Cavity classification systems

1. DENTAL CAVITY CLASSIFICATION SYSTEMS

2. • Dental caries lesions form a significant portion of any dental professional’s daily practice. Oral
health care and healthy teeth are important for people from any part of society. The effects of
dental caries on growth and physical, emotional, and cognitive development have implications on
success and productivity throughout the life span.
• Through various epidemiological studies across different parts of the Indian population, it was
observed that the prevalence of dental caries was high irrespective of the age groups.
• This disease can fall anywhere between non-cavitated surfaces to pulpal lesions or root defects. It
is imperative that all such classification systems must be simple, reliable, comprehensive, and
reproducible as well as validated by the observers.
• The need to classify caries with a focus on communication, outcome, prognosis, and treatment
planning forms the baseline of the discussion. Classifications of caries are necessary to develop a
common language for treatment indication and outcomes.
• These systems are used as a prognostic tool to determine the natural history and outcomes, guide
treatment decision-making, and predict the possibility of complications. This article reviews the
historical evolution, the respective strengths, and shortcomings of each classification system.

12. • 2. WHO Classification: [1979]
• World Health Organisation proposed DMF index to evaluate the caries experience in different populations.
This index measures the severity of the lesions as long as the distributions of the lesions in the population are
the same. The D/d component of DMFT/deft index is subdivided based on the depth of caries.
• D1 - Clinically detectable enamel carious lesions, with intact surfaces (non-cavitated)
• D2 - Clinically detectable cavities involving enamel.
• D3 - Clinically detectable cavities into dentin
• D4 - Lesions extending to pulp
•
• This classification/ index doesn’t record the progression rate of caries and root caries.

13. • Root surface caries severity index by Billings: [1985]
• With the observations in extracted teeth, Billing developed a caries index for segregating the root lesions by type with
treatment categories. This helps to assist in monitoring the progression of lesions following treatment.
• The grade I incipient lesions are treated by topical fluoride therapy alone, Grade II (shallow) lesions could be treated
successfully by smoothing using abrasive points and fine diamonds in combination with topical fluoride therapy.
Grade 3 cavitated lesions involve minimal cavity preparation with restoration using GIC.
• Grade I (Incipient): soft surface texture with no surface defect. Variable pigmentation from light tan to brown color
• Grade II (Shallow): Soft, irregular, rough surface texture, surface defect (less than 0.50 mm in depth).Variable
pigmentation from tan to dark brown.
• Grade III (Cavitation): Soft surface texture, cavitation present (greater than 0.50 mm in depth) with no pulpal
involvement. Variable pigmentation from light brown to dark brown.
• Grade IV (Pulpal): Deeply penetrating lesion with pulpal or root canal involvement. Variable pigmentation from
brown to dark brown color.

14. • Classification by G.J.Mount [1998]7
• The concept of the reversible nature of caries in its earliest stage, the increase in restorative
materials than in Black’s time, and adhesive materials with minimal microleakage led G.J Mount
to reconsider Black’s classification. This classification records the site and the extent of lesions
without specifying the cavity designs. The size of the lesion influences the material
choice. Dental caries is said to be a slow process and during the early stages, non-invasive
intervention can convert the lesion to an inactive state from an active state
SIZE
SITE Minimal
1
Moderate
2
Enlarge 3 Extensive 4
Pit and
fissure 1
1.1 1.2 1.3 1.4
Contact
area 2
2.1 2.2 2.3 2.4
Cervical 3 3.1 3.2 3.3 3.4

15. • Size 1. Minimal involvement of dentine, beyond the possibility of treatment by remineralization
alone.
• Size 2. Moderate dentine involvement - The remaining tooth structure supports the restoration and
is less likely to fail under normal occlusal load.
• Size 3. Enlarged with weakened cusps and incisal edges (requires protection from occlusal load).
• Size 4. Extensive tooth structure loss.

16. • Classification by Nyvad [1999]:
• WHO index was not reliable in certain populations because of the slow progression of caries.
• It was necessary to record caries at the non-cavitated level, to prevent its further progression.
• Hence Nyvad added a new update with lesion activity assessment and provided the best
management options for such non-cavitated lesions.
• Active and inactive caries are differentiated from the visible changes.
• This is used in both primary and permanent dentitions. All the lesions including fillings are
assigned a score.

