Journal of Dental Research

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Visual and Visuo-tactile Detection of Dental Caries

A.I. Ismail
J DENT RES 2004 83: C56
DOI: 10.1177/154405910408301S12

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International and American Associations for Dental Research

 PROCEEDINGS
Clinical
A.I. Ismail
Department of Cariology, Restorative Sciences, and
Endodontics, School of Dentistry, University of Michigan,
Ann Arbor, MI 48109-1078, USA; ismailai@umich.edu
J Dent Res 83(Spec Iss C):C56-C66, 2004
ABSTRACT
The objective of this review is to describe and discuss the
content validity of a sample of caries detection criteria
reported in the literature between January 1, 1966, and May
1, 2000. Using filters to locate randomized or controlled
clinical trials on dental caries, fluorides, sealants, and
"restorative" care, I identified a total of 171 documents
from MEDLINE and the Cochrane Collaboration's Oral
Health Group (CC-OHG) special register. These articles
met the following inclusion criteria: (1) Data had been
collected from samples of patients or populations; and (2)
dental caries was assessed clinically, and criteria were
either published or described in the paper. From the
selected articles, evidence tables were prepared describing
each caries detection criterion. Analysis of the content
validity of the criteria systems was based on evaluation of
the disease process, exclusion of non-caries lesions,
subjectivity, use of explorers, and drying of teeth prior to
examination. This review included 29 unique criteria
systems. Of those, 13 originated from the UK, 3 from the
USA, 4 from Denmark, and others from the World Health
Organization (WHO), Sweden, Switzerland, Norway,
Netherlands, and Canada. Thirteen of the criteria systems
either measured active and inactive early and cavitated
lesions or defined separate criteria for smooth and occlusal
tooth surfaces. Nine systems measured early as well as
cavitated stages of the caries process, and 7 measured
cavitation only. Eleven of the criteria systems provided
explicit descriptions of the disease process measured or
information on how to exclude non-caries from caries
lesions. The use of explorers and drying and cleaning of
teeth varied widely among the criteria. The majority of the
newly developed criteria systems originated from Europe.
In conclusion, this review of the content validity of the 29
criteria systems found substantial variability in disease
processes measured, inclusion and exclusion criteria, and
examination conditions.
KEY WORDS: dental caries, diagnosis, detection,
validity, criteria, measurement.
Presented at the International Consensus Workshop on
Caries Clinical Trials, Glasgow, Scotland, January 7-10,
2002
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International and American Associations for Dental Research
Visual and Visuo-tactile
Detection of Dental Caries
INTRODUCTION
S ince the late 19th century, it has been recognized that detection and classification
of dental caries are not easy tasks. The problems of misdiagnosis of caries lesions
and "hidden caries" are not new phenomena (Knapp, 1868; Anonymous, 1869). The
following account, reported in 1869 by a dentist from Missouri, USA (Anonymous,
1869), clearly shows the dilemmas that faced and still face dentists. The author
reported:
"A few months ago a young lady called on me for an examination of her teeth. I
endeavored to make it thorough. Seventeen cavities were found and so reported to
her. Her astonishment was very great for she had just come from one who had made
an examination of her teeth, and reported four cavities. In a couple of weeks I had
finished operations on her teeth and plugged eighteen cavities."
That dentist's solution to the problem, however, has also been the subject of
debate and study (and controversy) during at least the last 20 years. He reported:
"There are some cases of failure in diagnosis of dental decay, even when one
intends to be very thorough. First and foremost is the large size of the excavator used
for examination. The...excavator should be of the very smallest kind, and hatchet
shaped..... This excavator should be made for diagnosis alone, and not for cutting
enamel or dentine. The mouth mirror is another cause of defective diagnosis. One
that magnifies two diameters should be used, and not the ordinary natural mirror.
Saliva often obscures slight decay, especially in the fissures of the bicuspids."
Interestingly, the same dentist proclaimed that "once the teeth are separated, a
good eye, experienced in this kind of diagnosis, and the mirror will usually be
sufficient" (Anonymous, 1869). Visual detection of dental caries is not a new
suggestion!
The concept that dental caries is a process rather than a categorical disease with
"cavitated" and "not cavitated" states was also reported over 100 years ago. Magitot
(1886) divided the diseases into three stages: caries of enamel, caries of dentin, and
deep caries. Morsman, in 1888, stressed the importance of diagnosis as the "first
step" in the management of dental cariesa goal that is yet to be universally
achieved and supported.
In the early decades of the 20th century, the technical foundation of restorative
dentistry was developed. In the USA, a pioneering and inquisitive dentist, dental
teacher, and researcher, Dr. G.V. Black, developed a system for restoring decayed
teeth. Dr. Black was surprisingly well aware of the limitation of the restorative
approach to management of dental caries (Black, 1880, 1910, 1922, 1924). A recent
discovery of a speech presented in 1910 confirmed that he did recognize the
importance of caries in enamel. In a visionary lecture before the Philadelphia dental
society, Dr. Black (1910) stated:
"Studies of [the] beginning caries should be continuously made, as it appears in
the teeth of patients in the chair from day to day, with the view of becoming more
familiar with its tendencies to spread on the surface of the enamel and the positions
and directions of spreading.
"The whole subject of caries of the enamel is a most important one in its relation
to everyday practice..."
The dilemma is that while several solutions have been proposed, we still do not
have consistent and valid systems for clinical caries detection. Hence, this paper aims
to evaluate the content validity of published visual and visuo-tactile caries detection
systems. Content validation refers to the comprehensiveness of a system used to
measure a phenomenon (Feinstein, 1987).
Content validity, in contrast to criterion validity (correlational or predictive
validity), is not judged by statistical analyses (e.g., sensitivity and specificity or ROC
analysis). While research of caries diagnostic methods has focused exclusively on
criterion validity, the content validity of existing and proposed systems has not yet
J Dent Res 83(Spec Iss C) 2004 Clinical Caries Detection
been thoroughly evaluated. The most recent comprehensive review of
the sensitivity and specificity of clinical diagnostic systems (criterion
validity), conducted by the Research Triangle Institute/University of
North Carolina, investigated the evidence on the correlational validity
of caries diagnostic systems (Bader, 2001). That review found that the
visual and visuo-tactile methods have low sensitivity and moderate to
high specificity in detecting cavitated lesions. The correlational validity
in detecting enamel caries on occlusal surfaces was lower than the
desired 80% (Bader, 2001). The gold standard in the studies included in
