Reliablity of Nyvads

Reliability of the Nyvad criteria for
caries assessment in primary teeth

Mariana C. Sllos, Vera M. Soviero
Department of Preventive and Community
Dentistry, School of Dentistry, Universidade do
Estado do Rio de Janeiro, Rio de Janeiro,
Brazil
One of the purposes of diagnosing dental caries is to
detect and classify the lesions, in order to select the most
appropriate treatment for each tooth surface (1). Con-
sidering the slower rate of dental caries progression in
contemporary populations, the assessment of non-
cavitated lesions is of great importance for measuring the
eectiveness of preventive approaches in longitudinal
studies (26). If caries detection is restricted to counting
the number of tooth surfaces with cavities, the early
stages of the disease process are not considered. There-
fore, caries prevalence is underestimated and the
behaviour of individual caries lesions cannot be moni-
tored (7, 8). Many studies have conrmed that high
interexaminer and intra-examiner agreement can be
achieved even when precavitated lesions are recorded
(812), and since the 1950s, the inclusion of non-
cavitated lesions has been recommended (1318).
However, the World Health Organization decided not to
include enamel caries lesions in their caries index, mainly
because the diagnosis may not be reliable when the
diagnostic threshold is set at the non-cavitated level, just
as it was considered that the inclusion of enamel caries
lesions would make a comparison of the caries situation
amongst countries worldwide more dicult (19).
Besides the inclusion of lesions at the non-cavitated
stage, the assessment of lesion activity is of major
importance. The decision on clinical treatment will vary
depending on the classication of the lesion as being
active or inactive. Inactive or arrested lesions may not
need any intervention, whereas active lesions have to be
treated using non-operative procedures (such as oral
hygiene improvement and topical uorides) or operative
treatment (6, 7, 20). The Nyvad caries diagnostic system
was the rst classication system to dene clear criteria
for the activity assessment of both non-cavitated and
cavitated lesions (8). Recently, an International Caries
Detection and Assessment System (ICDAS) has been
suggested (4). This system is focused on the estimation of
lesion depth and does not include lesion activity in their
primary caries codes. A second score system to assess
activity has been suggested for use in combination with
the primary ICDAS codes (21).
Clinical studies have shown that the Nyvad classi-
cation system has construct validity because activity
assessment reected the expected eects of uoride
toothpaste on caries lesions (11, 22). Moreover, it has
also been observed that caries activity assessment has
predictive validity because active non-cavitated lesions
have a signicantly greater risk of progressing to cavity
than do inactive lesions (22). With the diagnostic
threshold set at active vs. inactive lesions, the criteria
have also been shown to be reliable, with kappa coe-
cient values in permanent teeth ranging between 0.68 and
0.80 for intra-examiner agreement and between 0.74 and
0.78 for interexaminer agreement (8). So far, the Nyvad
caries classication system has been used successfully in
clinical studies (11, 2224), but more studies on its reli-
ability in both permanent and primary teeth are needed.
The purpose of the present clinical study was to assess
the interexaminer and intra-examiner reliability of the
Sellos MC, Soviero VM. Reliability of the Nyvad criteria for caries assessment in
primary teeth.
Eur J Oral Sci 2011; 119: 225231. 2011 Eur J Oral Sci
This study assessed the interexaminer and intra-examiner reliability of the Nyvad
caries classication system in primary teeth and calculated the mean examination time.
