Classification of Dental Caries

dental caries may be classified in many ways: (On the basis of clinical features and
patterns) 

1. Morphology (Location of the Lesion).

2. Prior condition of the tooth.

3. Dynamics (Rate of destruction of the lesion).

4. Extent of the lesion( how much destruction ).

5. Chronology (age of patient  rarely used ).

6. ICDAS/ICCMS

 For clinical purposes , we cannot define caries in only one way  we use
combination of these methods

For example  acute occlusal caries

Why do we need to classify dental caries ?

1. To be able to determine the risk factors present in the patient  to make a

better diagnosis  better treatment

2. For a better understanding of the etiologies, locations, and activities of caries that
could cause many oral diseases

3. more precise and professional way to communicate with other dentists

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This is the most common classification

1. Crown caries ( above cemento- enamel junction )

Crown have 5 surfaces  depend on the surface we can classify crown caries into

a) occlusal caries ( Pit and fissure caries )

The most common site of caries ( more food accumulation + difficult
to clean compared to smooth surface )
Occurs in
i. pits and fissures of occlusal surface
ii. includes buccal pits of molars
iii. lingual surface of maxillary anterior teeth

 Occlusal caries usually appears earlier in life before smooth surface

caries
 Could be simple

 Could be extensive (As in pic  reached the lingual surface of upper

molar

b) Smooth surface cariesOccurs in the smooth surfaces of the teeth

Include
I. Interproximal surface caries occurs at mesial or distal contact
points

( not self cleansable ) also difficult to clean by patients ( floss )

 Examples 
Caries on the mesial surface of a posterior tooth

Caries affecting the interproximal surfaces of two adjacent

anterior teeth

II. Cervical and gingival surface ( near gingiva ) caries occurs on

buccal or lingual Surfaces (incisal or occlusal to the CEJ) of ant or
posterior teeth  self cleansable areas
we can say that patient who has cervical and gingival surface caries has worse oral
habits than in case of interproximal surface caries  because it's less to occur unless
he\she has really bad oral habit.

 In operative dentistry, lesions are classified based on the

preparation that’s needed

Class I  occlusal caries ( pits and fissures )

Class II  proximal surface of posterior teeth ( smooth surface )
Class III  proximal surface of anterior teeth not including incisal edge
Class IV  proximal surface of anterior teeth including incisal edge
Class V  gingival 3rd of facial or lingual surface of ant or post teeth
Class VI incisal edge or cusp tips
 2. Root Caries
 initiated at the root portion of the tooth ( below CEJ ) ‫مهم‬

 predominantly found in teeth of older age group with significant gingival

recession leading to exposed root surfaces

root caries ‫ في هاي الحالة ال اعتبره‬root ‫ و امتد الى ال‬crown ‫التسوس لو بدأ في ال‬
crown caries ‫لكن نعتبره‬

The bacterial flora causing the root caries maybe different from the flora
that initiate enamel caries

 You don’t have to have periodontal disease in order to have root

caries

 Root caries is a more complex process  involve many factors

 One of the factors that can accelerate root caries is periodontal

diseases

 Patient that don’t have periodontal disease  still can develop root
caries if they have other modifying factor like xerostomia

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‫ بنفس الوقت مثال ممكن صار عنا تسوس على ال‬primary & secondary ‫ممكن على سبيل المثال يكون السن فيه‬
) secondary ( ‫ ) حفرناه بعدين حطينا حشوة وبعد فترة صار تسوس حوالين الحشوة‬primary ( occlusal
) primary ( ‫ للسن نفسو‬interproximal surface ‫وممكن على سبيل المثال يصير تسوس على ال‬

 Dental caries may be classified according to the severity and rapidity of attack

 Caries progression is related to time  short term ( Acute) or long-term (Chronic)

caries .

