The document outlines the International Caries Detection and Assessment System (ICDAS). It begins with an introduction to caries assessment systems and outlines some of their shortcomings. It then discusses ICDAS in more detail, noting that it was developed based on a review of existing systems to provide a standardized international system. The document provides insights into ICDAS, discussing its future and conclusions. It also includes slides on measuring dental caries and reviewing other caries assessment systems such as DMF, Nyvad, and CAST.

1. International Caries Detection and
Assessment System (ICDAS)
Dr. Ghada Elmasuri
04/09/16 1

2. Outlines of the presentation
 Introduction
 Measuring Dental Caries
 Review of caries assessment systems developed over the
last decade.
 International Caries Detection and Assessment System
(ICDAS)
Insights into the ICDAS
Future of ICDAS
Conclusions and Recommendations
04/09/16 2
Slides numbers: 70
Estimated time: 40 minutes

3. Introduction
 An increasing concern more than a decade ago about
the quality and comparability of caries data assessed
using the traditional measurement of caries.
 Further, it has been shown that the diagnosis of caries
at the cavitation level results in a significant
underestimation of the actual caries experience in
populations.
Pitts et al., 1988; Manji et al., 1989; Ismail et al 1992; Pitts, 1993
;Machiulskiene et al., 1998; Nyvad et al., 1999; Pitts et al., 2004
04/09/16 3

4. Introduction
The International Caries Detection and Assessment System
(ICDAS) has was developed based on a systematic review of the
available clinical caries detection and assessment systems, to
provide an international system for caries detection that would
allow for comparison of data collected in different locations at
different points in time, and to bring forward the current
understanding of the process of initiation and progression of
dental caries to the fields of epidemiological and clinical
research.
Nyvad et al., 1999; Ekstrand et al., 1995; 1998; Pitts 2004 ; Ismail 2007
04/09/16 4

5. What is Dental Caries?
A localized post eruptive pathological process
of external origin involving softening of the
hard tooth tissue and proceeding to the
formation of cavity.
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6. Measuring Dental Caries
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7. What is Measuring Dental Caries?
 Measurement is a process of assigning values to
characteristics according to a set of rules. This is facilitated
through indices.
 “A numerical value describing the relative status of a
population on a graduated scale with definite upper and
lower limits, which is designed to permit and facilitate
comparison with other populations classified by same
criteria and methods.”
Russell A. L.
04/09/16 7

8. Why Measuring Dental Caries?
1. For epidemiological investigation in
population groups
2. For public health programme planning and
evaluation
3. For testing prevention and control
procedures.
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9. Prevalence of Dental caries is measured in terms of:
 Percentage of persons affected
 Number of teeth attacked
 Number of tooth surface involved
 Number of discrete cavities
 Size and degree of severity of carious lesion
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10. Ideal Requisites of an Index
1. CLARITY: The examiner should be able to remember the
rules of the index clearly in his mind.
2. SIMPLICITY: The index should be simple and easy to
apply so that there is no undue time lost during field
examinations.
3. OBJECTIVITY: The criteria for the index should be
objective and unambiguous, with mutually exclusive
criteria.
4. VALIDITY: The index must measure what it is intended to
measure.
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11. Ideal Requisites of an Index
5. RELIABILITY: The index should measure consistently
at different times and at variety of conditions.
6. QUANTIFIABILITY: The index should be amenable to
statistical analysis.
7. SENSITIVITY: The index should be able to detect
reasonably small shifts, in either direction in group
condition.
8. ACCEPTABILITY: The use of index should not be
painful or demeaning to the subject.
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12. Review of caries assessment
systems developed over the last decade
04/09/16 12

13. Black’s Classification System
 Developed by G.V. Black in the
early 1900s. Dental caries assessed
based on the tooth type and the
cavity location or tooth surfaces
involved.
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14. Black’s Classification System
 Strength
 Simple and practical with long
history of use in general dental
practice.
 Shortcoming
 Does not record noncavitated
lesions leading to
underestimation of caries
experience.
04/09/16 14

15. The Decayed, Missing, Filled (DMF) index
 Developed by Klein, Palmer and Knutson in 1938.
 World health organization has adopted this index in its oral
health assessment form for conducting national oral health
surveys.
 It has been used for more than 70 years as the key measure
of caries experience in dental epidemiology.
Larmas 2010
04/09/16 15

