icdas

Methods for Staging of the Caries Process to Enable Dentists to Manage Caries | Professor Nigel Pitts, Professor Kim Ekstrand

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Methods for staging of the caries process to enable dentists to manage caries

International Caries Detection and Assessment System (ICDAS)

Professor Nigel PittsDental Health Services Research Unit& Centre for Clinical Innovations

University of Dundee

Professor Kim EkstrandCariology and Endodontics

School of Dentistry

University of Copenhagen

On behalf of the ICDAS Foundationwww.icdas.org


International Caries Detection& Assessment System ICDAS:

Who has been involved since 2002?The ICDAS Core Group comprises:

• University of Dundee (Nigel Pitts + team)

• Temple University (was Michigan) (Amid Ismail + team)

• Indiana University (Dom Zero + team)

• University of Copenhagen (Kim Ekstrand)

• FDI [when able to contribute] (Elmar Reich> Martin Tyas> Michel Glick)

• NIH / NIDCR: (was Rob Selwitz>) (Al Kingman)

All working with Gail Douglas and the wider ICDAS Coordinating Committee, with wide involvement from many Countries, for over a decade

www.icdas.org

• Introduction and Historical Development

• Evidence to support validity of staging and adoption to date

• ICDAS Domains

• Next steps in use of ICDAS for Clinicians and Educators

• Summary



OutlineInternational Caries Detection and Assessment System (ICDAS)


• Background

• What is ICDAS in 2012?

• Developments in recent years

• “ICDAS” to “ICCMS™”


• ICDAS Domains


• Summary




ICDAS International Caries Detection &

Assessment System: Concept

To lead to:

Better quality information to inform decisions about appropriate diagnosis, prognosis and clinical management at both the individual and public health levels

• Pitts N B, Community Dental Health 2004 21:193-198 • http://www.icdas.org

For more on ICDAS see:-


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+ clinically detectable "cavities" limited to enamel

+ clinically detectable enamel lesions with “intact” surfaces

+ lesions detectable only with traditional diagnostic aids

+ sub-clinical initial lesions in a dynamic state of progression/regression

Mis-labelled "caries free" at the D threshold

3

+ clinically detectable

lesions in dentine

lesions into pulp

D 4

D3 + enamel=

D3

D1

N B Pitts © 2006

Diagnostic threshold

determines what is recorded as “diseased” or

“sound” D 3

D 2

D 1

The “iceberg of dental caries”Diagnostic thresholds in surveys, research & practice

ICDAS Caries Severity Codes in summary – thanks to Indiana University

“Staging” the caries process – compare to oncology decision making

www.icdas.org www.icdas.org

www.icdas.org

Ismail AI. Visual and visuo‐tactile detection of dental caries. J Dent Res 2004; 83: C56–66.

This review compiled details of the (many) previously published systems for classifying caries, in which the variable diagnostic criteria in many cases lacked construct validity and also made comparison of evidence from different studies impossible

International Consensus Workshop on Caries Clinical Trials ‐ Agreeing Where the Evidence Leads ‐

ICW CCT Systematic Review of previousCARIES CLASSIFICATION SYTEMS


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Terminology:ICW-CCT Consensus Statements

The consensus was to separate out three key terms:

lesion detection (which implies an objective method of determining whether or not disease is present)

lesion assessment (which aims to characterise or monitor a lesion, once it has been detected)

caries diagnosis (which should imply a human professional summation of all available data)

Pitts N B and Stamm J. ICW-CCT Statements. J Dent Research 2004 83C: 125-128.