The criteria were based on visual and tactile examinations to dierentiate active and
inactive lesions at cavitated and non-cavitated levels. Eighty children (37 yr of age)
were examined under standardized conditions by calibrated examiners. At the tooth
surface level, reliability was expressed as percentage agreement and kappa coecient,
using four diagnostic thresholds: sound vs. diseased; sound or inactive lesion vs. active
lesion; intact surface vs. surface discontinuity; and sound or non-cavitated lesion vs.
cavitated lesion. Interexaminer and intra-examiner kappa values were, respectively:
0.82/0.86; 0.80/0.86; 0.90/0.94; and 0.95/0.98. At the individual level, reliability of
estimates of the caries prevalence and of the decayed or lled surface (dfs) counts were
assessed at three diagnostic thresholds: sound vs. diseased; sound or inactive lesion vs.
active lesion; and sound or non-cavitated lesion vs. cavitated lesion. For caries prev-
alence, interexaminer and intra-examiner kappa values were, respectively: 0.84/0.94;
0.69/0.74; and 0.95/0.97. The mean examination time was 226.5 s (SD = 128.5). The
use of the Nyvad caries diagnostic criteria in primary teeth showed reliable results. The
examination time was acceptable.
Prof. Vera Mendes Soviero, Faculdade de
Odontologia, Clnica de Odontopediatria,
Universidade do Estado do Rio de Janeiro
UERJ, Av. 28 de Setembro, 157 (2/ andar), Vila
Isabel, 20511-030 Rio de Janeiro RJ, Brazil
Telefax: +552128686372
E-mail: verasoviero@gmail.com
Key words: dental caries; diagnosis; primary
teeth; reliability
Accepted for publication March 2011
Eur J Oral Sci 2011; 119: 225231
DOI: 10.1111/j.1600-0722.2011.00827.x
Printed in Singapore. All rights reserved
2011 Eur J Oral Sci
European Journal of
Oral Sciences
Nyvad caries classication system for caries assessment
and classication in primary teeth and to calculate the
mean examination time.
Material and methods
The study sample consisted of 80 children [45 boys and 35
girls; 37 yr of age (mean age 5.1 yr)], with a high caries
experience, from a government school in Rio de Janeiro,
Brazil. Children had to have at least four primary incisors
remaining to be included in the study. All children in the
study sample were born and raised in an urban area that
had a uoridated water supply (0.41.5 mg l
)1
of uoride).
Informed consent was obtained from parents, and the study
was approved by the Committee for Ethics in Research at
the Rio de Janeiro State University.
Dental examinations were carried out in a dental chair
under standardized conditions (compressed air for 35 s,
articial light, cotton rolls, a dental mirror, and a sharp
probe) by two calibrated examiners (V.S. and M.S.), inde-
pendently. Children had their teeth brushed by the rst
examiner before the examination. Then, they were
positioned in the dental chair and, if necessary, additional
biolm was removed during the examination using a
probe. Only primary teeth were recorded at the tooth sur-
face level.
The Nyvad criteria are based on visual and tactile
diagnoses to assess caries lesion activity at three progression
stages: the non-cavitated stage; the enamel discontinuity
stage; and the cavitated stage (8, 25). The codes used to
classify the criteria in primary teeth are shown in Fig. 1. In
the event of doubt, examiners were instructed to choose the
code representing the less severe status. However, in the
presence of two or more caries lesions on the same tooth
surface, the most severe caries lesion was registered according
to the following severity scale: active lesion >inactive lesion,
and cavitated lesion >surface discontinuity >non-cavitated
lesion. Each child was examined on two dierent days. The
examiner M.S. performed the rst examination, and the
examination time was measured using a digital chronometer,
which was started as soon as the dental mirror was placed in
the childs mouth. Immediately following the rst examina-
tion, V.S. carriedout the secondexamination. One weeklater,
M.S. repeated the examination.
The examiners were trained for 2 wk by two of the
authors of the criteria (Drs B. Nyvad and V. Machiulskiene),
with the training being based on clinical examinations and
A-a
B-a
C-a
A-b
B-b F-a F-b
G
I
H
J
C-b
A-c E-a E-b E-c
D-a D-b D-c
Fig. 1. Clinical aspects of the Nyvad caries diagnostic codes in primary teeth. A-a, A-b, and A-c: code 0, sound surfaces; B-a and B-b:
code 1, active non-cavitated lesions; C-a and C-b: code 2, active enamel discontinuity; D-a, D-b, and D-c: code 3, active cavitated
lesions; E-a, E-b, and E-c: code 4, inactive non-cavitated lesions; F-a and F-b: code 5, inactive enamel discontinuity; G: code 6, inactive
cavitated lesion; H: code 7, lling; I: code 8, lling associated with an active lesion; J: code 9, lling associated with an inactive lesion.