16. The Decayed, Missing, Filled (DMF) index
 When its applied only to tooth surfaces it is called the
DMFS index, and scores per individual range from 0 to 128
or 148, depending on whether the third molars are
included in the scoring.
Cappelli and Mobley 2007
 When written in lowercase letters, (dmft) is a variation
that is applied to expresses the number of affected teeth
in the primary dentition, with scores ranging from 0 to 20
for children.
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17. The Decayed, Missing, Filled (DMF) index
 The dmfs index expresses the number of affected surfaces in
primary dentition with a score range of 0 to 88 surfaces.
 Strength;
 Simple to use; accepted at global level;
 long track record of use supported by literature;
 allows for meaningful comparison of caries situation in various
populations;
 recognized by majority of countries and ministries of health
04/09/16 17

18. Shortcomings of DMF Index
1. Researchers have noted a significant amount of inter-
observer bias and variability.
 A practitioner has to judge whether a minor lesion will
develop into a major lesion over time, and whether a lesion
in primary tooth can safely remain untreated for the life of
the tooth.
LeSaffre et al., 2004
2. Inability of D component of DMF score to provide any
indication as to the number of teeth at risk or data that is
useful in estimating treatment needs.
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19. Shortcomings of DMF Index
3. It assesses only cavitated lesion extended into dentin and
cannot be use to assess root caries.
4. The indices do not account for teeth lost for reasons
other than decay (such as periodontal disease) and do not
account for sealed teeth since sealants and other.
5. DMF index gives equal weight to missing, untreated
decayed and well restored teeth.
Broadbent JM, Thomson 2005; Burt 1997
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20. Shortcomings of DMF Index
6. Underestimation of the prevalence and severity of
caries, because it does not register the initial
manifestation of caries like the white spot lesion.
Gonzales 1999
8. Cannot assess caries progression rate.
9. DMF index is invalid in elderly population, as teeth can
be lost for reasons other than caries.
Broadbent JM, Thomson 2005; Burt 1997
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21. Nyvad Caries Diagnostic Criteria
 Proposed by Nyvad in 1999.
 includes the initial manifestation of caries in the pre-
cavitated stages.
 This system differentiates between active and inactive caries
lesions at both the cavitated and non cavitated levels.
Nyvad et al., 1999
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22. 04/09/16 22

23. Nyvad Caries Diagnostic Criteria
 Strength
1. Can identify incipient caries lesion, hence can be used for
planning prevention programmes.
2. Underestimation of prevalence and severity of caries with
def index can be omitted as it measures only cavitation
state.
3. Reduce the need of treatment on a long term basis because
diagnosis of initial lesions can stop the progression of
lesion.
04/09/16 23

24. Nyvad Caries
Diagnostic Criteria
 The prevalence values
with Nyvad´s caries
diagnostic criteria were
97%, were higher than
those obtained with the
def index being 73%.
04/09/16 24

25. Shortcomings of Nyvad Caries
Diagnostic Criteria
1. It is more difficult to make an exact diagnosis of a
precavitated active lesion such as a white spot lesion over the
occlusal surface than over the facial surface, because of the
physiologic wear of the occlusal surface during mastication,
these lesions can disappear.
 These lesions can be underdiagnosed, progressing to frank
cavitation.
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26. Significant caries Index (SiC)
In 1981, WHO declared that “the global goal for oral health by
the year 2000 should be that the DMFT for the 12-year-olds
should not exceed 3”.
Over a period of 20ys, nearly 70% of the countries in the world
have achieved this goal, or being at borderline value.
A detailed analysis of the caries situation in many countries
showed a skewed distribution of caries prevalence and that a
proportion of 12-year-olds still has high or even very high
DMFT values even though a proportion is totally caries free.
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27. Significant caries Index (SiC)
Thus DMFT value does not accurately reflect this skewed
distribution leading to incorrect conclusion that the caries
situation for the whole population is controlled, while in
reality, several individuals still have caries.
Bratthall in 2000 proposed SiC indix in order to bring
attention to the individuals with the highest caries values in
each population under investigation.
Bratthall 2000
04/09/16 27