The Evidence Base in Caries Detection and Assessment

• Backer Dirks 1951 >

• Marthaler 1966 >

• WHO 1979

• Pitts & Fyffe 1988

• Ismail 1992

• Ekstrand, Ricketts & Kidd 98

• Fyffe et al 2000

• Nyvad 2001

• And many, many more (see Systematic Reviews NIH CDC and ICW‐CCT)

ICDAS

Reliable inclusion of clinical visual enamel & dentine caries detection is not new

www.icdas.org

Merging of systems to create ICDAS after the “ICW – CCT”

Pitts and Fyffe 1988 Ismail et al 1992 BASCD 1992 ERK 1998 (Ekstrand, Ricketts and Kidd) Indiana (various) DSTM 2000a and 2000b (Dundee Selectable Threshold)

+ others over time ……

The ICDAS Committee recognised the urgent need for valid comparability and a histological basis, both for Systematic Reviews and getting “evidence” into practice

Some of the Key References:

Pitts NB. “ICDAS” – an international system for caries detection and assessment being developed to facilitate caries epidemiology, research and appropriate clinical management. Community Dental Health 2004 21: 193-198

Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007 369: 51-59.

Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, Pitts NB. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dentistry and Oral Epidemiology 2007 35: 170-178

http://www.icdas.orgFor ICDAS references see

ICDASWardrobe

Epidemiology / Public Health

ICDAS

Clinical ResearchICDAS

Clinical PracticeICDAS

EducationICDAS

ICDASWardrobe

Clinical PracticeICDAS

Lesion Detection Tool

Activity Assessment Tool

CVA


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ICDAS in the literature

e-learning programme

Two following documents [Microsoft Word] may be downloaded.The Rationale and Evidence for the International Caries Detection and

Assessment System (ICDAS II)Criteria Manual for the International Caries Detection and Assessment

System (ICDAS II)

For further information please contact:Prof. Gail Douglas - ICDAS Co-ordinator [email protected]

http://www.icdas.orgHow should we best Control

dental caries in 2012?

We need a validated method to STAGE the disease process to plan, deliver and monitor appropriate care

Is restorative intervention the best way to manage a preventable disease process?

At the present time we have no substitutes which are the equal of original tooth tissues!

Courtesy of Dr Domenick T. Zero – Indiana University

The shared Vision for the InternationalCaries Detection and Assessment System – ICDAS is:

ICDAS: employs an evidence based and preventively oriented approach

ICDAS is: a detection & assessment system classifying stages of the caries process

ICDAS is for: use in dental education, clinical practice, research and public health

ICDAS provides: all stakeholders with a common caries language

ICDAS has evolved: to comprise a number of approved, compatible “formats”

ICDAS supports decision‐making: at both individual & public health levels

ICDAS has generated ICCMS™ to enable: improved long‐term caries outcomes

Following the July 2011 ICDAS Review in Kaunas, Lithuania

A Registered Charity

• http://www.icdas.org


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Population and Clinical Research on caries and

caries management

Standardized and EBD Cariology Education

Prevention-focussed Clinical Care for

individual patients

Population focussed Health Promotion, Prevention and

Needs Assessment

ICCMS™ Practice

ICCMS™ Education

ICDAS & ICCMS™

Research

ICDAS & ICCMS™

Public Health

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

www.icdas.org


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FDI World Dental Federation


• Evidence to support validity of staging and adoption to date• Histological validation• ICDAS in the literature • Staging disease linking to planning and monitoring treatment

• ICDAS Domains


• Summary




a) Sound b) Visible after airdrying c) visible without airdrying

d) Visible without airdrying e) Microcavitation or shadowed f ) dentine cavitation

1.1

Fig. 1

a) Sound b) Visible after airdrying c) visible without airdrying

d) visible without airdrying e) Microcavitation or shadowed f ) dentine cavitation

