenance are the priorities,
and ICCMS seeks to help the dental team deliver
such care.
The lower half of Fig. 4 illustrates the four key
elements of the ICCMS, namely Initial Patient.
Assessments (collecting personal and risk-based
information through histories and systematic data
collection); Lesion Detection, Activity and Appro-
priate Risk Assessment (detection and staging of
lesions, assessment of caries activity and caries risk
assessment using appropriate methods – such as

e47
Pitts & Ekstrand
Cariogram or CAMBRA (36)); Synthesis and deci-
sion making (integrating the patient-level and
lesion-level information (22)); and Clinical Treat-
ments (Nonsurgical & Surgical) with prevention
(ensuring that the treatment planning options
available are prevention orientated and include
nonsurgical options whenever appropriate). These
steps in the Management System are intended to
be re-visited in a cyclical manner, with monitoring
and review at risk-based intervals; they could read-
ily be delivered using appropriate Caries Manage-
ment Pathways. It is an important priority
internationally that reimbursement systems are
upgraded to match this type of clinical caries man-
agement and to reward those dental teams plan-
ning, providing and maintaining optimal health
for their patients.
The way in which the various coding options
from the ICDAS Wardrobe relate to grading the
severity of caries using the iceberg metaphor
(Fig 2) is set out graphically in Fig. 5. It should be
clearly understood that not everyone using the IC-
CMS is required to use all 6 ICDAS caries codes.
However, while some in practice favour the
merged coding system with fewer steps, others
prefer to use all six caries codes from the full IC-
DAS as this allows them to assess the success or
failure of preventive interventions for noncavitat-
ed caries lesions in their patients. The concept, as
from the start of ICDAS, is still to allow users to
select and use a carefully defined, evidence-
informed option to best fit their needs and prefer-
ences. This type of clarity regarding how different
ways of grading caries extent can be compared in
a compatible way is also seen in the initial version
of the recently published FDI World Dental Fed-
eration Caries Matrix (24) which usefully seeks to
provide an evolving framework that facilitates
communication between practitioners, researchers,
policy makers and patients. This communication
is essential if progress is to be made in imple-
menting the widespread scientific recommenda-
tions for the adoption of more preventive and less
surgically dominated caries management in main-
stream clinical practice.
ICDAS/ICCMS in education
The initial development of ICDAS has been taken
forward by dental academics working from many
dental schools (1), and the specification of the IC-
CMS was undertaken by representatives of 11
International Dental Schools, building on the needs
and experiences of dental education at both under-
e48
graduate and postgraduate levels. A very useful
parallel activity in recent years has been the joint
work of the European Organization for Caries
Research and the Association for Dental Education
in Europe who partnered in first the development
of a survey on education in cariology for under-
graduate dental students across Europe (37) and
then, having received a mandate to do so, devel-
oped a European Core Curriculum in Cariology
(38). This process has achieved International con-
sensus (involving dialogues with colleagues in
North and South America as well as in Europe) on
the competencies needed across the five key areas
that were agreed as essential in cariology educa-
tion (38). This process has also allowed a mapping
for the caries risk assessment, diagnosis and syn-
thesis parts on to the ICCMS (22). This illustrated
that while treatment planning for initial stage car-
ies (ICDAS codes 1, 2) and extensive caries (ICDAS
codes 5, 6) is, in many cases, quite straight forward;
real clinical decision-making skill is needed for
planning optimal care for moderate caries (ICDAS
codes 3, 4) .
ICDAS / ICCMS in research
The range of articles being published using IC-
DAS methodology (27) and the number of pre-
sentations being made around the world of
research using ICDAS is an encouraging marker
of the widespread adoption of the method by
many in the research community. The ICDAS &
ICCMS Systems provide a range of research
options for both population and clinical research
on caries generally and on caries management in
particular. A key aspect of the design of ICCMS
is that compatible (if not identical) systems of
staging caries are now being used in both
research and clinical practice. This should shorten
the translation time in getting research findings
incorporated into practice procedures.