28. Significant caries Index (SiC)
While mean scores provide a good measure of population
disease levels, it is important to also look at those who might
be carrying a significant burden of the dental disease
experience in the population.
SiC indix is used together with DMF to highlight oral health
inequalities more accurately among different population
groups within the community in order to identify the need
for special preventive oral health interventions.
Bratthall 2000
04/09/16 28

29. Significant caries Index (SiC)
SiC is calculated by sorting individuals according to their
DMFT values, than one third of the population with the
highest caries scores is selected and the mean DMFT for this
subgroup is calculated.
Strength:
It can bring authorities attention to the need of preventive
measures required for prevention/control of caries in these
subgroups.
Bratthall 2000
04/09/16 29

30. Shortcomings of Significant caries Index
(SiC)
1. It is just an extension of DMF index as it follows same
criteria for assessing dental caries and thus the same
limitations in assessing caries in a population as DMF
index.
2. Is more of significance in population where caries
prevalence is low and has a skewed distribution.
04/09/16 30

31. Specific Caries Index
 Proposed by Acharya in 2006 to be used in conjunction with
the DMFS index to provide qualitative and quantitative
information about caries prevalence, location, type of caries
lesion as well as untreated dental caries in an individual based
on clinical examination.
 Strength;
 The index has shown good reliability and validity in the study
conducted by original author but further search on various
databases did not reveal any other study using this index.
04/09/16 31

32. Specific Caries Index
 The SCI score for an
individual is
calculated by adding
the individual tooth
scores, scores for an
individual can range
from 0 to 192 (for 32
teeth).
04/09/16 32

33. Shortcomings of Specific Caries Index
1. It employs same caries detection criteria as DMF or DMFS;
2. Inability of this index, if used alone, to capture
information useful for treatment planning.
3. In cases of large lesions, which cover more than one
surface, only an assumption can be made regarding the
originating lesion.
4. Number of proximal lesions be underestimated in absence
of bitewing radiograph.
5. Lack of provision for assessing root caries.
04/09/16 33

34. PUFA (pulp-ulcer-fistula-abscess) index
Developed by Monse et al in 2010 to overcome DMF index
failure to provide information on the clinical consequences of
untreated dental caries, such as pulpal abscess, which may be
more serious than the carious lesions themselves.
Monse et al 2010
04/09/16 34

35. 04/09/16 35

36. PUFA (pulp-ulcer-fistula-abscess) index
Strength;
1.Simple to record.
2.Can be used for primary and permanent teeth alongside with DMF
index.
3.Can provide useful information for researches and authorities in
many developing countries, where access to oral health services is
limited and teeth are often left untreated or are extracted because
of pain or discomfort.
04/09/16 36

37. Shortcomings of PUFA
(pulp-ulcer-fistula-abscess) index
1. Stages of carious lesion progression in enamel are not
being assessed.
2. Few subjects with score “u” (ulcer).
3. Assessment of abscess and fistula can be combined into
one code.
4. Reliability and validity of this index requires further
discussion and research.
04/09/16 37

38. Caries Assessment Spectrum and Treatment
(CAST) Index
 Developed by Frencken et al 2011, because of the need to find
a reliable, pragmatic cohesive and easy to read reporting
system.
 Combines elements of the ICDAS II and PUFA indices, and the
M- and F-components of the DMF index.
 Strength;
 It covers the total dental caries spectrum – from no carious
lesion, through caries protection (sealant) and caries cure
(restoration) to carious lesions in enamel and dentine, and
the advanced stages of caries lesion progression in pulpal and
tooth surrounding tissue.
Frencken et al 2011
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39. 04/09/16 39

40. Shortcomings CAST Index
1. It does not record active and inactive carious lesions.
2. The CAST index has not been validated, nor has its
reliability been tested.
3. It is also not suggested for use in clinical trials.
4. It does not provide data on treatment or preventive
measures required for each code.
04/09/16 40

41. The Problem Of Diagnosis ?
Sensitivity Vs Specificity
Sensitivity: It is defined by the probability of the test
giving a positive finding when disease is present.
Specificity: It is the probability of a negative finding
when disease is absent.
The indications that are currently used of dental caries
diagnosis gives sensitivities of 60% and a specificity of 85%.
Leading to a profound effects on possible negligence of
early pathological demineralization.
Lussi 1991; Pitts 1995
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42. The Problem Of Diagnosis ?
Sensitivity Vs Specificity
04/09/16 42