Lesion open for assessment (extracted)Fig. 2

Fig. 3

2012 122011 232010 192009 122008 102007 62006 52004 1

Peer Reviewed Papers using ICDAS

Total to date 88+ Books/Chapters 6+ Abstracts/others 45

ICDAS in the literature

World‐wide adoption (as of May 2012)Country of study or first author

Australia• Bailey et al. (2009) Journal of Dental Research

Brazil• Arruda et al. (2012) Community Dentistry and Oral Epidemiology• Braga et al. (2010) Community Dentistry and Oral Epidemiology• Braga et al. (2010) Journal of Biomedical Optics• Braga et al. (2010) Dental Clinics of North America • Braga et al. (2010) Caries Research• Braga et al. (2009) Caries Research• Braga et al. (2009) Caries Research• Braga et al. (2009) Oral Surg Oral Med Oral Pathol Oral Radiol Endod.• Cadavid et al. (2010) Brazilian Oral Research • de Amorim et al. (2011) Clinical Oral Investigation• Diniz et al. (2012) Journal of the American Dental Association [Brazil]• Diniz et al. (2011) Operative Dentistry• Diniz et al. (2010) Journal of Dental Education• Diniz et al. (2009) Community Dentistry and Oral Epidemiology


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• Frencken et al. (2011) International Dental Journal• Leal et al. (2012) Caries Research• Mendes et al. (2010) Community Dentistry and Oral Epidemiology• Matos et al. (2011) Caries Research• Novaes et al. (2012) International Journal of Paediatric Dentistry• Novaes et al. (2010) Caries Research• Vidmar et al. (2012) NMR Biomed• Soviero et al. (2011) Journal of Dentistry

Colombia• Díaz‐Cárdenas and González‐Martínez (2010) Revista de Salud Pública• Martignon et al. (2010) Community Dental Health

Denmark• Bakhshandeh et al. (2011) Caries Research• Ekstrand et al. (2010) Caries Research• Ekstrand et al. (2011) Caries Research• Ekstrand et al. (2007) Operative Dentistry

France• Aidara et al. (2011) International Dental Journal• Joseph et al. (2011) European Archives of Paediatric Dentistry

Germany• Berger et al. (2009) Clinical Oral Investigation• Jablonske‐Momeni (2012) Lasers in Medical Science• Jablonski‐Momeni et al. (2011) Caries Research• Jablonski‐Momeni et al. (2010) Lasers in Medical Research• Jablonski‐Momeni et al. (2009) Journal of Dentistry• Jablonski‐Momeni et al. (2009) International Journal of Dentistry • Jablonski‐Momeni et al. (2008) Caries Research• Kühnisch et al. (2008) Community Dentistry and Oral Epidemiology• Paris et al. (2011) European Journal of Oral Science

Greece• Michalaki et al. (2010) European Archives of Paediatric Dentistry• Mitropoulis et al. (2012) Caries Research• Mitropoulis et al. (2010) Journal of Dentistry • Parapanisiou et al. (2009) European Archives of Paediatric Dentistry

Hungary• Pinke et al. (2011) Fogorvosi Szemle

Iceland• Agustsdottir et al. (2010) Community Dentistry and Oral Epidemiology

India• Shivakumar et al. (2009) Journal of Conservative Dentistry

Kuwait• Al‐Khatrash et al. (2011) Operative Dentistry• Honkala et al. (2011) International Dental Journal

Malaysia• Shoaib et al. (2009) Caries Research

Mexico• Cook et al. (2008) International Journal of Paediatric Dentistry• Guido et al. (2011) International Journal of Paediatric Dentistry• Soto‐Rojas et al. (2012) International Journal of Paediatric Dentistry

Puerto Rico

• Fontana et al. (2011) Journal of Dental Research

Romania• Maxim DC, Dănila I, Dascălu CG, Balcos C. (2010) Revista medico-chirurgicală̆ a Societă̆ţ̜ii de Medici ş̧i Naturaliş̧ti din

Iaş̧i

Sweden• Baeshen et al. (2011) American Journal of Orthodontics and Dentofacial Orthopedics

Switzerland• Neuhaus et al. (2010) Clinical Oral Investigation • Rodriques et al. (2008) Caries Research