226 Sellos & Soviero
discussions. Calibration was performed in a pilot study
involving 30 children, which was carried out under the same
conditions as the present study.
Evaluation
The agreement was rst analyzed at the tooth surface level.
Interexaminer and intra-examiner reliability of the caries
diagnostic codes (09) was assessed. Then, the codes were
dichotomized at four category thresholds: (i) sound (code 0)
vs. diseased (codes 19); (ii) sound or inactive lesion (codes
0, 4, 5, 6, 7, and 9) vs. active lesion (codes 1, 2, 3, and 8); (iii)
intact surface (codes 0, 1, 4, 7, and 9) vs. surface disconti-
nuity (codes 2, 3, 5, 6, and 8); and (iv) sound or non-
cavitated lesion (codes 0, 1, 2, 4, 5, 7, and 9) vs. cavitated
lesion (codes 3, 6, and 8). The results were expressed as
percentage agreement and Cohens kappa coecient for
each diagnostic threshold.
At the individual level, the caries prevalence (the per-
centage of children with caries) and the extent [the decayed
or lled surface (dfs) count for each child] was estimated
considering: (i) all caries lesions (codes 19); (ii) active caries
lesions (codes 1, 2, 3, and 8); and (iii) cavitated caries lesions
(codes 3, 6, and 8). For the dfs, interexaminer and
intra-examiner agreement was assessed using the method
described by Bland & Altman (26). In this analysis, the
dierence between the dfs counts obtained in the rst and
second examination is plotted against the mean count of
both examinations. Based on the SD of the dierences,
upper and lower limits of agreement are calculated, which
results in an interval where 95% of the dierences between
the examinations are found. For caries prevalence, agree-
ment was assessed by percentage agreement and Cohens
kappa coecient for each diagnostic threshold.
The MannWhitney U-test was used to verify the inu-
ence of the childrens age and caries experience on the mean
examination time. The signicance level for all of the
analyses was set at 5% (a = 0.05).
Results
A total of 6,400 tooth surfaces from 80 children were
suitable for the study. Table 1 presents the intra-
examiner and interexaminer percentage agreement and
kappa values at the tooth-surface level. In general, kappa
values were 0.80 or higher in all analyses, with the
exception of a kappa value of 0.76 when considering all
codes from 0 to 9. The percentage agreement varied from
0.96 to 0.99. The highest kappa values (0.95 and 0.98)
were observed when a positive diagnosis was based on
the presence of cavitation. Lower kappa values (0.80 and
0.86) were observed when a positive diagnosis was based
on the presence of an active lesion. In all the analyses the
intra-examiner agreement had slightly higher values than
the interexaminer agreement.