43. Need for an Integrated System
Unfortunately, in carious lesion detection, the scale of
measurement differs with clinicians, researchers,
techniques, and gadgets because a baseline or a gold
standard is absent.
Thus future of research, practice, and education in
cariology requires the development of an integrated
definition of dental caries and uniform measuring system
designed in such a way to produce reliable/reproducible
results.
04/09/16 43

44. International Caries Detection
and Assessment System
(ICDAS) – I and II
Developed in the year 2001 by the effort of large group
of researchers, epidemiologists and restorative dentists to
find a common caries assessment system based on of
insights gained from a systematic review of the literature
on clinical caries detection systems.
Ismail 2004
04/09/16 44

45. International Caries Detection
and Assessment System
(ICDAS) – I and II
To lead to better quality information to inform decisions
about the appropriate diagnosis, prognosis and clinical
management of dental caries at both the individual and
public health levels.
Pitts, 2004
04/09/16 45

46. International Caries Detection and Assessment
System (ICDAS) – I and II
 The ‘D’ in ICDAS stands for detection of dental caries by
i. stage of the carious process;
ii. topography (pit-and-fissure or smooth surfaces);
iii. anatomy (crowns versus roots);
iv. restoration or sealant status
 The ‘A’ in ICDAS stands for assessment of the caries process
by stage (non-cavitated or cavitated) and activity (active or
arrested)
04/09/16 46

47. International Caries Detection and
Assessment System
ICDAS I (2001) ICDAS II (2009)
Include (D) component for
caries detection and (A)
component for assessment of
caries process (whether
cavitated or non-cavitated
and active or arrested
caries). Root caries were not
included due to lack of
consensus and need for
further discussions.
Modified by ICDAS
coordinating committee in
2009 which describes both
coronal caries and caries
associated with
restorations and sealants
(CARS) and root caries.
04/09/16 47

48. International Caries Detection
and Assessment System
(ICDAS) – I and II
 There is insufficient” evidence on the validity of clinical
diagnostic systems for root caries based on the National
Institutes of Health (NIH) Consensus Development
Conference on dental caries diagnosis and management.
Bader et al 2001
 Root caries are frequently observed near the cemento-enamel
junction (CEJ), although lesions can appear anywhere on the
root surface.
04/09/16 48

49. International Caries Detection and Assessment
System (ICDAS) – I and II
 The color of the root lesions has been used as an indication of
lesion activity.
 Active lesions have been described as being;
 Yellowish or light brown in color,
 Darkly stained for arrested lesions.
 However, color subsequently has been shown not to be a reliable
indicator of caries activity.
Hellyer et al, 1999; Lynch and Beighton 1994
04/09/16 49

50. ICDAS/ A. Pits and fissures
B- Smooth surface (mesial and distal)
04/09/16 50

51. CARIES ADJACENT TO RESTORATIONS AND
SEALANTS (CARS) New in ICDAS II
04/09/16 51

52. C-Root Caries (New in ICDAS II)
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53. International Caries Detection and Assessment
System (ICDAS) – I and II
ICDAS has a 2-digit coding system (X-Y).
I.The first decision (code X; lesion detection) is to classify each tooth
surface on whether it is sound, sealed, restored, crowned, or
missing.
II.The second decision (attributed to code Y; lesion assessment) that
should be made for each tooth surface is the classification of the
carious status on an ordinal scale.
The ICDAS systems advocate the removal of plaque prior to the
initial examination in order to accurately detect the lesion.
04/09/16 53

54. ICDAS two-digit coding method/ Decision I
04/09/16 54

55. ICDAS two-digit coding method/ Decision II
04/09/16 55

56. ICDAS two-digit coding method
Example
A tooth restored with amalgam, which also exhibits an extensive
distinct cavity with visible dentin will be coded 4 (for an amalgam
restoration) and 6 (for a distinct cavity).
04/09/16 56

57. Wardrobe approach of ICDAS
To facilitate the use of ICDAS in different settings there is a range
of validated tools to select from, much as you would select the
appropriate clothes from your wardrobe depending on what you
were doing that day.
04/09/16 57