that review was histological examination of extracted teeth.
The objective of this paper is to review the content validity of
selected caries criteria system based on the perspective that dental
caries is:
(1) a disease process that is caused by an imbalance, in favor of
demineralization, in the demineralization-remineralization
cycle in the oral cavity;
(2) a disease process that may manifest itself first by minor
changes in the enamel structure that may lead, if it continues, to
the destruction of tooth structure and cavitation; and
(3) a disease process that may reverse or stop, resulting in complete
healing of the demineralized dental tissue or in preservation of
minutely damaged tissue.
MATERIALS & METHODS
This review is not a systematic search for all evidence ever published on
visual and visuo-tactile methods of caries detection. Rather, the review
focuses on the content validity of a sample of caries detection criteria
reported in literature published in MEDLINE and the Cochrane
Collaboration's Oral Health Group (CC-OHG) special register of
randomized or controlled clinical trials. Papers included in this review
met the following inclusion criteria: (1) Data were collected from
samples of patients or populations; and (2) dental caries assessed
clinically in the study and criteria were either published or described in
the paper. The review focused on papers published in English. Due to
time constraints, only the author read, selected, and abstracted the
relevant studies.
To sample relevant studies, in May, 2001, I conducted the
following searches of the two databases. In the first search, the
following filters were used to identify relevant documents published
between January 1, 1966, and May 1, 2001, in MEDLINE:
exp Tooth demineralization/ or demineralization.mp. or caries.mp.
or caires.mp. or craies.mp. or careis.mp. or "tooth cavit:".mp. or "teeth
cavit:".mp.or "dental cavit:".mp. or "tooth decay:".mp. or "teeth
decay:".mp. or "active decay".mp. or "white spots".mp. or "enamel
decay".mp. or "rampant decay".mp. or carious.mp. or "non-cavitated
lesion:".mp. or "noncavitated lesion:".mp. or "precavitat:".mp. or Tooth
remineralization/ or "dental fissure:".mp. or "tooth fissure:".mp. or
"teeth fissure:".mp. or "oral fissure:".mp. or "cariesfree".mp. or "caries-
free".mp. or "cariogenic:".mp. or Cariogenic agents/ or "filled
teeth".mp. or "filled tooth".mp. or dft.mp. or dfs.mp. or dmf:.mp.
This search found 37,397 citations.
The search also located citations classified under "sensitivity and
specificity" (explode "sensitivity and specificity") or those classified
under diagnostic errors (explode diagnostic errors) or predictive value
in the title (predictive value$.tw.). This search resulted in 154,996
citations. Finally, the terms "diagnosis, differential" and "diagnostic
criteria" ("diagnostic criteria".mp.) were searched. A total of 222,496
citations was classified as such or had these words. When these last
two searches were combined (with "or"), 366,519 citations were
identified. This group of citations was cross-matched with the "caries"
filter (the first 37,397 citations), resulting in 1022 citations. Of those,
997 were classified as "human" studies. Based upon a review of the
titles of the 977 citations, 136 articles were selected for photocopying
because the titles or abstracts of these articles indicated that the studies
may include criteria for the detection of dental caries.
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International and American Associations for Dental Research
C57
In the second search, the CC-OHG was searched for articles or
abstracts with the following key words: "caries and prevent" or
"fluoride*" or "sealant*" or "xylitol*" or "chlorhexidine" or "prevent".
A total of 3486 citations was located. A review of the titles of these
citations identified 123 relevant articles. After reading the abstracts of
the 123 articles, I photocopied 35 full reports.
Additionally, other key reviews, documents describing diagnostic
criteria used around the world, and papers published in the 19th
century or early part of the 20th century were included in this review.
The search methods used to locate these articles have been described in
a previous paper (Ismail et al., 2001).
Hence, 171 articles were photocopied, and the articles or abstracts
(for those documents presented only as abstracts) were read (a copy of
the citations of the 171 documents can be obtained from the author).
From these articles, 29 were selected for inclusion because they include
detailed description of unique criteria for caries detection. From these
included articles, one evidence table was prepared. The content validity
of each criteria system described in Table 1 was evaluated according to
the following characteristics and scoring system:
(A) Disease process
(1) Measures only one stage of an active disease process
(2) Measures at least two stages of an active disease process
(3) Measures active and inactive stages of the disease process
or defines separate criteria for measuring the stages of the
active disease processes on different tooth surfaces
(B) Exclusion of non-caries lesions
(1) Inclusion of signs not related to caries or no differentiation
between dental caries and other changes caused by staining or
developmental enamel defects
(2) Focuses only on signs related to the caries process and
differentiates between caries and staining or developmental
enamel defects
(C) Subjectivity
(1) Criteria contain vague terms that may increase examiner
subjectivity.
(2) Criteria clearly define the terms used to measure the caries
process.
Additionally, given concern about the use of sharp explorers
(Ismail et al., 2001), the criteria were scored for use of an explorer (0 =
Yes, 1 = No exploring or gentle exploring only, or explorer was used
to clean the teeth) and drying or cleaning of teeth (0 = No, 1 = Yes).
Based on this evaluation system, the possible score ranged between a
minimum of 3 and a maximum of 9.
RESULTS
The criteria systems included in this review are described in Table 1.
Thirteen of the 29 criteria systems were published in the UK (England
and Scotland), 3 were from the USA, 2 from the Netherlands, 2 from
the World Health Organization, 4 from Denmark, 2 from Sweden, 1
from Norway, 1 from Switzerland, and 1 from Canada. The criteria
varied in definitions of dental caries, content, details on use of
explorers, drying of teeth, and other examination conditions.
The evaluation of the criteria systems, presented in Table 2, shows
that 13 of the criteria systems measured both active and inactive stages
of the disease process or defined separate criteria for measuring the
stages of the active disease process on different tooth surfaces; 9
measured only the carious process at the cavitation stage, and 7
measured non-cavitated as well as cavitated active caries lesions. Only
7 of the 29 criteria systems differentiated between caries and non-
caries lesions (e.g., fluorosis or developmental defects). Subjectivity
rating found that 11 of the criteria systems defined the terms used to
measure the caries process in ways that may reduce subjectivity of the
examiners. Eleven of the 29 criteria systems relied on either visual
inspection or the use of "gentle exploring" or dull-ended explorer or
periodontal probes for detection of caries. Fourteen out of the 29
criteria systems required examination of dried teeth. Overall, the
(Text continues on p. C63.)
C58 Ismail J Dent Res 83(Spec Iss C) 2004