Working with IADR, there are now a range of
research and implementation agendas available in
this field (21). The IADR GOHIRA (Global Oral
Heath Inequalities Research Agenda) initiative
has defined research priorities associated with
both upstream arm of how best to introduce pre-
vention and common risk factors and the imple-
mentation arm, of getting research findings into
routine practice. An example of progress in this
area is that IADR Regional Development Pro-
gramme project led by Dr Rita Villena: a Multi-
country Programme to train and standardize
trainers on epidemiological and diagnostic criteria
 ICDAS / ICCMS - staging caries to enable caries management
of dental caries in the primary dentition of chil-
dren less than 6 years of age in Latin America. In
this study, an ICDAS trainer calibrated a refer-
ence examiner and trainer for each of eight Latin
American Countries who have then gone on to
cascade the training to local teams who have car-
ried out pilot studies in their countries prior to
the initiation of community caries preventive pro-
grammes aimed at the most disadvantaged
infants.
ICDAS/ICCMS in public health
Once again, the increasing number of public
health-based studies and surveillance exercises
conducted, where the additional information from
early stage caries is warranted for local and/or
national information needs, using ICDAS/ICCMS
criteria is encouraging (27). It should be appreci-
ated that there are a range of options for collecting
ICDAS data which allow the use of the full ICDAS
codes or a merged codes format (22) and that, from
the same data set, backward compatible estimates
of D3MFT/S (i.e. DMF using caries into dentine
stages of disease only) can readily be computed (9).
It is also important to be aware that, for those
who feel that using compressed air to dry teeth in a
field setting is too complex, an approved epidemio-
logical modification allows the use of gauze for
drying at the merging of codes 1 and 2 into code
‘A’. Others, particularly those in the European
Association for Dental Public Health, have found
that the use of portable compressed air for drying
teeth in the field is feasible when this type of infor-
mation is required. Similarly, while some have
found the dual coding system (which records
details of restorative and/or sealant status of tooth
surfaces as well as caries status) unusual for epide-
miological studies, others have found this useful
for obtaining up to date information about the type
of care being offered to subjects examined.
The magnitude of the differences between esti-
mates of ‘No detectable caries’ made by WHO
Basic Methods-style surveys and estimates made
by local practitioners or those collecting more com-
prehensive estimates, including more stages of car-
ies and supplementing clinical examination with
radiographic information have been underlined by
the results of a National Child Dental Health Sur-
vey conducted in Iceland (39). Collecting data
using the full ICDAS codes allowed the results to
be calculated at both the D1 threshold (enamel and
dentine caries) as well as the D3 threshold (dentine
caries only). The percentage of children with ‘no
detectable caries’ in permanent teeth at 12 years of
age was found to be 48% (D3 threshold clinical
visual), or 34% (D1 threshold clinical visual), or
22% (D3 threshold clinical visual + radiographic) or
15% (D1 threshold clinical visual + radiographic).
Similarly, the percentage with ‘no detectable caries’
in permanent teeth at 15 years was 35% (D3 thresh-
old clinical visual), or 20% (D1 threshold clinical
visual), or 16% (D3 threshold clinical visual +
radiographic) or 6% (D1 threshold clinical visual +
radiographic). These variations in the proportion
of children affected, demonstrates the importance
of carefully specifying and reporting the diagnostic
criteria employed in studies and surveys.
The 2011 ICDAS Workshop in Kaunas discussed
at length the confusion in the literature and
amongst users of caries data about diagnostic
thresholds and how DMF data collected with dif-
ferent conventions are reported. To be clearer in
the future for all users of caries data, the Workshop
has recommended that ICDAS data be reported
specifying in subscript that ICDAS criteria were
used and listing the codes which are recognized as
caries. For example, survey results could now be
described as DICDAS 1-6MFT (for the D1 threshold
clinical visual data) or DICDAS 4-6MFT (for D3
threshold clinical visual data). It should be noted
that different regions are now using different cut-
offs for the D3 threshold (9) and specifying exactly
which codes have been used will aid comparability
between studies.