58. Wardrobe approach of ICDAS
 This ‘wardrobe’ of validated tools allows users to select the best
criteria and conventions for each specific application of the
system.
 Example; in a national study that aims to compare dental caries
prevalence over time, the number and configuration of tooth
surfaces may be selected to match previous surveys. Also, the
stage of caries detection may be adjusted to match previous
studies conducted in a country.
Pitts, 2004
04/09/16 58

59. Performance of ICDAS
Peer review papers
Search methods for identification of studies
Google, Google Scholar, the Cochrane Library MEDLINE and EMBASE electronic databases were searched.
04/09/16 59

60. Search Results
04/09/16 60

61. Performance of ICDAS
Evidence Based Results
Author& Location Objectives Findings
Ekstrand et al., 2007
Dundee, Scotland
and Copenhagen,
To test the
reproducibility and
accuracy of the ICDAS I
and ICDAS II caries
detection systems for
coronal primary caries
in vitro.
Both the ICDAS caries
detection systems I and II are
valid and reliable for
detecting caries and
predicting the depth of the
lesion at any coronal surface.
04/09/16 61

62. Search Results
04/09/16 62

63. Performance of ICDAS
Evidence Based Results
Author& Location Objectives Findings
Ismail et al., 2008
US
Assessed the prevalence,
severity of dental caries,
using the International
Caries Detection and
Assessment System
(ICDAS).
The use of ICDAS
provided useful
information on caries
distribution including
both cavitated (ICDAS 3-
6) as well as the non
cavitated carious lesion
(ICDAS 1-2).
04/09/16 63

64. Search Results
04/09/16 64

65. Performance of ICDAS
Evidence Based Results
Author&
Location
Objectives  MMethodology Findings
Shoaib et al.,
2009
Malaysia
To assess the
validity and
reproducibility
of the ICDAS II
criteria in
primary teeth.
Three trained examiners
independently examined
112 extracted primary
molars (52 first primary
molars and 60 second
primary molars), ranging
from clinically sound to
cavitated using ICDAS II
system.
The ICDAS II
criteria are
appropriate for use
in the
primary dentition
both for
approximal and
occlusal surfaces.
04/09/16 65

66. The ICDAS has been shown to be reproducible and accurate
(Jablonski-Momeni et al., 2008) and to allow the detection
and assessment of early lesions and longitudinal follow-up
(Burt et al., 2006; Ekstrand et al., 2007; Finlayson et al.,
2007; Ismail et al., 2007, 2008; Sohn et al., 2007; Cook et al.,
2008; Jablonski-Momeni et al., 2008; Varma et al., 2008).
Summary of evidences
04/09/16 66

67. Strength of ICDAS
1. Clinically reliable in permanent teeth and acceptable in
primary teeth.
2. Designed to detect 6 stages of caries severity, varying from
initial changes visible in enamel to frank cavitation in
dentine.
3. Very suitable for use in clinical trials assessing the efficacy
and/or effectiveness of caries control agents.
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68. Shortcomings of ICDAS
1. Root caries assessment criteria has not been tested in any
epidemiological or clinical studies.
2. Data obtained are unpragmatic, non-cohesive and difficult to
read.
3. May lead to overestimation of seriousness of dental caries.
4. Results are difficult to compare against the widely-used DMF
index.
5. In very young children, some claim it is not practical to dry
6. surfaces to assess for early enamel caries (others, however
have used it successfully for this age group).
04/09/16 68

69.  ICDAS adaptation of
the WHO “Stepwise”
approach to the
Surveillance of Non-
Communicable
Diseases for use
with dental caries
and oral health
indicators.
FUTURE OF ICDAS
04/09/16 69
Pitts, 2009

70.  WHO Stepwise approach to Surveillance (STEPS) is a simple,
standardized method for collecting, analysing and
disseminating data in WHO member countries.
 By using the same standardized questions and protocols, all
countries can use STEPS information not only for
monitoring within-country trends, but also for making
comparisons across countries. The approach encourages
the collection of small amounts of useful information on a
regular and continuing basis.
FUTURE OF ICDAS
04/09/16 70

71.  This philosophy is entirely consistent with the
wardrobe approach of ICDAS and its use would result
in improved comparability of data collected nationally
and internationally and thereby facilitates systematic
reviews in the area. This foundation allows researchers
and clinicians to choose the stage of disease and
characteristics for assessment.
FUTURE OF ICDAS
04/09/16 71