Table 1. Criteria for Detection of Dental Caries

Diagnostic System Year and Country Tooth Surface Description

Jackson 1950, UK Crown There should be positive and clear evidence of enamel dissolution before the diagnosis of caries is made.
(1) A clear mirror and sharp probes must be used for examination. For the detection of pit and fissure lesions,
Ash's Sickle Probe No. 54 is to be used, and for approximal lesions, Ash's Probe No. 12 is to be used.
(2) Each tooth must be dried thoroughly, and every surface examined.
(3) Before each examination, the sickle probe is to be sharpened lightly with a medium sandpaper disc to
make a conical point.
(4) A pit or fissure is counted as carious if, with a little pressure, the point sticks without doubt and requires a
definite pull to be removed. Anything that is at all doubtful is not included.
(5 Stained pits or fissures are not counted as carious unless they satisfy this test.
(6 The probe must be used in all fissures and pits in several angles.
(7 Approximal lesions are considered detectable if Ash's No. 12 probe catches a roughened surface or a
definite cavity.
(8) Stained or opaque light areas on other smooth surfaces are not called carious unless there is positive
and undoubted evidence of enamel dissolution.
(9) Arrested caries is counted as carious, and exposed dentin in hypoplastic teeth is counted as carious,
only if there is positive evidence of softening.
Parfitt 1954, UK Crown The first sign of caries as a slight discoloration, with loss of luster on the enamel surface.
Grade 1 = slight discoloration with loss of luster of the enamel surface
Grade 2 = Surface is roughened and pitted, a condition which can be detected by explorer point.
Grade 3 = further penetration and loss of tissue, causing pitting to reach the dentin
Grade 4 = loss of dentin and cavitation
Backer-Dirks et al. 1961, Netherlands Crown For approximal caries, the clinical examination by mirror and explorer was completely abandoned, because
of poor accuracy which makes it almost impossible to standardize diagnosis.
Pits and fissures were cleaned with a new sharp explorer and dried with compressed air. The diagnosis was
made with a small hand light of high intensity. Incident and transmitted light was used. Caries was estimated
in 4 different grades. Caries I signifies a minute black line at the bottom of the fissure. In caries II, there is also
a white zone along the margins of the fissure. Caries III denotes the smallest perceptible break in the continuity
of the enamel (cavity) with or without undermined margins. Caries IV is a large cavity more than 3 mm wide.
McHugh et al. 1964, UK Crown Teeth were counted as carious if a probe stuck definitely in a pit or fissure on being applied with gentle
pressure, or if there were other signs of caries. Only limited pressure could be applied with the replaceable
probe points without causing breakage, and this helped in the standardization of "sticky fissures". In addition,
each carious cavity was given a "penetration score" on the following basis:
1 = sticky fissure
2 = fissure or free-surface cavity with softness at base and staining or opacity of the enamel
3 = cavity with obvious dentin involvement (All detectable approximal cavities in teeth with approximal
contacts were given this score unless there was pulp involvement.)
4 = cavity with obvious pulp involvement
Marthaler 1966, Switzerland Crown First look! Probe only when doubtful.
Grade 1: slightly brown narrow line or [on smooth surfaces Class V] white spot with hard surface, smallest
extent not exceeding 2 mm
Grade 2: clearly brown or black line or [or on Class V lesions] white spot, smallest extent exceeding 2 mm.
For Class III lesions [proximal of anterior teeth], the lesion has a dark brown discolored surface.
Grade 3: cavity, discontinuity of the enamel surface
Grade 4: cavity with the narrowest extent of the entrance broader than 2 mm
Mller 1966, Denmark Crown Buccal and lingual smooth surfaces:
Grade I: a white opaque spot that keeps its luster after a short (3 sec) period of drying
Grade II: After being dried, the area appears white and chalky.
Caries in pits and fissures:
Grade I: Area is dark by incident as well as transmitted light; the lesion is confined to a small dark line.
Grade II: In addition to Grade 1, a white zone can be seen along the margins of the fissure, which
appears dark in transmitted light.
Grade III: There is smallest perceptible break in the continuity of the enamel.
Radike 1968, USA Crown (I) Frank lesionsThe detection of these lesions on the basis of gross cavitation usually does not present a
problem in diagnosis. When cavitation is present, the diagnosis is positive.
(A) Cavitation in this context can be defined as a discontinuity of the enamel surface caused by loss of tooth
surfaces.
(B) Cavitation which is the result of the caries process must be distinguished from fractures and smooth
lesions or erosion and abrasion.
(II) Lesions not showing cavitationThe most difficult part of the examiner's task is the detection of lesions
without frank cavitation. These are lesions close to the decision point between carious and sound. The criteria
for detection of these lesions are summarized in three categories, each presenting its special problems.
(A) Detection of pit and fissure lesions of the occlusal, facial, and lingual surfaces.
(1) Area is carious when the explorer "catches" or resists removal after insertion into a pit or fissure with
moderate to firm pressure and when accompanied by one or more of the following signs of caries:
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International and American Associations for Dental Research

