|Year : 2015 | Volume
| Issue : 1 | Page : 10-14
Evaluation of cavitated and non-cavitated carious lesions using the WHO basic methods, ICDAS-II and laser fluorescence measurements
Mridula Goswami, Anju Singh Rajwar
Department of Pedodontics and Preventive Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
|Date of Web Publication||9-Jan-2015|
Dr. Anju Singh Rajwar
40-B, Pocket- B, Mayur Vihar Phase-2, New Delhi - 110 091
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: This study was aimed to compare the diagnostic outcome of the WHO criteria, ICDAS-II criteria and laser fluorescence measurements in measuring the caries ratings of children. Settings and Design: Cross-sectional study. Materials and Methods: The study involved 31 children between 3 and 14 years of age, attending the Department of Pedodontics at Maulana Azad College of Dental Sciences, New Delhi. The surface-related caries status was registered according to the WHO basic method criteria (1997). Additionally, the ICDAS-II visual criteria and the DIAGNOdent readings were documented. Statistical analysis used: The data were analysed with ezANOVA and Excel 2000 (Microsoft Corporation, Redmond, WA, USA). Results: The mean ICDAS-II values amounted to 8.76 ± 0.72. The mean values for DMFS/def were 7.67 ± 0.91, whereas for DIAGNOdent it amounted to 4.00 ± 0.62. Conclusions: In conclusion, this study showed the diagnostic potential of the ICDAS-II criteria in comparison to the traditional WHO criteria by means of the non-cavitated caries lesions additionally detected. The DIAGNOdent use in field studies that already apply detailed visual criteria seems to bring limited additional information.
Keywords: Caries detection, dental caries, DIAGNOdent, early diagnosis, ICDAS-II
|How to cite this article:|
Goswami M, Rajwar AS. Evaluation of cavitated and non-cavitated carious lesions using the WHO basic methods, ICDAS-II and laser fluorescence measurements. J Indian Soc Pedod Prev Dent 2015;33:10-4
|How to cite this URL:|
Goswami M, Rajwar AS. Evaluation of cavitated and non-cavitated carious lesions using the WHO basic methods, ICDAS-II and laser fluorescence measurements. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2019 Nov 15];33:10-4. Available from: http://www.jisppd.com/text.asp?2015/33/1/10/148961
| Introduction|| |
The detection of caries is a challenge in dentistry, especially regarding the occlusal surfaces. Incipient occlusal caries have proved difficult to detect because of the widespread use of fluorides and its superficial remineralization potential, which allows the development of dentinal caries under a macroscopically intact surface.  For this reason, early detection is important to establish adequate preventive measures and avoid premature tooth treatment by restorations.
In recent decades, epidemiological studies have shown a general drop in the caries prevalence together with a concentration of lesions in the pits and fissures of permanent molars in children and young adults in many industrialized countries.  While progression of caries lesions generally appears to slow down with increasing age,  dentists diagnose young patients and adults with occlusal lesions at the non-cavitated level more frequently. , Therefore, the early detection, assessment and correct diagnosis of those lesions are key targets in the overall effort to move away from operative to non-operative preventive dentistry. 
The method used in the majority of epidemiological caries screenings is based on the DMF Index, which was established as early as in 1938.  With this index, the caries status is typically determined according to the level of cavitation. Current WHO basic methods criteria  score a caries lesion in a pit or fissure only, when "a manifest cavity, undermined enamel, or a detectably softened floor or wall is detectable; the CPI probe should be used to confirm visual evidence of caries." In contrast, detailed visual examination methods ,,, record early visible signs of the carious process such as opacities, brown discolorations, enamel breakdowns or microcavities without an obvious cavity. These visual signs have proven to be good indicators of the presence of enamel and/or dentin lesions. , The changing disease patterns with a general caries decline associated with a relatively high number of non-cavitated carious lesions was one of the reasons that led to the development of the harmonized International Caries Detection and Assessment System II [ICDAS-II] in recent years. ,,
The ICDAS was developed in 2002 by an international group of researchers (cariologists and epidemiologist) based on a systematic review of clinical caries detection systems to provide clinicians, epidemiologists, and researchers with an evidence-based system for caries detection. This method would allow a standardization of data collection and would also enable better comparability among studies. ,,,
In 2003, the ICDAS-I was devised based on the principle that the visual examination should be carried out on clean, plaque-free teeth, with carefully drying of the lesion/surface to identify early lesions. According to this system, the replacement of the traditional explorers and sharp probes with a ball-ended periodontal probe would avoid traumatic and iatrogenic defects on incipient lesions. Later, in 2005, this criterion was modified and the ICDAS-II was created at the ICDAS workshop in Baltimore. The improvement included an exchange of codes to insure that the system would reflect increased severity. , Apart from purely visual and visual-tactile caries diagnosis, there are several other methods for the detection of dental caries. This includes radiography, laser or light fluorescence-based methods, and electrical impedance measurements. It is well known that fluorescence-based methods make use of the phenomenon that carious lesions fluoresce more strongly than sound tissues when excited by light at specific wavelengths. The devices DIAGNOdent and DIAGNOdent pen (KaVo, Biberach, Germany) function on the same principle: They emit red light at 655 nm that causes fluorescence of bacterial metabolites in infected dentine. 