Among the 6,400 tooth surfaces examined, disagree-
ments between examiners were observed in 242 (3.8%)
cases. Most of these disagreements (65.3%; 158/242)
concerned the dierentiation between sound surfaces and
non-cavitated lesions, representing 2.5% (158/6,400) of
all tooth surfaces. From the total number of disagree-
ments, 33.5% (81/242) were related to the dierentiation
between sound surfaces and inactive non-cavitated
lesions, representing 1.3% (81/6,400) of all tooth sur-
faces; 26.0% (63/242) concerned disagreement between
Table 1
Percentage agreement, kappa coecient values, and respective 95% CIs for interexaminer (V.S. M.S. 1st) and intra-examiner
(M.S. 1st M.S. 2nd) examinations considering all codes and four diagnostic thresholds (n = 6,400 tooth surfaces)
Interexaminer
(V.S. M.S. 1st)
Intra-examiner
(M.S. 1st M.S. 2nd)
Nyvad criteria Percentage agreement = 96 Percentage agreement = 97
(codes 09) j = 0.76 j = 0.83
Diagnostic thresholds ) + ) +
1. Sound vs. diseased (n) ) 5794 91 5813 58
+ 77 438 74 455
Percentage agreement (95% CI) 97 (9798) 98 (9798)
Kappa (CI) 0.82 (0.800.85) 0.86 (0.840.86)
2. Sound or inactive lesions vs. active lesions (n) ) 6020 76 6031 35
+ 46 258 53 281
Kappa (95% CI) 0.80 (0.760.83) 0.86 (0.830.89)
3. Intact surface vs. surface discontinuity (n) ) 6090 35 6096 12
+ 18 257 21 271
Kappa (95% CI) 0.90 (0.880.93) 0.94 (0.920.96)
4. Sound or non-cavitated lesion vs. cavitated lesion (n) ) 6192 9 6198 5
+
11 188 3 194
Kappa (95% CI) 0.95 (0.920.97) 0.98 (0.960.99)
Code 0, sound surfaces; code 1, active non-cavitated lesions; code 2, active enamel discontinuity; code 3, active cavitated lesions; code
4, inactive non-cavitated lesions; code 5, inactive enamel discontinuity; code 6, inactive cavitated lesion; code 7, lling; code 8, lling
associated with an active lesion; code 9, lling associated with an inactive lesion; +, positive diagnoses; ), negative diagnoses.
Caries assessment in primary teeth 227
sound surfaces and active non-cavitated lesions, repre-
senting 0.9% (63/6,400) of all tooth surfaces; and 5.8%
(14/242) concerned disagreement between active non-
cavitated lesions and inactive non-cavitated lesions,
representing 0.2% (14/6,400) of all tooth surfaces. The
remaining disagreements (34.7%; 84/242) were related to
other combinations. The cross-tabulation showing the
interexaminer agreement is available as supporting
information (Table S1).
Disagreements in intra-examiner examinations were
observed in 171 (2.7%) of the 6,400 tooth surfaces and
the majority (70.7%; 121/171) were again related to the
dierentiation between sound surfaces and non-cavitated
lesions. The cross-tabulation showing the intra-examiner
agreement is available as supporting information
(Table S2).
Comparison between examinations was also made
based on caries prevalence (Table 2) and dfs count
(Table 3), which are variables at the individual level.
Considering the presence of at least one surface with
caries (codes 19) or with cavitated lesions (scores 3, 6, or
8), the percentage agreement on caries prevalence was
high, ranging from 93.8% to 98.7% with corresponding
kappa values ranging from 0.84 to 0.97. The lowest
agreement was observed when caries diagnosis at the
individual level was based on the presence of at least one
surface with an active lesion (codes 1, 2, 3, or 8). In this
case, the interexaminer percentage agreement was 85%
(j = 0.69) and the intra-examiner percentage agreement
was 87.5% (j = 0.74).
Table 3 shows the mean dfs (i.e. the number of tooth
surfaces aected by caries per subject) for both examin-
ers according to three diagnostic thresholds. In no situ-
ation was the mean dfs statistically signicantly dierent
among examinations. Table 4 shows the data related to
the analysis of the interexaminer and intra-examiner
agreement on dfs counts. The mean dfs dierence
between examinations was below 1 in all situations,
indicating a high level of agreement for the three diag-
nostic thresholds. The limits of agreement denote the
interval which holds 95% of the dierence: the smaller
the range between the limits, the higher the agreement.
The narrowest interval was observed when the diagnostic
threshold was set at the cavity level (from )0.72 to 0.67
surfaces for intra-examiner analysis, and from )1.40 to
1.60 surfaces for interexaminer analysis), indicating very
high agreement. The wider interval (from )4.90 to 4.60
surfaces) was seen for interexaminer agreement when all
types of lesions were included in the dfs counts. When
only active caries lesions were included in the dfs counts,
the limits of agreement ranged from )3.90 to 3.20
surfaces for interexaminer analysis and from )3.20 to
3.60 surfaces for intra-examiner analysis.