ICDAS/ICCMS – Next steps for users
A range of further developments are currently in
train, to assist with information capture and mak-
ing clinical systems simpler and more practice
friendly. Figure 6 shows a screen from a software
tool being developed for the iPad (and similar
tablet devices and laptop computers) in which
data entry of ICDAS codes is simplified and
speeded up compared with conventional paper
charts and in which digital re-configuration of
data is also facilitated according to the task at
hand and the type of epidemiological data
needed. This results screen shows how data can
be presented and the various controls allowing
the operator to specify the diagnostic threshold
used, (Decay threshold), whether to report by
Tooth or Surface, and age and sex information.
This software tool is a precursor to ‘Practice’ ver-
sion which will simply ICDAS charting using
methods which could be built into future practice
systems worldwide.
e49
Pitts & Ekstrand
Fig. 6. Screen shot of an ICDAS Epidemiology software tool being developed for the iPad (and similar tablet devices
and laptop computers) to facilitate data entry, collation and manipulation.
Working with partners, the ICDAS Foundation
intends over the coming years to introduce:
• New Web developments
• Updated eLearning Programmes with case stud-
ies
• A new ICDAS Book
• More software tools
in order to make the ICDAS and ICCMS systems
even more useful and user-friendly across the four
domains.
In summary, ICDAS and ICCMS are methods for
first staging of the caries process and then enabling
dentists to manage caries. For more than a decade,
an International group, constituted as a Charitable
Foundation, has been synthesizing best evidence to
stage the caries process in order to obtain better
quality information to inform decisions about
appropriate clinical management at both the indi-
vidual and public health levels. There is now a
wealth of published international evidence to
support the validity and utility of this method of
staging caries and showing the increasingly wide-
spread adoption of the systems continues, using a
flexible choice of formats from the ICDAS ICCMS
Wardrobe. Since 2002, ICDAS has been across four
domains to provide tools for: Clinicians, Educators,
Researchers and those in Public Health. A range of
new developments are currently in train, many of
which should help clinicians and educators to bet-
ter plan, deliver and monitor appropriate caries
treatment.
e50
Conclusion
ICDAS provides flexible and increasingly interna-
tionally adopted methods for classifying stages of
the caries process and the activity status of lesions
which can be incorporated into the ICCMS. The
ICCMS provides options to enable dentists to inte-
grate and synthesize tooth and patient information,
including caries risk status, in order to plan, man-
age and review caries in clinical and public health
practice.
Acknowledgements
The work and concepts included in this presentation
have been the result of extensive and enduring collabora-
tions – within the core ICDAS Committee, with ORCA,
FDI and IADR colleagues and with other academic and
clinical colleagues worldwide. We would like to specifi-
cally acknowledge the significant contributions that all
these individuals have made by generously sharing their
time, effort and expertise, as well as the support of a
wide range of funding agencies. Specific thanks are to:
Colgate, Smile-on and other companies who have sup-
ported this work through no-strings educational grants
over the years including Johnson & Johnson, Cadbury
and CariesScan.
References
1. ICDAS Foundation website http://www.icdas.org/
home (accessed June 15th 2012)
 ICDAS / ICCMS - staging caries to enable caries management
2. Pitts NB. “ICDAS”: an international system for car-
ies detection and assessment being developed to
facilitate caries epidemiology, research and appro-
priate clinical management (editorial). Community
Dent Health 2004;21193–8.
3. Pitts NB, Stamm J. ICW-CCT Statements. J Dent Res
2004;83: : 125–8.
4. Ismail AI. Visual and visuo-tactile detection of dental
caries. J Dent Res 2004;83:C56–66.