1. Acute caries ( rampant caries ) ‫تسوس سريع‬

 cause destruction to high number of teeth in very short time

2. Chronic caries ‫تسوس لفترة مزمنة او طويلة‬

3. Active caries ‫التسوس لسا شغال‬

4. Arrested caries ‫تسوس كان شغال و توقف‬

1. Acute Caries (Rampant Caries)

 It is characterized by sudden, rapid, and almost uncontrollable destruction of

teeth
‫يعني بصير تسوس لعدد كبير من االسنان بنفس الوقت‬
 Involve many teeth at the same time

 also involves surfaces of teeth that are relatively caries free

 proximal and cervical surfaces of anterior teeth including mandibular

incisors) ( smooth surfaces usually cleansable )

Caries in mandibular incisors  indicates that the patient has high

active caries because the saliva of the submandibular salivary gland (
gravity ) that is known for its highly protection against caries

 most often observed in the primary teeth of young children and permanent
teeth of teenagers (11-19 years )

 acute caries is lighter, brownish or grayish color

Why young children around have acute caries?
 drink a lot of milk
 they don’t brush their teeth probably.

Why teenagers ( 11-19 years) have acute caries more than others?
 more junk food
 less supervised by parents

 some time it can be happened in xerostomia patients ( decreased salivary flow )

for example after radiation therapy

2. Chronic Caries happens for long time

 Which most people can suffer

 lower progression of lesion ( acute caries  short time )

 The average lesion size is smaller than in acute caries.

 darker color.

 it's mostly (not always) appears in the pits and fissures ( occlusal caries )

 There’s a continuous change in the dynamics and progression of the lesion.

(A continuous cycle of switching between demineralization and

remineralization states depending on the environment such as when the
patient isn’t persistent on brushing his teeth).
3. Active Caries
 Describe lesion that progressively destroys more tooth structure.

‫هنا عملية التسوس بتكون شغالة و بعدها شغالة‬

 Occur when the oral environment is favoring demineralization  this mean

that caries is active

 Usually matt and dull and could easily be excavated by a hand excavator
compared with arrested caries which are smoother and shinier and more
cleansable .

 we can look at color and texture and other features to determine activity
  Plaque stagnation areas such as the areas ( eg at the gingival level ) are more
prone to active Caries.

Rampant vs active ??
Rampant ( acute ) caries  usually active

4. Arrested Caries

 a lesion that may have formed earlier and then stopped

 Occurs when the active degradative process is interrupted or ceases

 In simple words when patients have had active caries  but the oral
environment is shifting towards remineralization (especially if there’s no
Cavitation )

 An example is when a patient with many white spot lesions (the first sign
of caries) starts to brush his teeth or goes to the dentist and thus these
lesions do not progress any further

 Some remineralization and discoloration ( staining ) usually characterize it

not every stain means it has active caries it could be an arrested caries
 ‫من االمثلة على ال ‪ arrested caries‬انو لما يكون عندي بروكزيمال كيرز مبلش في سن معين و لسبب‬
‫من االسباب خلعت السن الي جنبو وقتها السن الي مبلش فيه الكيرز بصير متاح للعاب و للتنظيف و يتوقف فيه‬
‫الكيرز و يتحول الى ارريستيد‬

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‫‪Moderate caries  ICDAS‬‬

1. Incipient caries  no restoration needed

 The lesion is confined to enamel and does not penetrate the DEJ

 The early carious lesion on visible smooth surfaces of teeth is clinically

manifested as a white, opaque region ( white spot lesions )

 An important feature of the early lesion is the apparently intact surface layer
overlying subsurface of demineralization

 intact surface zone layer and underneath it is the body of lesion

 can be stopped ( remineralized ) if it is early lesion

 Note: in new classifications up to 70% of lesions cross the DEJ and they’re still
not cavitaty  so they’re still under the incipient Caries category

2. Advanced caries

 The lesion penetrates the DEJ

 Cannot be reversed

 Creates a lesion that usually requires restoration

 Could be cavitated or non cavitated

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Also we can add adult caries ( elderly caries )

1. Infancy caries (early childhood caries or nursing caries or bottle feeding caries )

 a unique distribution of dental decay

 The four primary maxillary anterior incisors are affected firstthese teeth
are anatomically positioned in the mouth that is frequently bathed by a
feeding formula

‫االسنان االمامية اللبنية العلوية االربعة بصيبهم تسوس في حالة االطفال النهم بالعادة بكونو في‬
‫مجرى الحليب عند الرضاعة‬

 Should be treated because it could affect the eruption of permanent teeth

 most often seen in

a. children with unusual dietary history such as

 addition of syrup, honey or sucrose to the formula

 the use of pacifier ( ‫ ) لهاية‬dipped in honey or other

sweeteners
 b. prolonged and unrestricted night-time breast- feeding  can result in
increased caries rate.