Since there is a need to better understand the diagnostic outcome of this visually based system in an epidemiological setting, this study was aimed to compare the caries ratings of 3- to 14-year-olds according to both WHO basic methods  and ICDAS-II detection criteria. In addition, laser fluorescence measurements (DIAGNOdent 2095, KaVo, Biberach, Germany) were carried out to investigate to what extent the current DIAGNOdent recommendations  align with the ICDAS-II criteria in vivo.
| Materials and Methods|| |
The study involved 31 children between 3-14 years of age attending the Department of Pedodontics and Preventive dentistry, at Maulana Azad Institute of Dental Sciences, New Delhi. Fourteen males and seven females were examined.
Clinical examination (WHO/ICDASII)
The caries status according to the WHO standard was determined as DMFS index for each tooth surface in the permanent dentition, as def in the primary dentition and as combined def and DMFS in mixed dentition. The examination took place in the clinics using a dental mirror with a plane surface, a CPI probe and a halogen lamp. The scoring according to ICDAS-II visual criteria [Table 1] was then carried out after performing complete oral prophylaxis. After cleaning, isolating and prolonged air drying [5 seconds], each tooth surface was assessed according to ICDAS-II criteria.
Laser fluorescence measurements
Maintaining the isolation of the teeth, the visual assessment was followed by laser fluorescence measurement with the DIAGNOdent device (DIAGNOdent 2095, KaVo, Biberach, Germany) as shown in [Figure 1] and [Figure 2]. For all measurements, the same conical probe A was used. Prior to the daily measurements, the device was calibrated following the manufacturer's instructions. The calibration was repeated hourly to rule out internal device errors as well as to ensure uniform results. The calibration was checked at the end of the daily measurements; no deviations greater than 3 against the ceramic standard occurred during the study period. The measurement of each site consisted of a brief air-drying for about 5 seconds with the air syringe of the dental unit. The inherent fluorescence of each tooth was adjusted by holding the tip against the sound smooth surface of the anterior tooth and pressing the ring button until the calibration was completed.
|Figure 2: The occlusal and the interproximal tip of the DIAGNOdent device|
Click here to view
The DIAGNOdent tip was then placed on the occlusal fissure and slightly tilted circular movements were performed along the entire fissure pattern as shown in [Figure 3]. The examiner was encouraged to re-measure carefully the sites with doubtful readings. The maximum reading for each surface was recorded. The analysis of the DIAGNOdent readings used the cut-off values recommended by Lussi et al.  for dried and cleaned occlusal surfaces.
The data were analyzed with ezANOVA and Excel 2000 (Microsoft Corporation, Redmond, WA, USA).
Repeated measures ANOVA was used to compare the three methods for caries detection. Pair-wise comparisons were made between ICDAS-II and DMFS/def, ICDAS-II and DIAGNOdent, and DIAGNOdent and DMFS/def.
| Results|| |
The mean ICDAS-II values amounted to 8.76 ± 0.72. The mean values for DMFS/def were 7.67± 0.91, whereas for DIAGNOdent it amounted to 4.00 ± 0.62 as shown in [Figure 4].
|Figure 4: Mean values of detected carious lesions for all the three methods|
Click here to view
The differences in mean values between ICDAS-II and DIAGNOdent and DMFS/def and DIAGNOdent, were statistically significant. However, the differences in mean values between ICDAS-II and DIAGNOdent were not statistically significant.
Thus ICDAS-II emerges out to be the best method among the three that detected the highest number of carious lesions (cavitated and non-cavitated).
| Discussion|| |
In addition to the conventional assessment of the caries status according to WHO basic methods criteria,  ICDAS-II criteria were applied in this study. The positive experiences collected from this investigation essentially confirm that this visually based diagnostic system has a number of benefits: While the examination procedure is very similar to the WHO process, non-cavitated caries lesions that would not be detected by the WHO assessment are recorded.
The prevalence of non-cavitated caries lesions compared to cavitations (DFS) points out the limitations of the DMF index for populations where the main caries burden is concentrated on the occlusal surfaces in molars.  Besides, the WHO criteria prove insufficient on their own in order to identify the preventive and/or therapeutic treatment needs for the examined molars.
The high portion of non-cavitated caries lesions in permanent molars can mainly be attributed to the post-eruptive onset of the caries process within up to 6 years after tooth eruption. Sporadic visits to the dentist and low utilization of preventive measures may also play a part.  Some dentists might be hesitant to seal non-cavitated caries lesions while feeling more confident about sealing pits and fissures of sound molars immediately after the eruption of a tooth. In addition to the ICDAS-II criteria, this study included the results of laser fluorescence measurements. According to the cut-off values recommended by Lussi et al.,  the DIAGNOdent readings under sound category (0-15) included the non-cavitated lesions, which the ICDAS-II visual criteria normally detected. Hence, the mean values for DIAGNOdent came out to be the least in this study.