UK• Banerjee et al. (2011) Journal of Dentistry• Bonner et al. (2011) Primary Dental Care• Ormond et al. (2010) Primary Dental Care• Nazir et al. (2011) Journal of Orthodontics • Pretty, I.A. (2006) Journal of Dentistry

• Pitts et al. (2011) European Journal of Dental Education• Pitts, N.B. (2004) Community Dental Health • Pitts, N.B. (2011) Journal of Dentistry• Varma et al. (2008) Journal of Dentistry

USA• Burt et al. (2006) Caries Research• Graye et al. (2012) Journal of Clinical Dentistry • Ferreira Zandoná et al. (2010) Caries Research• Ferreira Zandoná and Zero (2006) Journal of American Dental Ass. • Finlayson et al. (2007) Community Dentistry and Oral Epidemiology• Ismail et al. (2011) Community Dentistry and Oral Epidemiology• Ismail et al. (2008) Community Dentistry and Oral Epidemiology• Ismail et al. (2008) Pediatric Dentistry• Ismail et al. (2007) Community Dentistry and Oral Epidemiology• Kolker et al. (2007) Pediatric Dentistry• Lim et al. (2008) Journal of the American Dental Association• Nriagu et al. (2006) International Journal of Hygiene and Environmental Health• Nelson et al. (2011) Community Dental Health• Rechmann et al. (2012) Journal of Biomedical Optics• Reisine et al. (2008) Community Dentistry and Oral Epidemiology• Sohn et al. (2008) Journal of the American Dental Association• Sohn et al. (2007) Journal of the American Dental Association• Stahl and Ferreira Zandoná (2007) General Dentistry• Tellez et al. (2012) Community Dental Health• Tellez et al. (2006) Journal of Public Health Dentistry• Zandona et al. (2009) Operative Dentistry

ICDAS codes and histological extent of cariesImages provided courtesy of Dr Andrea Ferreira Zandona, University of Indiana

Traditionally a binary choice: sound vs end stage disease

www.icdas.org


Some conventions allow small cavities in enamel and dentine shadows: variability high!

www.icdas.org


ICDAS codes stage the continuum of carieswww.icdas.org


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• ICDAS Domains • Clinicians • Educators • Researchers • Dental Public Health and Epidemiology*


• Summary





caries management



individual patients


Needs Assessment

ICCMS™ Practice

ICCMS™ Education

ICDAS & ICCMS™

Research

ICDAS & ICCMS™

Public Health


for Clinicians

www.icdas.org


ICDAS-enabled, patient-centred, Caries Management

Clinical Visual Lesion

Detection

RRMRecall, Reassessment

& Monitoring

Lesion Detection

Aids

Assessmentof Patient

Lesion Activity

Assessment

Lesion Diagnosis

PTOPreventive

Treatment Options:

OTOOperative

Treatment Options

Lesion Prognosis

Patient: Dentition / Lesion History

Patient: Caries Risk Assessment

Patient: Behavioural Assessment

Tooth/Surface Patient

BLCBackgroundLevel Care

Prognosis for Patient

synthesis

integrated, personalised

Treatment Planning

How the CarieScan PRO works

• The product platform is based on the application of a technique called ac impedance spectroscopy (ACIST).

• The measurement relies on the application of small electrical signals through the tooth while monitoring the response to the sensor.

• Analysis of the impedance response relates to the physical structure of the tooth and any subsurface loss of mineral within it

www.Cariescan.com

2010-2: Development of ICDAS’s International Caries Management System (ICCMS™)

ICDAS Workshop at Temple University, USA – April 2010

ICDAS Symposium at Montpellier, France – July 2010

(FDI Science Committee in Salvador, Brazil – Sept 2010)

EADPH Special Interest Working Group - Sept 2010

ICDAS Workshop re ORCA Kaunas - July 2011

Working-up ICDAS Book - Currently“Clinical Management of Dental Caries:

How to plan and deliver rational, evidence-based caries care”

www.icdas.org


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Caries Classification & Management System

including e-Learning, software and data aspects

Initial Patient

Caries Risk Assessment

Synthesis and

Decision -Making

Detection, Activity and Enhanced

Risk Assessment

Clinical Treatments (Non-surgical & Surgical)

with prevention

Monitoring & Review

Monitoring & Review

The International Caries Classification and Management System (ICDAS-ICCMS™)

With parallel “Upstream”

Common Risk Factor

Approach Activities

In concert with other

improvements in Oral and

GeneralHealth

Goal: to improve oral health through the implementation of a new paradigm for managing dental caries and its consequences, one that is based

on our current knowledge of the disease process and its prevention, so as to deliver optimal oral and thus

general health and well being to all peoples (FDI Global Caries Initiative)

©

ICDAS stages

0 1 2 3 4 5 6 PUFAWellness Initial Caries Moderate Caries Extensive Caries Pain / Sepsis

Caries Prevention & Control

Conventional Dental Caries Classifications

Health Disease

Traditional “cavitated” d3mft“Non-cavitated”

D1 Lesions(can derive

D1MFT (or S)

Pain. Pulp &Sepsis

How to stay healthy?

www.icdas.org

Dental Caries: The ICDAS* Caries Continuum (using ICDAS stages and assessment with PUFA)

0 1 2 3 4 5 6 PUFAWellness Initial Caries Moderate Caries Extensive Caries Pain / Sepsis

* ICDAS is a Charitable Foundation committed to open access

Caries Prevention & Control

A holistic view of the The International Caries Classification and Management System™

Health Disease

Traditional “cavitated” d3mft“Non-cavitated”

d1 lesions(can derive d3mft

or d3mfs)

Pain, Pulp &Sepsis

How to stay healthy?

www.icdas.org

The ICDAS Framework develops into the ICCMS™ICDAS–based personalised care in Japan

唾液量

唾液緩衝能

ＳＭ

ＬＢ

飲食の回数

プラーク

フッ素

dmft

DMFT

即青

ゆっくり青

緑

黄

0

10 万

50 万

100 万1,000

1 万10 万100 万

0

1

2

3

4

5

63

0

0

1

2

3

1

2 4 6

0

2

3

唾液量

唾液緩衝能

ＳＭ

ＬＢ

飲食の回数

プラーク

フッ素

dmft

DMFT

即青

ゆっくり青

緑

黄

0

10 万

50 万

100 万1,000

1 万10 万100 万

0

1

2

3

4

5

63

0

0

1

2

3

1

2 4 6

0

2

3

情報の共有化

共通理解

Common Information

Caries Risk


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caries management



individual patients


Needs Assessment

ICCMS™ Practice

ICCMS™ Education

ICDAS & ICCMS™

Research

ICDAS & ICCMS™

Public Health


www.icdas.org

for Educators

ORCA and ADEE / ADEA

Monitoring & Review

Domains comprising the European Core Curriculum in Cariology

Domain IVCaries Management

Decision Making & Surgical Therapy

Domain IIICaries Management Decision Making & Preventive Non-Surgical Therapy

Domain VEvidence-based Cariology in Clinical & Public Health Practice

Domain IIRisk Assessment, Diagnosis and

Synthesis

Clinical Decision Making

Domain IThe Knowledge Base

Schulte A G, Pitts N B, Huysmans M C D N J M, Splieth C, Buchalla W. European Core Curriculum in Cariology for undergraduate dental students. European Journal of Dental Education 2011, 15, Supplement 1

Monitoring and Review

Domain IVCaries Management

Decision Making & Surgical Therapy

Domain IIICaries Management Decision Making & Preventive Non-Surgical Therapy

Domain VEvidence-based Cariology in Clinical & Public Health Practice

Domain IIRisk Assessment, Diagnosis and

Synthesis

Clinical Decision Making

Domain IThe Knowledge Base

0 1 2 3 4 5 6 PUFAWellness Initial Caries Moderate Caries Extensive Caries Pain /