The stagnation of milk about the neck of anterior teeth and the
fermentation of disaccharide lactose contribute to carious process

 There are two chronological periods when acute ,rapidly progressed

caries is commonly observed ( acute  rampant caries )

 Acute exacerbation in caries rate is usually seen at 4-8 years of age and at
11-18 years of age

 The acute attack in the period of 11-18 years of age usually characterized
as adolescent caries

2. Adolescent Caries  11- 18 years

 The acute attack in the period of 11-18 years of age (this age is very
sensitive as most teenagers develop bad habits such as smoking, drinking
sodas, and other harmful dietary habits.

 Characteristics are similar to rampant caries and involve many teeth

The characteristic features of this type of caries are:

I. Lesions are in teeth and surfaces that are relatively immune to caries

II. Lesions had relatively small opening in enamel with extensive undermining

III. There is rapid penetration of enamel and extensive involvement of dentin

That’s why it looks like small black spot on enamel but when we want to treat
it, we can see it in the dentine much bigger.

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ICDAS/ICCMS caries classification

International Caries Detection and Assessment System
(International Caries Classification and Management System)

 a comprehensive set of clinical protocols that address all diagnostic, preventive

and restorative decisions necessary “to preserve tooth structure and restore only
when indicated

 It is based on the well-established and widely used International Caries Detection

and Assessment System (ICDAS™).

 Look about caries as a whole process

 Includes 4 important elements

1. History  Patient-Level Caries Risk Assessment :

classifying the caries risk into

 low
 moderate
 high
 the presence of
 active caries lesion
 previous caries experience
 PUFA

 signs of xerostomia or dry mouth

 current or previous head and neck radiation

 places an individual in the high risk category

2. Classification  Caries Staging and Lesion Activity with Intraoral Caries Risk
Assessments
Staging  incipient or advanced … moderate ??  ‫تشرح الحقا‬
Activity  active or inactive  ‫تشرح الحقا‬
 by combining these stages we get the whole picture

3. Decision Making  Synthesis and Diagnosis ( based on elements 1 and 2)

4. Management  Personalized Caries Prevention, Control & Tooth Preserving
Operative Care

 So basically, it’s an international system that defined (and coded) some new
categories ( stages of Caries progression) by combining the categories that we
previously learnt about .

 It’s mainly a visual classification system

 you only need to dry the tooth and view it under light .

 Applies to all surfaces of teeth

What are the stages of carious lesions based on the ICDAS/ ICCMS Caries
merged categories ?
I. Sound surfaces (ICDAS code 0 )

 Show no evidence of visible caries  whether dried or wet

 No change in enamel translucency

 Developmental defects are still recorded as sound  because they’re

not caries

 enamel hypomineralization
 tooth wear due to attrition or erosion or abrasion

 noncarious-related stains

 Florosis
II. Initial stage Caries (ICDAS codes 1 and 2 )

 In both codes is present the first distinct visual change in enamel which
is the white spot lesion and/or brown carious discoloration

 No evidence of surface breakdown or dentine shadowing

 Code 1: you need to dry the tooth in order to see the lesion

 seen only after prolonged air drying

 Code 2: lesion could be seen without drying the tooth

 seen on a wet or dry surface

III. Moderate stage Caries (ICDAS codes 3 and 4 )

 Code 3  A white or brown spot lesion with localized enamel

breakdown (with cavitation), without visible dentine exposure
  Code 4: underlying dentine shadow (but no cavitation )

IV. Extensive stage Caries (ICDAS codes 5 and 6)

 Frank cavitation in enamel with exposed dentine

 Code 5: less extensive than code 6 but still involves dentine 

lesions exhibit cavitation involving less than half the tooth surface

 Code 6: more extensive and progressed than code 5  involves half

of the tooth surface or more
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ICCMS caries diagnosis:

1. First you determine the extent based on ICDAS classification and activity of the
carious lesion

2. Then you determine the diagnosis in order to use it for assessment of the
overall Caries risk on the patient and the likelihood of progression ( or
development of new carious lesion )
3. Then you decide the treatment

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