17. Score Category Criteria
0 Sound Normal enamel translucency and texture.
1 Active caries
(intact surface)
The surface of enamel is whitish/yellowish opaque with loss of luster, rough surface on probing;
covered with plaque.
No clinically detectable loss of tooth structure.
2 Active caries
(surface
discontinuity)
Same criteria as score 1.
Localized enamel surface defect (microcavity). No undermined enamel or softened floor detectable
with the explorer.
3 Active caries
(cavity)
Enamel/dentin cavity easily visible with the naked eye; soft/leathery surface on probing.
With/without pulp involvement.
4 Inactive caries
(intact surface)
Surface of the enamel is whitish, brownish or black. Enamel may be shiny and feels hard and
smooth on probing. No clinically detectable loss of substance.
5 Inactive caries
(surface
discontinuity)
Same criteria as score 4 Localized enamel surface defect (microcavity). No undermined enamel or
softened floor detectable with the explorer.
6 Inactive caries
(cavity)
Enamel/dentin cavity easily visible with naked eye; surface of cavity may be shiny and feels hard on
probing. No pulpal involvement.
7 Filling (sound
surface)
Enamel/dentin.
8 Filling + active
caries
cavitated/ noncavitated.
9 Filling + inactive
caries
cavitated/noncavitated.

18. • Active non-cavitated lesions can be managed by non-operative measures (oral hygiene instructions/
fluorides), whereas inactive non-cavitated can be cleaned by brushing with fluoridated
toothpaste. Consumption of fluoride within the optimal levels can result in the emergence of
fluoride-resistant oral Streptococcus sp.

19. International Caries Assessment and Detection System (ICDAS I and II):
• In 2002, an International team of caries researchers developed the ICDAS system for caries detection and
assessment, which was later modified in 2005 as ICDAS II.
• The main aim of the committee is to integrate other criteria and provide a standard classification system that
can be used for both research and clinical purposes. The ICDAS II included coronal caries, caries associated
with restorations and sealants (CARS), and root caries.
• The bacteria most responsible for causing caries are Streptococcus mutans, lactobacilli, and actinomyces.
Understanding oral bacteria assists in not only understanding the pathogenesis of dental caries but also in
preventing and treating them.
• The “D”in ICDAS stands for dental caries detection and “A” for evaluation of stages (non-cavitated or cavitated) and
activity (active or arrested). Each tooth surface is designated by two digits. The first digit describes the tooth and the
second describes the caries lesion

20. • 1. Code for restoration status:
• 0 = unrestored/unsealed
• 1 = Sealant, partial
• 2 = Sealant, full
• 3 = Tooth colored restoration
• 4 = Amalgam restoration
• 5 = Stainless steel crown
• 6 = Porcelain or gold or PFM crown or veneer
• 7 = Lost or broken restoration
• 8 = Temporary restoration
• 9 = Used for the following conditions
• 96 = Tooth surface cannot be examined; Surface excluded
• 97 = Tooth missing because of caries (tooth surfaces will be coded 97)
• 98 = Tooth missing for reasons other than caries (all tooth surfaces will be coded 98)
• 99 = Unerupted (tooth surfaces coded 99)

21. • 2. Coronal caries (pit and fissure caries/smooth surface caries) codes vary from 0-6 depending on the degree of the lesion
• 0- Sound tooth surface: No evidence of caries after 5-sec air drying
• 1- First visual change in enamel: Opacity or discoloration (white or brown) is visible at the entrance to the pit or fissure seen after
prolonged air drying
• 2- Distinct visual change in enamel visible when wet, the lesion must be visible when dry
• 3- Localized enamel breakdown (without clinical visual signs of dentinal involvement) seen when wet and after prolonged drying
• 4- Underlying dark shadow from dentine
• 5- Distinct cavity with visible dentine
• 6- Extensive distinct cavity with visible dentine.
• Code for Root Caries:14
• This criteria is not been tested in any of the clinical studies.
• CODE E: If the root surface cannot be visualized directly, then it is excluded.
• CODE 0: The root surface with normal anatomical color and no unusual discoloration/surface defect that distinguish it from the
surrounding root areas.
• CODE 1: Demarcated area on the root surface or at the cementoenamel junction that is discolored with no cavitation (loss of anatomical
contour<0.5mm)
• CODE 2: Demarcated area on the root surface or at the cement-enamel junction discolored with cavitation (loss of anatomical contour
≥0.5mm)

22. • American Dental Association Caries Classification System ( ADA-CCS) [ 2008]15
• In 2008, American Dental Association compiled the information from the discussion of experts in a
council meeting and developed easy to use the system in clinical practice.
• The extent and the activity of caries are scored for each of its tooth surfaces. The characteristics of
active and arrested caries are differentiated by visual changes. Active caries appears white to
yellow in color with rough enamel and soft dentine on probing. Whereas, inactive caries appear
brownish-black in color with smooth enamel and hard dentine on tactile sensation.
• Sound surface - No clinically detectable lesion, normal color, translucency, and gloss of hard
tissues.
• Initial caries lesion - Clinically detectable lesion with mild demineralization involving
enamel/dentin/cementum. Milder forms are detectable after drying.
• Moderate lesion - Vital signs of enamel breakdown or signs of dentin moderately demineralized.
• Advanced lesion - Enamel is fully cavitated and dentin is exposed. Dentin lesion is
deeply/severely demineralized.