The mean examination time was 226.5 s (SD =
128.5 s) and was not inuenced by the childrens age,
whereas it was inuenced by their caries experience
(Table 5).
Discussion
This study assessed the interexaminer and intra-examiner
agreement on caries diagnosis in primary teeth using the
Nyvad classication system. Usually, agreement in caries
Table 2
Interexaminer (V.S. M.S. 1st) and intra-examiner (M.S. 1st M.S. 2nd) reliability in the assessment of caries prevalence
(percentage of children with caries) according to three diagnostic thresholds (n = 80 subjects)
Diagnostic thresholds
Interexaminer estimate Intra-examiner estimate
V.S.
M.S.
1st Agreement j
M.S.
1st
M.S.
2nd Agreement j
At least one surface aected by caries (codes 19) 72.5 73.8 93.8 0.84 73.8 73.8 97.5 0.94
At least one surface with active caries lesions (codes 1, 2, 3, or 8) 58.8 61.3 85.0 0.69 61.3 61.3 87.5 0.74
At least one surface with cavitated caries lesions (codes 3, 6, or 8) 40.0 37.5 97.5 0.95 37.5 38.8 98.7 0.97
associated with an active lesion; code 9, lling associated with an inactive lesion.
Table 3
Mean decayed or lled surface (dfs) and SD for examiners V.S. and M.S (1st and 2nd examinations) according to three diagnostic
thresholds (n = 80 children)
Diagnostic thresholds
Mean dfs (SD)
V.S. M.S. 1st M.S. 2nd
Tooth surfaces aected by caries (codes 19) 6.59 (8.57) 6.71 (8.44) 6.53 (8.33)
Tooth surfaces with active lesions (codes 1, 2, 3, or 8) 3.80 (5.85) 4.18 (5.99) 3.95 (5.86)
Tooth surfaces with cavitated lesions (codes 3, 6, or 8) 2.55 (4.63) 2.46 (5.53) 2.49 (4.53)
diagnosis is analyzed at the tooth surface level when
codes are assigned to each surface. Although this type of
analysis is important to identify how reproducible the
method is, it does not show the impact of agreement level
on epidemiological data.
No two examiners, and not even the same examiner,
are expected to agree completely or give identical results
in repeated examinations. However, it is most important
to know whether this disagreement could cause problems
in clinical practice (i.e. cause the clinician to choose an
inappropriate treatment, or bring about a misleading
conclusion to a clinical study) (26).
The high reproducibility of the Nyvad caries classi-
cation system in the present study was in accordance
with results from studies carried out on permanent teeth
in young individuals (8, 24). As also observed in previous
studies (8), disagreements were concentrated on the
dierentiation between sound surfaces (code 0) and
non-cavitated lesions (codes 1 and 4). Therefore,
non-cavitated stages still represent the major problem in
clinical diagnosis.
Despite its common usage, the Cohen kappa coe-
cient is not always the most suitable indicator for
assessing agreement. It was originally proposed to mea-
sure agreement between two examiners when subjects are
classied into two nominal categories. The extension of
its application to multicategory data may result in mis-
leading interpretations. When kappa is used for multi-
category data, the categories should be grouped to
become dichotomies. Even so, kappa values can be
highly inuenced by the way in which multicategory
classications are grouped. (27)
A more comprehensive analysis should also focus on
the disagreements and their possible impact on the -
nal outcomes. Thereby, it would provide a better
understanding of the diculties related to each level of
diagnosis and allow for a more profound comparison
between studies. A detailed analysis of disagreements
may identify some of their eects on clinical research
and practice. In the present study, most of the dis-
agreements were between sound surfaces (code 0) and
non-cavitated lesions (codes 1 and 4). In the case of
inactive lesions, this would not result in any over-
treatment in a clinical situation, because neither sound
surfaces nor inactive lesions require any intervention.