J Dent Res 83(Spec Iss C) 2004 Clinical Caries Detection C59

Diagnostic System Year and Country Tooth Surface Description

(a) a softness at the base of the area

(b) opacity adjacent to the pit or fissure as evidence of undermining or demineralization
(c) softened enamel adjacent to the pit or fissure which may be scraped away with the explorer
(2) Area is carious if there is loss of the normal translucency of the enamel, adjacent to a pit, which is in
contrast to the surrounding tooth structure. This condition is considered to be reliable evidence of
undermining. In some of these cases, the explorer may not catch or penetrate the pit.
(B) Detection of lesions on smooth area[s] of facial and lingual surfaces
(1) Area is carious if surface is etched or if there is a white spot as evidence of subsurface
demineralization, and if the area is found to be soft by:
(a) penetration with explorer
(b) enamel can be scraped away with explorer
(2) Area is sound when there is apparent evidence of demineralization (etching or white spots) but no
evidence of softness.
(C) Detection of lesions on proximal surfaces: It was not possible to attain agreement on a single set of
criteria, since procedures used for diagnosis of proximal surfaces varied considerably. Some examiners
depended largely upon visual-tactile methods, some depended largely upon radiographs and
transillumination, while others used a combination of these procedures. The following is intended to be
a composite of the best elements from all procedures:
(1) For area exposed to direct visual and tactile examination, these are diagnosed as under "B" above
for smooth areas.
(2) For hidden areas not exposed to direct visual-tactile examinations:
(a) (visual examination) If the marginal ridge shows an opacity as evidence of undermined enamel,
the proximal surface is carious.
(b) (tactile examination) Any discontinuity of the enamel in which an explorer will enter is carious if
it also shows other evidence of decay, such as softness, shadow by transillumination, or loss of
translucency.
(c) (radiography) Any definite radiolucency indicating a break in the continuity of the enamel
surface is carious.
(d) (transillumination; use mostly for anterior teeth) A loss of translucency producing a characteristic
shadow in a calculus-free and stain-free proximal surface is adequate evidence of caries.
Mller and Poulsen 1973, Denmark Crown Pits and fissures
Discoloration not definite "sticking"
Sticking with or without discoloration, no dentin involvement
Definite cavity with dentin involvement
Probable pulp complication
Vestibular and lingual smooth surfaces
White opaque area with loss of luster, no loss of substance
Discontinuity in the enamel, loss of substance, no dentin involvement
Dentin involvement
Probable pulp complication
Proximal surfaces (diagnosed by means of radiographs)
Murray and Shaw 1975, UK Crown C1: a pit, fissure of smooth surface in which there is discoloration in both incident and transmitted light, with
minute discontinuity in the enamel surface which does not allow definite "sticking" of the probe on gentle
pressure
C2: a cavity in a pit, fissure or a smooth surface in which a probe sticks with gentle pressure and requires a
definite pull to be removed
C3: a large open cavity, probably with pulpal involvement
When in doubt, score low.
Bennie et al. 1978, UK Crown 1 = sticky fissure
2 = fissure or free-surface cavity with softness at base and staining or opacity of the enamel. A blunt sickle
probe with terminal diameter of 0.7 mm enters the lesion.
3 = cavity with obvious dentin involvement (All detectable approximal cavities in teeth with approximal
contacts were given this score unless there was pulp involvement.)
4 = cavity with obvious pulp involvement
Howat 1981, UK Crown Visual method:
(Surface must be cleaned, dried, and illuminated, and a spoon excavator is required for size measurements.)
Pits and fissures:
V1visibly intact enamel with one or both of the following: dark line at base of fissure; white change in
walls of fissure
V2breakdown of walls of fissure with either visible open cavity or shadow or opacity beneath the enamel
as evidence of undermining, all less than 1.5 mm measured across the fissure
V3breakdown of walls of fissure with either a visible open cavity, or shadow or opacity beneath the
enamel as evidence of undermining, all greater than 1.5 mm measured across the fissure
Free smooth surfaces:
V4white chalky opaque lesion, but intact surface

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International and American Associations for Dental Research

C60 Ismail J Dent Res 83(Spec Iss C) 2004

(continued from previous page)

Diagnostic System Year and Country Tooth Surface Description

V5break in enamel with cavity less than 0.5 mm in diameter

V6cavity greater than 0.5 mm in diameter
Mesio-distal surfaces:
V7shadow by transillumination, or loss of translucency
V8observable cavity
Tactile methods:
(No special preparation of surface required; however, a standardized probe is necessary. The most refined probe
appears to be the Holst probe, which is used once then returned to the manufacturer for re-standardization.)
T1sticky on probing; the probe requires a definite pull to be removed
T2The explorer "catches" or resists removal in a pit or fissure with moderate to firm pressure, and
adjacent softened enamel may be scraped away with the explorer.
T3The explorer "catches" or resists removal in a pit or fissure with moderate to firm pressure and is
accompanied by softness at the base of the area.
Free smooth surfaces:
T4a surface discontinuity, including defective (soft or brittle) enamel, tip of probe sticking superficially
T5cavity with a detectably softened floor
T6cavity detected by probing; probe sticking superficially
Mesio-distal:
T7cavity detected by probing, with a detectable softened floor
Visual-tactile (The surfaces must be cleaned, dried, and illuminated.):
Pits and fissures:
VT1fissure showing discoloration with incident as well as transmitted light and no definite stickiness
VT2The explorer "catches" or resists removal in a pit or fissure with moderate to firm pressure, and is
accompanied by opacity adjacent to the pit or fissure as evidence of undermining or
demineralization.
VT3visible cavity, probe penetrates to dentin
Free smooth surfaces:
VT4white spots with loss of luster with hard intact surface
VT5white spots with softness detected by penetration and scraping away of enamel by an explorer
VT6break in enamel in a chalky or brown-stained area of diminished translucency less than 0.5 mm in
diameter, with soft floor
VT7definite cavity with soft floor, diameter greater than 0.5 mm.
Mesio-distal:
VT8white or brown area of enamel seen by direct vision; dark area of enamel seen by transillumination,
no visible cavity entered by the probe (mostly for anterior)
VT9if the explorer detects roughness, softening, or surface discontinuity in a chalky or brown-stained
area of diminished translucency
NIDCR 1987, USA Crown and root Coronal caries:
Frank lesions are detected as gross cavitation. Incipient lesions may be subdivided into three categories
according to location, each with special diagnostic considerations. These categories are:
(A) Pits and fissures on occlusal, buccal, and lingual surfaces. These areas are diagnosed as carious when
the explorer catches after insertion with moderate to firm pressure and when the catch is accompanied
by one or more of the following signs of decay:
(1) softness at the base of the area
(2) opacity adjacent to the area, providing evidence of undermining or demineralization
(3) softened enamel adjacent to the area which may be scraped away with the explorer (Care should
be taken to avoid removal of enamel that could be remineralized.)
(B) smooth areas on buccal (labial) or lingual surfaces
These areas are carious if they are decalcified or if there is a white spot as evidence of subsurface
demineralization and if the area is found to be soft by:
(1) penetration with the explorer, or
(2) scraping away the enamel with the explorer. These areas should be diagnosed as sound when there
is only visual evidence of demineralization, but no evidence of softness.
(C) Proximal surfaces: For areas exposed to direct visual and tactile examination, as when there is no adjacent
tooth, the criteria are the same as those for smooth areas on facial or lingual surfaces. For areas not avail-
able to direct visual-tactile examination, the following criterion applies: A discontinuity of the enamel in which
the explorer will catch is carious if there is softness. Visual evidence of undermining under a marginal ridge is
not acceptable evidence of a proximal lesion unless a surface break can be entered with the explorer.
Root caries: Active caries lesions in root surfaces are yellow/orange, tan, or light brown. Lesions in remission
tend to be darker, sometimes almost black. When root caries is covered by small amounts of plaque, the
discoloration of the lesions usually shows through. The tactile criterion of softness to an explorer tip must be
met for a definite diagnosis of root caries.
WHO 1987, World Crown Caries is recorded as present when a lesion in a pit or fissure, or on a smooth tooth surface, has a detectably
softened floor, undermined enamel, or softened wall. A tooth with a temporary filling should also be included
in this category. On approximal surfaces, the examiner must be certain that the explorer has entered a lesion.
When any doubt exists, caries should not be recorded as present.
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J Dent Res 83(Spec Iss C) 2004 Clinical Caries Detection C61
Diagnostic System Year and Country Tooth Surface Description