5. Pitts NB. Modern concepts of caries measurement.
J Dent Res 2004; 83:: 43–7
6. Longbottom CL, Huysmans MC, Pitts N, Fontana M.
Glossary of key terms (published online ahead of
print June 3, 2009). Monogr Oral Sci 2009;21:209–16.
7. Fontana M, Young DA, Wolff MS, Pitts NB, Longbot-
tom C. Defining dental caries for 2010 and beyond.
Dental Clinics in North America. 2010;54:423–40.
8. Ismail AI, Sohn W, Tellez M et al. The International
Caries Detection and Assessment System (ICDAS):
an integrated system for measuring dental caries.
Community Dent Oral Epidemiol 2007;35:170–8.
9. Topping GV, Pitts NB. International Caries Detection
and Assessment System Committee. Clinical visual
caries detection. Monogr Oral Sci 2009;21:15–41.
10. International Caries Detection and Assessment Sys-
tem Coordinating Committee - Rationale and Evi-
dence for the International Caries Detection and
Assessment System (ICDAS II) - Reviewed Septem-
ber 2011 (unchanged from 2005). ICDAS Foundation
Website downloads page http://www.icdas.org/
downloads (accessed June 15th 2012)
11. Criteria Manual - International Caries Detection and
Assessment System (ICDAS II). Revised in December
and July 2009 (Bogota, Colombia and Budapest,
Hungary) – from a Workshop held in Baltimore,
Maryland, March 12th-14th 2005. ICDAS Foundation
Website downloads page http://www.icdas.org/
downloads (accessed June 15th 2012)
12. Ekstrand KR, Ricketts DNJ, Kidd EAM, Qvist V,
Schou S. Detection, diagnosing, monitoring and logi-
cal treatment of occlusal caries in relation to lesion
activity and severity: an in vivo examination with
histological validation. Caries Res 1998;32:247–54.
13. Ekstrand KE, Ricketts DN, Longbottom C, Pitts NB.
Visual and tactile assessment of arrested initial
enamel caries lesions: an in vivo examination. Caries
Res 2005;39:173–7.
14. Ekstrand KR, Zero DT, Martignon S, Pitts NB. Lesion
activity assessment. Monogr Oral Sci 2009;21:63–90
15. Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility
and accuracy of three methods for assessment of
demineralization depth of the occlusal surface: an in
vitro examination. Caries Res 1997;31:224–31.
16. Ekstrand KR, Martignon S, Ricketts DJ, Qvist V.
Detection and activity assessment of primary coronal
caries lesions: a methodologic study. Oper Dent
2007;32:225–35.
17. Ekstrand KR, Luna LE, Promisiero L, Cortes A, Cue-
vas S, Reyes JF et al. The reliability and accuracy of
two methods for proximal caries detection and depth
on directly visible proximal surfaces: an in vitro
study. Caries Res 2011;45:93–9.
18. Pitts NB. Are we ready to move from operative to
non-operative/preventive treatment of dental caries
in clinical practice? Caries Res 2004;38:294–304.
19. Pitts NB, Richards D. International Caries Detection
and Assessment System Committee. Personalized
treatment planning. Monogr Oral Sci 2009;21:
128–43.
20. Pitts NB. International Caries Detection and Assess-
ment System Committee. Introduction – How the
detection, assessment, diagnosis and monitoring of
caries integrate with personalized caries manage-
ment. Monogr Oral Sci 2009;21:1–14.
21. Pitts N, Amaechi B, Niederman R, et al. Global oral
heath inequalities: dental caries task group –
research agenda. Adv Dent Res 2011;23:211–20.
22. Pitts N, Melo P, Martignon S, Ekstrand K,
Ismail A. Caries risk assessment, diagnosis and
synthesis in the context of a European Core Cur-
riculum in Cariology. Eur J Dent Educ 2011;15
(suppl 1):23–31.