This disagreement has often been related to stained
ssures on occlusal surfaces. In the case of active le-
sions, it could be a relevant disagreement in terms of
the clinical practice as it could change the treatment
decision. Although total agreement is not expected,
disagreements must be avoided as much as possible. It
is important to reinforce that improvement in agree-
ment is highly related to the quality of training and
experience of the examiners (8, 10, 22, 23).
Table 5
Mean examination time in seconds (s) according to age and number of aected tooth surfaces
n Mean time (s) SD Min. Max.
Age*
3650 months 24 203.29
a
136.17 47 601
5170 months 29 224.17
b
134.75 54 586
Older than 71 months 27 249.74
c
114.78 66 525
Number of aected tooth surfaces**
0 22 106.64
a
45.57 47 226
16 29 191.72
b
58.38 74 313
7 29 352.31
c
112.74 178 601
Max., longest examination time; Min., shortest examination time.
*MannWhitney U-test (a b; a c; b c: P > 0.05).
**MannWhitney U-test (a b; a c: P < 0.01); (b c: P = 0.01).
Table 4
Interexaminer (V.S. M.S. 1st) and intra-examiner (M.S. 1st M.S. 2nd) agreement in the assessment of number of tooth surfaces
aected by caries per subject [decayed or lled surface (dfs)] according to three dierent thresholds (n = 80 subjects)
Diagnostic thresholds Examiners
Mean dfs
dierence
per subject
Limits of
agreement
Range of the dfs
dierences between
the two examinations
Surfaces aected by caries (codes 19) V.S. M.S. 1st )0.13 [)4.90; 4.60] [)6; 14]
M.S. 1st M.S. 2nd 0.20 [)3.50; 3.90] [)9; 6]
Surfaces with active lesions (codes 1, 2, 3, or 8) V.S. M.S. 1st )0.40 [)3.90; 3.20] [)8; 6]
M.S. 1st M.S. 2nd 0.22 [)3.20; 3.60] [)10; 6]
Surfaces with cavitated lesions (codes 3, 6, or 8) V.S. M.S. 1st 0.03 [)1.01; 1.06] [)2; 5]
M.S. 1st M.S. 2nd )0.03 [)0.72; 0.67] [)2; 1]
For numerical variables, such as dfs counts, the Bland
& Altman method (26) is considered an appropriate
method with which to assess agreement between repeated
measurements: the narrower the interval, the higher the
agreement between measurements. As expected, the
narrowest interval of agreement was found to be when
the cut-o point was set at cavitated lesions. However,
for the other two cut-o points, considering all codes or
only active lesions, the limits of agreements were not
excessively wide and the nal mean dfs count did not
dier signicantly between examiners or within an
examiner (Tables 4 and 5). These results encourage the
use of more comprehensive assessment of carious lesions
in clinical studies.
In our opinion, the main advantage of the Nyvad caries
classication systemis the ability to assess the progression
stage and activity of the lesions simultaneously, using a
very straightforward code system. In addition, the
dierentiation between enamel discontinuity and a dentin
cavity provides important information for monitoring
caries progression. The theoretical underpinning of the
Nyvad caries classication system is to provide a dis-
cernible link between the diagnosis and the best treatment
option.
Although dental biolm has to be removed from the
tooth surfaces to allow proper visualization of early
carious lesions, professional cleaning of the teeth is not
recommended before examination using the Nyvad sys-
tem. Most of the biolm is usually removed during
toothbrushing, and only those surfaces where the patient
does not usually clean eectively will remain covered by
biolm. In the present study, children were assisted by
the examiner during toothbrushing because they were
very young.
When visual examination combining surface features
(opacity, roughness, colour, and location of the lesion) is
not enough to classify activity, tactile examination using
a probe is recommended (8). For a proper understanding
of the surface texture, the probe must be sharp.