Bauer et al. 1988, USA Root Discrete, well-defined, and discolored cavitation on the root surface into which the explorer entered easily and
displayed some resistance to withdrawal
Dowell and Evans 1988, UK Crown Surfaces are recorded as decayed if, in the opinion of the examiner after visual inspection, there is a carious
cavity into dentin. If doubt exists, the surface will be investigated with the probe using only light pressure, and
unless the point enters the lesion, the surface will be recoded as sound. The catching of the probe in a pit or
fissure is not enough to warrant the diagnosis of caries unless there is additional visual evidence. Hard
arrested caries into dentin is included as decayed.
Pitts and Fyffe 1988, UK Crown Initial caries: No detectable loss of substance. For pits and fissures, there may be significant staining, discoloration,
or rough spots in the enamel that do not catch the explorer, but where loss of substance cannot be positively
diagnosed. For smooth surfaces, these may be white, opaque areas with loss of luster.
Enamel caries: demonstrable loss of tooth substance in pits, fissures, or on smooth surfaces, but no softened
floor or wall or undermined enamel. The texture of the material within the cavity may be chalky or crumbly,
but there is no evidence that cavitation has penetrated the dentin.
Caries of dentin: Detectably softened floor, undermined enamel, or a softened wall, or the loss has a
temporary filling. On approximal surfaces, the explorer point must enter a lesion with certainty.
Pulpal involvement: deep cavity with probable pulpal involvement. Pulp should not be probed.
Nielson and Pitts 1991, UK Crown Visual impression of caries (including white-spot lesions) where there is no loss of contour
Loss of contour, but the Williams probe does not penetrate the surface of the lesion under light pressure
The Williams probe enters the lesion without force.
Obvious pulpal involvement.
Ismail et al. 1992, Canada Crown Pits and fissures:
After drying and cleaning the tooth, the examiner visually checks whether the surface is cavitated (loss of
enamel). If not, and if the pits and fissures are light or dark brown at base, and/or a white change
(demineralization) in sides of the pits or fissures is detected, then the area is diagnosed as potentially carious.
Stained pits and fissures are also coded in this category.
A cavity is defined as any loss of tissue beyond the boundaries of developmental pits and fissures on occlusal
surfaces and when an actual defect is observed on a smooth surface. Arrested cavitated lesions do not have
softened floors or sides that can be detected by an explorer with gentle pressure. The lesions are localized
most often in caries-non-susceptible areas. The lesion size was classified into small or large by means of the
0.5-mm ball end of a WHO periodontal probe.
Small or large active cavitated lesions contain demineralized dentin (usually light brown) and have soft texture
when explored with gentle pressure. The lesion is usually located in a caries-susceptible area.
Smooth surfaces:
Non-cavitated caries lesions located on non-susceptible areas (other than contact areas and the area within
1.5 mm of the gingival line). These lesions should have the following characteristics: They are not hypoplastic
or fluorotic areas; clear from but parallel to the gingival line; surface is glazed and hard; not usually covered
by plaque; usually white in children.
Non-cavitated caries lesions located in a contact area or within 1.5 mm of the gingival line, usually in contact
with it. These lesions have a matted surface and are usually covered by dental plaque.
Cavitated lesions: same definition as used for pits and fissures
Bjarnason et al. 1992, Sweden Crown Incipient: white-spot lesions with unbroken surface or previously widened sealed pits and fissures
Manifest caries: caries lesions showing cavitation, frank recurrent lesions connected with restorations, and new
cavities on previously restored surfaces
Weerheijm et al. 1992, Netherlands Crown Occlusal surfaces were judged according to the following criteria:
1 = narrow dark line or decalcification in the fissure
2 = broad dark line or narrow dark line combined with a decalcification in the fissure
3 = dentin lesion
Scores 1 and 2 represent lesions limited to the enamel without clinical signs of dentin caries.
Beighton et al. 1993, UK RootThe diagnosis of primary root caries was made by consideration of changes in color, texture, and surface
contour of the tooth.
The color of each lesion was categorized by visual comparison with a standard guide of four shades (yellow,
light brown, dark brown, and black) which was prepared from photographs of primary root-caries lesions.
The dimensions of each lesion, the occluso-gingival and mesio-distal lengths, and greatest loss of surface
contour were measured with a periodontal probe marked with 1-mm intervals.
The texture of the lesion was classified into three grades: hard, leathery (assessed by means of a new Ash No.
6 probe with moderate pressure but displaying resistance to its withdrawal), and soft lesions which were easily
penetrated and displayed no resistance to withdrawal of the probe.
Pitts 1994, UK Crown Preventive care advised (PCA):
Clinically detected enamel lesions (cavitated or not) and lesions detectable only with additional diagnostic aids
Operative care advised (OCA):
Clinically detectable lesions in dentin and lesions found in dentin by means of diagnostic aids
Rosen et al. 1996, Sweden Root and crown According to the location of the lesion: Caries lesions transversing the cemento-enamel junction and involving
both the coronal and root portions of a tooth surface were classified as coronal caries.
Cavitation: Lesions were classified as manifest caries as soon as the tooth structure has disintegrated as a
cavity was formed.