72.  The future of ICDAS depends on acceptance of the
concepts of integration and utility within a caries
detection and assessment system and to the fields of
epidemiological and clinical research by the
cariology community.
FUTURE OF ICDAS
04/09/16 72

73. Application of ICDAS
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74.  These recommendations have been formulated following
the ICDAS II workshop in Baltimore (USA) for improvement
in caries diagnosis using ICDAS;
1. Investigate different methods for effectively cleaning and
drying of teeth and their impact on the usability of ICDAS.
2. Develop and test new explorers to allow for the detections
of surface roughness or “tackiness” of root surfaces without
causing damage to the surface.
3. Define the appropriate time required to dry teeth to
identify the first visible signs of dental caries.
FUTURE OF ICDAS
04/09/16 74

75.  Additionally, a need for the following supporting
resources was identified in the workshop:
1. A library of images to depict the different codes and
conditions related to ICDAS.
2. Statistical protocols for analysis of reliability data
as well as for analysis of the ICDAS system in clinical
and epidemiological studies.
3. Standardized protocols and online simulations to
train examiners to use ICDAS.
FUTURE OF ICDAS
04/09/16 75

76. References
 World Health Organization. Oral health surveys– basic methods. 4. ed. Geneva:
World Health Organization; 1997.
 Klein H, Palmer C. Studies on dental caries vs. familial resemblance in the caries
experience of siblings. Pub Hlth Rep. 1938;53:1353-64.
 Larmas M. Has dental caries prevalence some connection with caries index
values in adults? Caries Res. 2010;44(1):81-4.
 Cappelli DP, Mobley CC. Prevention in Clinical Oral Health Care. Philadelphia,
Pa: Mosby Elsevier; 2007.
 LeSaffre E, Mwalili SM, Declerk D. Analysis of caries experience taking inter-
observer bias into account. J Dent Res. 2004;83(12):951-5.
 Broadbent JM, Thomson WM. For debate: problems with the DMF index
pertinent to dental caries data analysis. Community Oral Dent Epidemiol.
2005;33(6):400-9.
 Burt BA. How useful are cross-sectional data from surveys of dental caries?
Community Dent Oral Epidemiol. 1997 Feb;25(1):36-41.
04/09/16 76

77. References
 Gonzales, María Clara y col.Caries Dental. Guías de Práctica Clínica Basada en la
Evidencia ISS-ACFO 1999.
 Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic
system differentiating between active and inactive caries lesions. Caries
Research. 1999;33:252-260
 Bratthall D, Introducing the Significant Caries Index together with a proposal
for a new global oral health goal for 12-year-olds. Int Dent J 2000, 50: 378-384.
 Mehta, Abhishek. "Comprehensive review of caries assessment systems
developed over the last decade." RSBO (Online) 9.3 (2012): 316-321.
 Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Palenstein
Helderman W. PUFA– An index of clinical consequences of untreated dental
caries. Community Dent Oral Epidemiol. 2010;38:77-82.
 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.
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78. References
 Ismail AI. Visual and visuo-tactile detection of dental caries. J Dent Res.
2004;83:C56-66.
 Bader JD, Shugars DA, Bonito AJ. Systematic review of selected dental caries
diagnostic and management methods. J Dent Educ. 2001;65:960–8. [PubMed]
 Hellyer PH, Beighton D, Heath MR, Lynch EJ. Root caries in older people
attending a general practice in East Sussex. Br Dent J. 1990;169:201–6. [PubMed]
 Lynch E, Beighton D. A comparison of primary root caries lesions classified
according to color. Caries Res. 1994;28:233–9.
 Ahlawat.P Comprehensive Implementation of the International Caries
Detection and Assessment System (ICDAS) in a Dental School and University
Oral Health Centre: A Stepwise Framework Dent. J. 2014, 2, 41-51.
 Pitts NB. Modern Concepts of Caries Measurement. J Dent Res 83(Spec Iss
C):C43-C47, 2004.
 ICDAS Coordinating Committee. Rationale and Evidence for the International
Caries Detection and Assessment System (ICDAS II) in
http://www.icdas.org/uploads/Rationale%20and%20Evidence%20ICDAS%20II
%20September%2011-1.pdf
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