However, the intention is not to test whether the probe
catches irregularities on the enamel, but rather to feel
the texture or the consistency of the lesion. For enamel
lesions, the tip of the probe must be placed at an angle of
about 30 to the tooth surface and be moved gently
across the lesion, so that the dierence between the
smooth texture of a sound surface or inactive lesion and
the rough texture of an active lesion can be felt. For
dentin lesions, tactile examination, using slight pressure,
dierentiates hard tissue from soft tissue or a leathery
consistency. In fact, surface texture has been considered
as a better indicator of activity than colour (7, 20). That
is why activity assessment may not be based only on the
colour of the lesion, especially for dentin lesions. Many
dark-brown dentin lesions have a leathery consistency,
indicating that they are still active. As the transition
between active and inactive stages does not occur
instantaneously, mixed lesions must be considered as
active. We believe that all these considerations on
activity assessment were of great importance for the high
levels of agreement achieved on activity assessment in the
present study. Disagreement on the dierentiation
between active and inactive lesions was very infrequent,
indicating a good reproducibility of activity assessment
when a consensus on the presence of the lesion was
reached.
For proper detection of non-cavitated lesions, tooth
surfaces must be dried and visualized under good
illumination. The requirement of compressed air and
articial light is therefore a prerequisite for the Nyvad
caries classication system, as well as for other caries
classication systems that aim to detect initial carious
lesions; otherwise, non-cavitated lesions are underesti-
mated.
The mean examination time is not frequently men-
tioned in reliability studies in the literature. In the
present study, the mean time needed for the examina-
tion was less than expected. The average examination
time for each child was 3 min and 46 s. In a previous
study, with older children and adolescents, the exami-
nation time was estimated to be between 5 and 8 min
(8). This dierence was probably because more tooth
surfaces are present in mixed or permanent dentitions
compared with the primary dentition. We expected that
younger children would need more time for examina-
tion because it is often more dicult to control their
behaviour in the dental chair. However, age did not
inuence examination time. Probably, behaviour con-
trol was not a problem in the present study because
both examiners were specialized in paediatric dentistry.
On the other hand, the more the tooth surfaces were
aected by caries the longer the examination took be-
cause, if a tooth surface was not sound, examiners
needed additional time to reect and assign a code to
that surface.
This present study concludes that the Nyvad caries
classication system showed a high level of agreement
and suitable examination time, and may be considered
reliable for dental caries clinical studies in primary teeth.
More studies on the reliability of the system should be
performed with larger samples and in populations with
dierent rates of caries prevalence to conrm these
ndings.
Acknowledgements We gratefully acknowledge Professors Bente
Nyvad (Denmark) and Vita Machiulskiene (Lithuania) for their
generous introduction to the clinical use of the criteria, Prof. Vibeke
Baelum (Denmark) for her relevant suggestions on statistical
analysis and Soraya Leal (Brazil) for her contribution to the nal
version of this manuscript.
References
1. Baelum V, Heidmann J, Nyvad B. Dental caries paradigms in
diagnosis and diagnostic research. Eur J Oral Sci 2006; 114:
263277.
2. Ismail AI. Clinical diagnosis of precavitated carious lesions.
Community Dent Oral Epidemiol 1997; 25: 1323.
3. Nyvad B. Diagnosis versus detection of caries. Caries Res 2004;
38: 192198.
4. Pitts NB. ICDAS an international system for caries
detection and assessment being developed to facilitate caries
epidemiology, research and appropriate clinical management.
Community Dent Health 2004; 21: 193198.
5. Ismail AI. Visual and visuo-tactile detection of dental caries.
J Dent Res 2004; 83: C56C66.
6. Thylstrup A, Bruun C, Holmen L. In vivo caries models
mechanisms for caries initiation and arrestment. Adv Dent Res
1994; 8: 144157.
7. Nyvad B, Fejerskov O. Assessing the stage of caries lesion
activity on the basis of clinical and microbiological examina-
tion. Community Dent Oral Epidemiol 1997; 25: 6975.
8. Nyvad B, Machiulskine V, Baelum V. Reliability of a new
caries diagnostic system differentiating between active and
inactive caries lesions. Caries Res 1999; 33: 252260.