(continued on next page)

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International and American Associations for Dental Research

C62 Ismail J Dent Res 83(Spec Iss C) 2004

(continued from previous page)

Diagnostic System Year and Country Tooth Surface Description

Discoloration: White- or brown-spot lesions on the crowns and yellowish or brownish to black lesions on the
roots were recorded as initial caries.
Surface structure: The manifest lesions were classified as hard or soft and the initial lesions as smooth or rough.
WHO 1997, World Crown Caries is recorded as present when a lesion in a pit or fissure, or on a smooth tooth surface, has an unmis-
takable cavity, undermined enamel, or a detectably softened floor or wall. A tooth with a temporary filling, or
one which is sealed but also decayed, should also be included in this category. In cases where the crown has
been destroyed by caries and only the tooth is left, the caries is judged to have originated on the crown and
therefore is scored as crown caries only. The CPI probe should be used to confirm visual evidence of caries on
the occlusal, buccal, and lingual surfaces. Where any doubt exists, caries should not be recorded as present.
Pitts et al. 1997, UK Crown Code 1: arrested dentinal decay. Surfaces are regarded as falling into this category if, in the opinion of the
trained examiner, after inspection there is arrested caries in dentin.
Code 2: Surfaces are recorded in this category if, in the opinion of a trained examiner, after visual inspection
there is a caries lesion into dentin.
Code 3: Surfaces are regarded as falling into this category if, in the opinion of the trained examiner, there is a
caries lesion that involves the pulp, necessitating an extraction or pulp treatment.
Amarante et al. 1998, Norway Crown Occlusal caries
Grade 1: caries characterized by white or brown discoloration without substance loss. No radiographic
findings.
Grade 2: little substance loss with break in the enamel surface or discoloring. Fissure with gray/opaque
adjacent enamel and/or caries restricted to enamel in the x-ray.
Grade 3: moderate substance loss and/or caries in the external 1/3 of the dentin radiographically
Grade 4: considerable substance loss and/or caries in the middle 1/3 of the dentin radiographically
Grade 5: great substance loss and/or caries in the internal 1/3 of the dentin radiographically
Similar grades were used for buccal and lingual surfaces and secondary caries.
Ekstrand et al. 1998, Denmark Crown 0 = no or slight change in enamel translucency after prolonged air drying
1 = opacity (white) hardly visible on the wet surface, but distinctly visible after air drying
1a = opacity (brown) hardly visible on the wet surface, but distinctly visible after air drying
2 = opacity (white) distinctly visible without air drying
2a = opacity (brown) distinctly visible without air drying
3 = localized enamel breakdown in opaque or discolored enamel and/or grayish discoloration from the
underlying dentin
4 = cavitation in opaque or discolored enamel, exposing the dentin beneath
Nyvad et al. 1998, Denmark Crown (1) Active caries (intact surface): Surface of enamel is whitish/yellowish opaque with loss of luster; feels rough
when the tip of the probe is moved gently across the surface; generally covered with plaque. No clinically
delectable loss of substance.
Smooth surface: Caries lesion is typically located close to gingival margin.
Fissure/pit: intact fissure morphology; lesion extending along the walls of the fissure
(2) Active caries (surface discontinuity): Same criteria as score 1. Localized surface defect (microcavity) in
enamel only. No undermined enamel or softened floor detectable with the explorer.
(3) Active caries (cavity): Enamel/dentin cavity easily visible with the naked eye; surface of cavity feels soft or
leathery on gentle probing. There may or may not be pulpal involvement.
(4) Inactive caries (intact surface): Surface of enamel is whitish, brownish, or black. Enamel may be shinny and
feels hard and smooth when the tip of the probe is moved gently across the surface. No clinically
detectable loss of substance.
Smooth surface: Caries lesion typically located at some distance from gingival margin.
Fissure/pit: Intact fissure morphology; lesion extending along the walls of the fissure.
(5) Inactive caries (surface discontinuity): Same criteria as score 4. Localized surface defect (microcavity) in
enamel only. No undermined enamel or softened floor detectable with explorer.
(6) Inactive caries (cavity): Enamel/dentin cavity easily visible with the naked eye; surface of cavity may be
shiny and feels hard when probed with gentle pressure. No pulpal involvement.
Fyffe et al. 2000, UK Crown White-spot lesionVisual assessment of dried tooth indicates intact surface, no clinically detectable loss of
substance, with a white or cream-colored area of increased opacity presumed carious by the trained examiner.
Brown-spot lesionVisual assessment of dried tooth indicates intact surface, no clinically detectable loss of
substance, with a brown/black discoloration, presumed carious by the trained examiner.
Enamel cavityIn the opinion of the trained examiner, there is a lesion with demonstrable loss of surface but
no visual, clinical evidence of the lesion penetrating dentin.
Dentin lesion (uncavitated)Surfaces are regarded as falling into this category if, in the opinion of the trained
examiner, there is a caries lesion into dentin but no visible evidence of cavitation.
Dentin cavitySurfaces are regarded as falling into this category if, in the opinion of the trained examiner,
there is a carious cavity into dentin.
Pulp involvedSurfaces are regarding as falling into this category if, in the opinion of the trained examiner,
there is a carious cavity that involves the pulp, necessitating an extraction or pulp treatment.
Arrested dentinal decaySurfaces are regarding as falling into this category if, in the opinion of the trained
examiner, there is arrested caries in dentin.

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International and American Associations for Dental Research

J Dent Res 83(Spec Iss C) 2004 Clinical Caries Detection C63

Table 2. Content Validity of the Criteria Systems Described in Table 1

Disease Exclusion of Use of Drying

Diagnostic System Year and Country Process* Other Lesions* Subjectivity* Explorer* of Teeth* Total

Jackson 1950, UK 1 1 1 0 1 4
Parfitt 1954, UK 3 1 1 0 0 5
Backer-Dirks et al. 1961, Netherlands 2 1 1 1 1 6
McHugh et al. 1964, UK 1 1 1 0 1 4
Marthaler 1966, Switzerland 2 1 1 1 0 5
Mller 1966, Denmark 3 1 1 0 0 4
Radike 1968, USA 1 2 2 0 0 5
Mller and Poulsen 1973, Denmark 2 1 1 0 1 5
Murray and Shaw 1975, UK 1 1 1 0 1 4
Bennie et al. 1978, UK 2 1 1 0 0 4
Howat 1981, UK 3 1 1 0 0 5
NIDCR 1987, USA 1 2 2 0 0 5
WHO 1987, World 1 2 2 0 0 5
Bauer et al. 1988, USA 1 1 1 0 0 3
Dowell and Evans 1988, UK 1 1 1 1 0 4
Pitts and Fyffe 1988, UK 3 1 2 0 1 7
Nielson and Pitts 1991, UK 3 1 2 1 0 6
Ismail et al. 1992, Canada 3 2 1 1 1 8
Bjarnason et al. 1992, Sweden 2 1 1 0 0 4
Weerheijm et al. 1992, Netherlands 2 1 1 1 1 6
Beighton et al. 1993, UK 2 2 2 0 1 7
Pitts 1994, UK 3 1 1 0 0 5
Rosen et al. 1996, Sweden 3 1 1 0 0 5
WHO 1997, World 1 2 2 1 0 6
Pitts et al. 1997, UK 3 1 2 1 1 8
Amarante et al. 1998, Norway 3 2 1 0 1 7
Ekstrand et al. 1998, Denmark 3 1 2 1 1 8
Nyvad et al. 1998, Denmark 3 1 2 1 1 8
Fyffe et al. 2000, UK 3 1 2 1 1 8