23. • PUFA INDEX [2010]:
• In all the previous systems, the consequences of untreated dental caries such as pulpal involvement
and an abscess is not been recorded. Caries of dentine are assigned for those teeth with pulpal
involvement. To overcome the limitations of the above classifications, the PUFA index was
developed by Monse et al. Uppercase letters for permanent dentition and lowercase letters for
primary dentition.16
• P/p - Pulpal involvement with the opening of the pulp chamber is visible or only roots or root
fragments left as a result of the carious process.
• U/u - Ulceration due to trauma from sharp edges of a dislocated tooth with pulpal involvement or
root.
• F/f - Fistula: when pus releasing sinus tract is in relation to a tooth with pulpal involvement is
present.
• A/a - Abscess: when pus containing swelling is in relation to a tooth with pulpal involvement is
present.

24. • Caries Assessment Spectrum and Treatment CAST [2011]
• Frencken and associates, combine ICDAS, PUFA index and M-F of DMF index. CAST spectrum
describes the wide range of carious lesions from no caries disease through the sealant, restoration
to lesions in enamel, dentine, pulp, and surrounding tissues. This system also allows to calculate
the DMF scores, hence used as a tool in epidemiological surveys.

25. Characteristic Code Description
Sound 0 No visible evidence of a distinct carious lesion.
Sealed 1 Pits and fissures are at least partially sealed with a sealant
material
Restored 2 Cavity restored with an (in)direct restorative
material without a dentine carious lesion and no
fistula/abscess present
Enamel 3 Distinct visual change in enamel. A clear carious related
discolouration (white or brown in colour) is visible,
including localized enamel breakdown without clinical
visual signs of dentine involvement
Dentine 4 Internal caries-related discoloration in dentine. Shadows of
discolored dentine lesion visible through enamel with or
without visible localized breakdown.
5 Distinct cavitation into dentine with no pulpal involvement.
Pulp 6 Involvement of pulp chamber. Distinct cavitation reaching
the pulp chamber or only root fragments are present
Abscess / fistula 7 Pus containing swelling/sinus tract related to a tooth with
pulpal involvement due to dental caries is present
Lost 8 The tooth has been removed because of caries.
Other 9 Does not match with any of the other categories

26. • FDI Caries Matrix System [2008]20
• Federation Dentaire Internationale constructed a framework, integrating the previous classification
systems. The objective of this framework is to provide a chart that would act as a base for risk
assessment and surveillance, disease prevention, and health promotion.
•
• The matrix consists of three tiers, placed one above the other. The pathology and extent of the
lesions are represented along the horizontal axis. + and – indicates lesion activity. Level 1 in the
matrix outlines WHO methods of assessment ( D3MFT); level 2 tier includes D1MFT, ADA,
collapsed ICDAS, and other systems which help in differentiating cavitated and non-cavitated
enamel lesions. Level 3 tier represents the full ICDAS system.M, F and PUFA is also been added
in this matrix.

27. Classification and
Year
Basis Salient features Demerits
G.V Black 4, 1908 Location First attempt at classification Degree of lesion is not recorded i.e, even white
spot lesions are surgically treated.
WHO5 ,1979 Depth of lesion Used as epidemiological tool. Allows recording
of non-cavitated lesions.
Root caries not recorded.
Billing’s root caries
Index6,1985
Degree and progress of
lesions
Provides a treatment plan.
G.J Mount7, 1998 Site and extent Guides in choice of restorative material. Non
cavitated lesions are not treated
surgically, rather eliminated by
remineralisation.
Lesion activity is not assessed
Nyvad8,1999 Lesion activity Provides treatment options for active and
inactive lesions.
Difficulty in assessing precavitated. Lesion
activity in occlusal surface due to physiological
wear.
ICDAS13, 2005 Extent of lesion Records coronal and root caries. Tooth with
restoration also recorded. Used in both the
dentitions.
Complicated system. Root caries assessment is
not validated.
ADA-CCS15,2008 Extent of lesions Easy to use Lesions activity is not yet
implemented
PUFA16,2010 Consequence of
untreated lesions
Untreated dental caries conditions recorded.
Applicable in both the dentitions.
Unnecessary extension of index. Different score,
assigned for fistula and abscess, though it’s the
presentation of same condition.
CAST19,2011 ICDAS + PUFA+ M,F Wide range of conditions associated with caries
recorded.
Suitable only in epidemiological studies

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