9. Machiulskine V, Nyvad B, Baelum V. A comparison of
clinical and radiographic caries diagnoses in posterior teeth of
12yearold Lithuanian children. Caries Res 1999; 33: 340348.
10. 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 Dent Oral Epidemiol 2007; 35: 170178.
11. Lima TJ, Ribeiro CC, Tenuta LM, Cury JA. Low-fluoride
dentifrice and caries lesion control in children with different
caries experience: a randomized clinical trial. Caries Res 2008;
42: 4650.
12. Assaf AV, Meneghim MC, Zanin L, Mialhe FL, Pereira
AC, Ambrosano GMB. Assessment of different methods for
diagnosing dental caries in epidemiological surveys. Community
Dent Oral Epidemiol 2004; 32: 418425.
13. Parfitt GJ. A standard clinical examination of the teeth.
Br Dent J 1954; 96: 296300.
14. Backer-Dirks O. Longitudinal dental caries study in children
915 years of age. Arch Oral Biol 1961; 6: 94108.
15. Pitts NB, Fyffe HE. The effect of varying diagnostic thresh-
olds upon clinical caries data for a low prevalence group. J Dent
Res 1988; 67: 592596.
16. Neilson A, Pitts NB. The clinical behaviour of free smooth
surface carious lesions monitored over 2 years in a group of
Scottish children. Br Dent J 1991; 171: 313318.
17. Pitts NB. Diagnostic tools and measurements impact on
appropriate care. Community Dent Oral Epidemiol 1997; 25: 24
35.
18. Ekstrand KR, Ricketts DNJ, Kidd EAM, 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: 247254.
19. WHO. Oral Health Surveys: basic methods, 4 edn. Geneva:
WHO, 1997.
20. Holmen L, Thylstrup A, A
rtun J. Clinical and histological

features observed during arrestment of active enamel carious
lesions in vivo. Caries Res 1987; 21: 546554.
21. Ekstrand KR, Martignon S, Ricketts DJN, Qvist V.
Detection and activity assessment of primary coronal caries
lesions: a methodologic study. Oper Dent 2007; 32: 225
235.
22. Nyvad B, Machiulskine V, Baelum V. Construct and pre-
dictive validity of clinical caries diagnostic criteria assessing
lesion activity. J Dent Res 2003; 82: 117122.
23. Gonza lez MC, Ru z JA, Fajardo MC, Go mez AD, Moreno
CS, Ochoa MJ, Rojas LM. Comparison of the def index with
Nyvads caries diagnostic criteria in 3-and 4-year-old Colom-
bian children. Pediatr Dent 2003; 25: 132136.
24. Machiulskine V, Baelum V, Fejerskov O, Nyvad B. Preva-
lence and extent of dental caries, dental fluorosis, and devel-
opmental enamel defects in Lithuanian teenage populations
with different fluoride exposures. Eur J Oral Sci 2009; 117: 154
160.
25. Machiulskine V, Nyvad B, Baelum V. Prevalence and
severity of dental caries in 12-year-old children in Kaunas,
Lithuania 1995. Caries Res 1998; 32: 175180.
26. Bland JM, Altman DG. Statistical methods for assessing
agreement between two methods of clinical measurement.
Lancet 1986; 327: 307310.
27. Maclure M, Willett WC. Misinterpretation and misuse of
the kappa statistic. Am J Epidemiol 1987; 126: 161169.
Supporting information
Additional Supporting Information may be found in the online
version of this article:
Table S1. Distribution of diagnoses at the inter-examiner examin-
ations based on Nyvad criteria.
Table S2. Distribution of diagnoses at the intra-examiner examin-
ations based on Nyvad criteria.
Please note: Wiley-Blackwell is not responsible for the content or
functionality of any supporting materials supplied by the authors.
Any queries (other than missing material) should be directed to the
corresponding author for the article.
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.

Reliablity of Nyvads

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Reliablity of Nyvads

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Reliability of the Nyvad criteria for

caries assessment in primary teeth

rtun J. Clinical and histological

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