* Disease process:
1 =measures only one stage of an active disease process; 2 = measures at least two stages of the active disease process; and 3 = measures active and
inactive stages of the disease process or defines separate criteria for measuring the stages of the active disease process on different tooth surfaces.
Exclusion of non-caries lesions:
1 =inclusion of signs not related to caries or no differentiation between dental caries and other changes caused by staining or developmental enamel
defects; 2 = focuses only on signs related to the caries process and differentiates between caries and staining or developmental enamel defects.
Subjectivity:
1 =Criteria contain vague terms that may increase examiner subjectivity; 2 = criteria clearly define the terms used to measure the caries process.
Use of an explorer: 0 = yes; 1 = no exploring, gentle exploring only, or explorer used for cleaning the teeth.
Drying or cleaning of teeth: 0 = no, 1 = yes.

(continued from p. C57)
content validity scores of the criteria systems developed during the
preceding 5 years were higher than those of the other criteria systems
described in Table 1. It is also interesting to note that most of the
criteria systems published during the 1990s were developed in Europe.
Table 3 lists examples of studies that have used the criteria
systems described in Table 1. There is substantial variation in the
definition of the disease process and methods used to measure dental
caries. For example, Frankl and Alman (1968) reported that a dentist
"experienced in the techniques of public health examinations"
conducted the examinations, but they did not report the criteria used to
define the dental caries process measured by that experienced dentist.
Other systems left the decision on the presence or absence of a caries
lesion to a "trained examiner". The description of the examination
protocols ranged from no reporting at all on how the examinations
were conducted to detailed descriptions of drying and professionally
cleaning the teeth prior to examination. When explorers were used, the
studies varied by the type of explorer, the force with which the
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explorer was used, and the training of the examiners. When reliability
scores were reported, the studies showed good to excellent agreement
among the examiners. However, none of the studies provided detailed
analysis of reliability for each stage of the caries process.
DISCUSSION
During the last 100 years, the dental profession has made significant
progress in reducing the burden of dental caries in economically
developed countries. The scientific and technological advances during the
20th century have profoundly revolutionized how dentistry is practiced
and how dental diseases are managed. However, while dental caries still
represents the major chronic disease afflicting humans, the application of
understanding of the dynamic process of caries development has not yet
been widely incorporated into dental practice and research. Criteria
systems used for the clinical detection of caries lesions have not yet been
scrutinized according to standard protocols that are in use in social and
clinical sciences. Content validity of caries detection criteria has not yet
been investigated. The importance of the "first step" (i.e., detection and
diagnosis) in caries management has not been widely recognized, and

International and American Associations for Dental Research

C64 Ismail J Dent Res 83(Spec Iss C) 2004

Table 3. Examples of Caries Detection Systems and Methods Reported in the Dental Literature

Disease Explorer
Year Author(s) Country Study Design CriteriaProcess Conditions Exam Training Examiner Reliability

1968 Frankl USA Cohort without Not specified but NRa NR NR NR NR

and Alman randomization examinations were
conducted by a
dentist experienced
in the techniques of
public health
examinations"?
1978 Mainwaring UK RCT Radike, 1968 Cavitation or Yes Yes, Yes Reliability
and Naylor visual signs with discarded coefficients
an explorer catch after 20 uses > 0.98
1980 Gibson and Canada Cohort study NR Sticky pits and NR Yes NR NR
Richardson fissures; carious pits
and fissure (visible
signs of caries and
stickiness)
1980 Murray UK RCT without Study-specificb Early and cavitated Yes; teeth Yes Yes Reprodu-
and Shaw randomization were dried cibility ratio
with com- is < 0.26
pressed air (disagree-
ment ratio)
1981 Howat UK Convenience Study-specificb Early to Drying Yes Yes Test-retest
clinical sample cavitated cavitation: correlation
visual, visual- coefficients
tactile, and tactile are > 0.93
1988 Stephen et al. UK Double-blind Bennie et al., 1978 Absence of clinical No drying; Yes Yes Reliability
randomized (unit caries was scored No. 5 plane 2-day coefficients
not specified) visually, but if cavitation mirror and calibration ranging
was suspected, a cavity Williams' from 0.92
was scored only if a periodontal to 0.99.
0.6-mm blunt probe probe and sharp
could enter the lesion, No. 2H sickle
but resistance to with- probes
drawal was still obtained.
1990 De Vries et al. Denmark Cross-sectional Marthaler, 1966 Incipient and cavitated Dry teeth Yes, to No No
remove plaque
1992 Bjarnason et al. Sweden Cross-sectional Study-specificb Incipient and Polished and NR Yes, Intraclass
manifest caries dry teeth 2 days correlation
coefficients
of 0.8 for
clinical
examination
1992 Disney et al. USA Cohort study Radike criteria, 1968 Cavitated Children Yes, #23 Yes Kappa =
did not brush explorer 0.41-0.53
before being
examined.
Compressed
air was used
for drying.
1992 Downer UK Cross-sectional British Association Caries was diagnosed No Yes, blunt No No
for the Study of at the cavitation level explorer
Community Dentistry with presumptive involve-
ment of dentin.
1992 Ismail et al. Canada Cross-sectional Study-specificb Caries was diagnosed Teeth were Yes, #23 used Yes Kappa =
study from incipient to dried and with gentle 0.8-0.9
cavitation cleaned by pressure
means of an
explorer.
1995 Angulo et al. Sweden, Cross-sectional WHO, 1987 NR NR NR NR NR
1997 O'Mullane et al. Ireland RCT Bennie et al., 1978 Sticky fissure to Yes, no CPITN probe Yes Intra-class
cavitation drying correlation
> 0.93
1998 Amarante et al. Norway Cross-sectional Study-specificb 5 stages of caries ranging Dry teeth; Yes Yes Weighted
from discoloration to debris removed kappa: Inter,
"great substance loss" by rubber cup 0.80-0.93;
Intra, 0.92-0.95
1998 Schwarz et al. China Quasi-experi- WHO with a separate Cavitation No Yes Yes Kappa = 0.9
mental design score for arrested caries
(cavitation exposing den-
tin but hard floors and walls)
1999 Brambilla et al. Italy Quasi-experi- WHO, 1987 Cavitation Yes Yes Yes Differences in
mental design mean DMFT
scores ranged
around + 0.1
1999 Papas et al. USA RCT, double-blind "Pitts Diagnostic Incipient caries of enamel, NR NR NR NR
Criteria (WHO)" caries into dentin
2000 Ekstrand et al. Denmark, Cohort study Study-specificb Incipient to Dried and NR Yes Kappa > 0.8
Russia cavitation professionally
cleaned teeth
2000 Forgie et al. UK RCT Pitts, 1994 Incipient and cavitated Yes Drying No Yes Kappa =
of teeth 0.75+
2001 Machiulskiene Denmark Quasi-experi- Nyvad et al., 1998 Assessment of stage of Drying Yes Yes Kappa between
et al. mental (CCT with cavitation as well as Explorers 0.74 and 0.84
randomization of stage of activity used gently
schools)