This shows that the DIAGNOdent readings may indicate a more progressed caries lesion when compared to the ICDAS-II and WHO criteria. Moreover, laser fluorescence measurements as part of routine epidemiological screening programs have a limited practicability as they require a professional tooth cleaning, and are more time-consuming investigation than visual inspection alone. This study was conducted on a smaller scale to detect carious lesions using three different methods, however a more detailed study with larger sample size needs to be undertaken to evaluate carious lesions using WHO method, ICDAS-II and laser fluorescence measurements.
In conclusion, this epidemiological study showed the potential of the ICDAS-II criteria in comparison to the traditional WHO criteria by means of the number of caries lesions additionally detected. When using ICDAS-II criteria in vivo, the laser fluorescence device seems to bring no additional detection gain while incurring considerable extra work and expense. Hence, its use in field studies that already apply detailed visual criteria should be considered carefully when there is a lack of personal and financial resources.
| References|| |
Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro
. Caries Res 1999;33:261-6.
Marthaler TM. Changes in dental caries 1953-2003. Caries Res 2004;38:173-81.
Hannigan A, O′Mullane DM, Barry D, Schafer F, Roberts AJ. A caries susceptibility classification of tooth surfaces by survival time. Caries Res 2000;34:103-8.
Kuhnisch J, Heinrich-Weltzien R, Senkel H, Clasen AB, Sto¨sser L. Dental health and caries topography in 8-yr-old German and immigrant children. Eur J Paediatr Dent 2001;2:191-6.
Kuhnisch J, Senkel H, Heinrich-Weltzien R. Comparative study on the dental health of German and immigrant 8- to 10-years olds in the Westphalian Ennepe-Ruhr district. Gesundheitswesen 2003;65:96-101.
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.
Klein H, Palmer CE. Studies on dental caries. VII. Sex differences in dental caries experience of elementary schoolchildren. Public Health Rep 1938;53:1685-90.
WHO. Oral Health Surveys. Basic methods 1997. 4 th
ed. Geneva: WHO. Web. 22 October 2013.
Pitts NB, Fyffe HE. The effect of varying diagnostic thresholds upon clinical caries data for a low prevalence group. J Dent Res 1988;67:592-6.
Ekstrand KR, Ricketts DN, Kidd EA, Qvist V, Schou S. Detection, diagnosing, monitoring and logical treatment of occlusal caries in relation to lesion activity and severity: An in vivo
examination with histological validation. Caries Res 1998;32:247-54.
Ekstrand KR, Ricketts DN, Kidd EA. Occlusal caries: Pathology, diagnosis and logical management. Dent Update 2001;28:380-7.
Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res 1999;33:252-60.
Konig KG. Findings in serially sectioned teeth showing early fissure lesions. Adv Fluorine Res 1966;4:73-9.
Pitts NB. ′′ICDAS′′ - an international system for caries detection and assessment being developted to facilitate caries epidemiology, research and appropriate clinical management. Community Dent Health 2004;21:193-8.
International Caries Detection and Assessment System (ICDAS) Coordinating Committee. Rationale and Evidence for the International Caries Detection and Assessment System (ICDAS II). Scotland: Dental Health Services Research Unit; 2005. Available from: http://www.icdas.org
[Last accessed on 2013 October 22].
International Caries Detection and Assessment System (ICDAS) Coordinating Committee. Criteria Manual - International Caries Detection and Assessment System (ICDAS II). Scotland: Dental Health Services Research Unit; 2005. Available from: http://www.icdas.org
[Last accessed on 2013 October 22].
Jablonski-Momeni A, Stachniss V, Ricketts DN, Heinzel-Gutenbrunner M, Pieper K. Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro
. Caries Res 2008;42:79-87.
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.
Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, 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.
Ismail AI, Sohn W, Tellez M, Willem JM, Betz J, Lepkowski J. Risk indicators for dental caries using the International Caries Detection and Assessment System (ICDAS). Community Dent Oral Epidemiol 2008;36:55-68.
Hibst R, Paulus R, Lussi A. Detection of occlusal caries by laser fluorescence: Basic and clinical investigations. Med Laser Appl 2001;16:205-13.
Lussi A, Longbottom C, Gygax M, Braig F. Influence of professional cleaning and drying of occlusal surfaces on laser fluorescence in vivo
. Caries Res 2005;39:284-6.
Ismail AL, Brodeur JM, Gagnon P, Payette M, Picard D, Hamalian T, et al
. Prevalence of non-cavitated and cavitated carious lesions in a random sample of 7-9 year-old schoolchildren in Montreal, Quebec. Com munity Dent Oral Epidemiol 1992;20:250-5.
Kuhnisch J, Heinrich-Weltzien R, Senkel H, Sto¨sser L. Oral health and use of dental care by 8-year-old immigrants and German students of the Ennepe-Ruhr district. Gesundheitswesen 1998;60:500-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]