23. Pitts N. Modern perspectives on caries activity and
control. JADA 2011;142:790–2.
24. Fisher J, Glick M (with Fernandes C.P., Jin L.J.,
Meyer G.B., Y€ ucel T, Clarkson J., Jones D., Meyer D.,
and Pitts N.). A new model for caries classification
and management: The FDI World Dental Federation
Caries Matrix. JADA 2012; 143: 546–51.
25. A 90-minute e-learning program developed to sup-
port training in the use of ICDAS. Available free for
download in English, Spanish, German and Portu-
guese. ICDAS Foundation E-Learning page at
http://www.icdas.org/icdas-e-learning-course
(accessed June 15th 2012)
26. PowerPoint Training Pack (52 slides) - ICDAS Crite-
ria For Detecting Coronal Caries. (2005). ICDAS
Foundation Website downloads page: http://
www.icdas.org/downloads (accessed June 15th
2012)
27. ICDAS in the Literature, http://www.icdas.org/ic-
das-in-the-literature (accessed June 15th 2012)
28. The Alliance for a Cavity-Free Future, http://
www.AllianceforaCavity-FreeFuture.com (accessed
June 15th 2012).
29. Twetman S, Axelsson S, Dahlen G, Espelid I, Mej are
I, Norlund A et al. Adjunct methods for caries detec-
tion: a systematic review of literature. Acta Odontol
Scand, 2012;Early Online:1–10.
30. Hally JD, Pitts NB. Developing the first dental care
pathway: the oral health assessment. Primary Dental
Care 2005;12:117–21.
31. Clinical Pathways Project - DHSRU Dundee: The
NHS Oral Health Assessment Final Report April
2006. DH Reference Number: ZPD/105/CP (CDO
Website Department of Health, England).
32. Ormond C, Douglas G, Pitts N. The use of the Inter-
national Caries Detection and Assessment System
(ICDAS) in a National Health Service General Dental
Practice as part of an Oral Health Assessment. Pri-
mary Dental Care 2010;17:153–9.
33. Bonner BC, Chan KPS, Bourgeois DN, Douglas
GVA, Pitts NB. The feasibility of utilising European
general dental practitioners and ICDAS caries codes
to monitor population oral health at local, national
and international levels. Primary Dental Care
2011;18:83–90.
34. Oral Health Assessment and Review – Full Guid-
ance. Scottish Dental Clinical Effectiveness Pro-
gramme. Pitts NB (Guidance Development Group
e51
Pitts & Ekstrand
Chair) and the SDCEP Guidance Development
Group –May 2012 http://www.sdcep.org.uk/
index.aspx?o=3079
35. Sugiyama S, Toyoshima Y, IIjima Y, Momoi Y,
Tsuge S. ICDAS – New management of caries
treatment developed by ICDAS detection of
treatable caries lesion features tooth substance
preservation remedy. J Health Care Dent 2009;11:
17–70.
36. Twetman S, Fontana M. Patient caries risk assess-
ment. Monogr Oral Sci 2009;21:91–101.
37. Schulte AG, Buchalla W, Huysmans MCDNJM,
Amaechi BT, Sampaio F, Vougiouklakis G et al. A
e52
survey on education in cariology for undergraduate
dental students in Europe. Eur J Dent Educ 2011;15
(Suppl. 1):3–8.
38. Schulte AG, Pitts NB, Huysmans MCDNJM, Splieth
C, Buchalla W. European Core Curriculum in Cariol-
ogy for undergraduate dental students. Eur J Dent
Educ 2011;15(Suppl. 1):9–17.
39. Agustsdottir H, Gudmundsdottir H, Eggertsson H,
Jonsson SH, Gudlaugsson JO, Saemundsson SR et al.
Caries Prevalence of permanent teeth: a national sur-
vey of children in Iceland using ICDAS. Community
Dent Oral Epidemiol 2010;38:299–309.