a NR = not relevant. b Refer to Table 1.

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International and American Associations for Dental Research

J Dent Res 83(Spec Iss C) 2004 Clinical Caries Detection
dentists are usually underpaid for this activity.
This review focused on the content validation of caries detection
systems. As stated before in this paper, calls to study and detect early
caries lesions were made in the 19th century and by G.V. Black in
1910. Over the last 20 years, there have been many attempts to expand
the methods used to detect and diagnose the presence of caries lesions.
However, the narrow focus on "drilling and filling" and the
misconception that early caries lesions cannot be reliably measured
may have led to the development of criteria systems that have skewed
the understanding of dental caries epidemiology, prevention, and
management.
In a previous review, I discussed the reasons why early non-
cavitated lesions should be included in new diagnostic systems of
dental caries (Ismail, 1997). First, there is evidenceeven from
studies published in the 1940s, 1970s, 1980s, and 1990sthat non-
cavitated caries lesions are more prevalent than cavitated lesions in
economically developed countries (Ismail, 1997; Amarante et al.,
1998). Second, non-cavitated caries lesions are more likely to be
restored compared with sound tooth surfaces (Ismail and Gagnon,
1995; Ismail et al., 1997). Third, non-cavitated lesions, especially on
smooth tooth surfaces in young children, may serve as indicators of
caries activity (Domoto et al., 1994; Grindefjord et al., 1995; Imfeld et
al., 1995). Fourth, inclusion of non-cavitated lesions may provide a
better understanding of the mechanism of action of fluoride, sealants,
and other preventive agents (Ismail, 1997). Fifth, inclusion of early
signs of the caries process improves the precision of clinical trials of
preventive agents (Howat et al., 1981).
Analysis of the data presented in Tables 1 and 2 shows that there
is a gulf between researchers in Europe and those in the USA.
European researchers, as early as the 1960s, have included early signs
of dental caries in their criteria systems. By contrast, criteria developed
in the USA have focused on measuring the cavitated stage of caries or
the stage when an explorer sticks in teeth with visual signs of caries
demineralization. The sensibility of the European criteria systems
favors the disease process, while the sensibility of the USA systems
favors reliability and comparability. The guiding principle for any new
caries diagnostic system in the 21st century should be its contemporary
content validity, provided that it is accompanied by a detailed protocol
for calibration of examiners. Research studies should be conducted to
identify scientifically based protocols that can lead to achieving a high
degree of reliability among examiners. Any newly proposed protocol
should define the tools, methods of use, and length and frequency of
training of examiners in studies of dental caries.
This review shows the lack of consistency regarding the use of
explorers. The first account for the need of a sharp instrument to detect
caries lesions was reported by a dentist in the USA who attributed wide
variation in diagnosis to the "...large size of the excavator used for
examination. The...excavator should be of the very smallest kind, and
hatchet shaped.....This excavator should be made for diagnosis alone
and not for cutting enamel or dentine" (Anonymous, 1869). During the
20th century, the use of the term "explorer catch" became part of the
tradition of caries diagnosis (Sognnaes, 1940). The 2001 NIH
Consensus Development Conference on Dental Caries Diagnosis and
Management Throughout Life concluded that "...the use of sharp
explorers in the detection of primary occlusal caries appears to add little
diagnostic information to other modalities and may be detrimental"
(http://odp.od.nih.gov/consensus/cons/115/115_statement.htm#1).
Similarly, there seems to be a variation among the criteria systems
described in Table 1 regarding whether teeth should be cleaned or
dried before an examination. Some criteria stipulated that teeth should
be cleaned with a toothbrush or professionally, while others
recommended cleaning by means of an explorer. The majority of the
criteria listed in Table 1 did not report on whether the teeth were
cleaned or dried before examination. While no data are available to
compare the accuracy and reliability of examiners of clean vs. unclean
or dry vs. wet teeth, the detection of early signs of caries cannot be
achieved unless the teeth are clean and dry.
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International and American Associations for Dental Research
C65
In conclusion, analysis of the data summarized in this review
paper underscores the need to define one criteria system for visual and
visuo-tactile detection of dental caries that has content validity based
upon current scientific evidence and the consensus of experts in the
fields of cariology and restorative sciences. There is also a need to
initiate a research program to test key constructs in caries detection and
develop examination protocols that enable researchers to achieve a
high degree of reliability. In achieving these goals, the workshop
should address the following questions:
(1) What stage of the caries process should be measured in clinical
trials?
(2) What are the definitions for each stage of the caries process?
(3) What is the best approach, in terms of objectivity and
consistency, which should be used to detect each stage of the
caries process for different tooth surfaces?
(4) What is the consensus on examiners' training protocols that
can provide the highest degree of examiner reliability?
All answers to these questions should be based on scientific
evidence. If evidence does not exist, the participants in this conference
should define the research questions that must be answered to advance
the field of caries detection, diagnosis, and management.
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