SepsisThe ICDAS Caries Continuum

Pitts N, Melo P, Martignon S, Ekstrand K, Ismail A. Caries risk assessment, diagnosis and synthesis in the context of a European Core Curriculum in Cariology. European Journal of Dental Education 2011, 15, Supplement 1

Clinical Decision Making - most challenging for Moderate Caries


caries management



individual patients


Needs Assessment

ICCMS™ Practice

ICCMS™ Education

ICDAS & ICCMS™

Research

ICDAS & ICCMS™

Public Health


for Researchers

www.icdas.org



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Research

BRASIL

ECUADOR

PERU

CHILE

ARGENTINA

COLOMBIA

URUGUAY

VENEZUELA


caries management



individual patients


Needs Assessment

ICCMS™ Practice

ICCMS™ Education

ICDAS & ICCMS™

Research

ICDAS & ICCMS™

Public Health


for Public Health

www.icdas.org


Percentage “no detectable caries” at 12 years was 48%, or 34%, or 22% or 15%!

Percentage with “no detectable caries” at 15 yrs was 35%, or 20%, or 16% or 6%!

First digit = Restoration/Sealant code

Second digit = Caries code

Restoration and Sealant Codes

0 = Not sealed or restored1 = Sealant, partial2 = Sealant, full3 = Tooth coloured restoration4 = Amalgam restoration5 = Stainless steel crown6 = Porcelain, gold, PFM crown or veneer7 = Lost or broken restoration8 = Temporary restoration8 = Temporary restoration

Caries Severity Codes

0 = Sound tooth surface1 = First visual change in enamel2 = Distinct visual change in enamel3 = Enamel breakdown, no dentine visible4 = Dentinal shadow (not cavitated into dentine)5 = Distinct cavity with visible dentine6 = Extensive distinct cavity with visible dentine

ICDAS Code: 1 4

ICDAS coding for restoration status and caries severity

www.icdas.org


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Acknowledgements to:Smile‐on for partnering with development and to

Colgate / GABA for an Educational Grant to support the Project


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• ICDAS Domains

• Next steps in use of ICDAS for Clinicians and EducatorsWorking with partners:‐• Web developments• Updated eLearning and case studies• ICDAS Book • More software tools….

• Summary




ICDAS e‐learning training Programme developed with Smile‐on.com, supported by Educational Grant from Colgate Palmolive

CASE STUDIES


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• Introduction and Historical Developmento For more than a decade an International Group, constitutesd as a Charitable

Foundation, has been synthesising best evidence to stage the caries process to obtain better quality information to inform decisions about appropriate clinical management at both the individual and public health levels

• Evidence to support validity of staging and adoption to dateo There is now a wealth of published international evidence to support the

validity and utility of this method of staging caries and widespread adoption continues using a flexible choice of formats from the ICDAS ICCMS™ Wardrobe

• ICDAS Domains o Since 2002, this has been across four domains, for: Clinicians, Educators,

Researchers and those in Public Health

• Next steps in use of ICDAS for Clinicians and Educatorso A range of developments are in train, many of which should help clinicians and

educators to plan, deliver and monitor appropriate caries treatment



SummaryInternational Caries Detection and Assessment System (ICDAS)

AcknowledgementsThe work and concepts included in this presentation have been the result of collaborations ‐ within Dundee, within the core ICDAS Committee, with ORCA, FDI and IADR colleagues and with other academic and clinical colleagues worldwide.

We would like to specifically 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 as well as a number of international oral health companies

Specific thanks to: Colgate, Smile‐on and other companies who have supported this work through no‐strings educational grants over the years: including J&J, Cadbury and CariesScan.


www.icdas.org

icdas

Documents

detectable lesions

detectable enamel lesions

d threshold

dentine lesions

pulp d

sound d

d3 enamel

detectable cavities