Variables affecting the inter- and intra-examiner reliability of ICDAS for occlusal caries diagnosis in permanent molars

Evaluation of DIAGNOdent pen for initial occlusal caries diagnosis in permanent teeth

BACKGROUND

To verify the validity of diagnosing initial caries on occlusal surface of permanent posterior teeth by laser fluorescence instrument DIAGNOdent pen.

METHODS

Patients from School of Stomatology in Wuhan University were selected and their posterior teeth were examined using DIAGNOdent pen and the International Caries Detection and Assessment System (ICDAS II) by an experienced dentist. After teeth extraction, histological criteria were used to determine the severity of the lesions. The sensitivity, specificity, accuracy, the area under the curve (AUC), and correlation of DIAGNOdent pen and ICDAS II were analyzed compared with histological criteria. Examiners' agreement was measured.

RESULTS

The sensitivity range was 0.440-1 while that of specificity was 0.750-0.994. The accuracy and AUC were above 80% and 0.7 respectively. Consistency of examiners' kappa values of ICDAS II, DIAGNOdent pen, and histological criteria were ranged from 0.629 to 0.840.

CONCLUSIONS

ICDAS II and DIAGNOdent pen can be effectively used in tandem or independently for the assessment of initial caries.

Occlusal Caries Detection with Intraoral Scanners in Pediatric Dentistry: A Comparative Clinical Study

Background: The aim of this clinical study was to compare the occlusal caries detection (OCD) performance of the intraoral scanners (IOSs) Trios 4 (TIO, 3Shape) and Emerald S (EME, Planmeca) and the Diagnocam (DIA, KaVo) with the established visual (WHO) examination (VIS, reference method). Methods: Between 08/2022 and 02/2023, 60 children (mean age 9.6 ± 2.5 years) were examined as part of their regular dental checkups. OCD was performed at the tooth level, separately for primary and permanent unrestored teeth. Furthermore, two thresholds were analyzed: sound versus overall caries (pooled data of enamel and dentin caries, TH1) and pooled data of sound and enamel caries versus dentin caries (TH2). Results: The best agreement with the reference method (reliability) in both dentitions was obtained for DIA (ĸ = 0.829/ĸ = 0.846; primary/permanent teeth), followed by EME (ĸ = 0.827/ĸ = 0.837) and TIO (ĸ = 0.714/ĸ = 0.680). Similar results were shown for the diagnostic quality (sensitivity, specificity and area under the curve of the receiver operating characteristic curve), with higher values for TH1 than for TH2. Both IOSs and the DIA showed worse results than the reference method VIS. Conclusions: Currently, IOS should be used as an additional caries detection tool, especially for visualization, and cannot be recommended as a basic tool for diagnosis or invasive/noninvasive therapy decisions in OCD.

Prevalence of Dental Caries in Schoolchildren from the Galapagos Islands: ESSO-Gal Cohort Report

Objective

Dental caries remains a prevalent disease worldwide. Several epidemiological studies have shown that it affects the oral health of the pediatric population, and the Galapagos population in Ecuador is no exception. The aim of this study was to determine the prevalence of dental caries and its association, based on baseline information from the Galapagos Oral Health Study (ESSO-Gal), in children of the Galapagos Islands, Ecuador.

Methods

A cross-sectional study was conducted involving 804 children aged 2-11 years. The prevalence of dental caries was assessed using the International Caries Detection and Assessment System (ICDAS II) criteria, while the presence of dental biofilm was assessed using the Silness-Löe index. Descriptive statistics, including frequency analysis and measures of central tendency and dispersion, were performed. Inferential statistical analyses were conducted to identify associations between variables. Statistical analyses were performed using the SPSS version 25.0 statistical program.

Results

The caries prevalence rates based on ICDAS II codes 1-6, 1-2, and 3-6 were 98.01%, 96.9%, and 85%, respectively. A statistically significant difference was observed among the different islands regarding the cutoff point for ICDAS II codes 3-6 (p ≤ 0.001). Participants aged 6-11 years had the highest caries prevalence.

Conclusions

The results show a high prevalence of dental caries among children in the Galapagos Islands, which increases with age. Contrary to expectations, the study did not find a significant correlation between the severity of dental caries and the presence of dental biofilm.

Comparison of two clinical approaches based on visual criteria for secondary caries assessments and treatment decisions in permanent posterior teeth

Background

This cross-sectional study aimed to compare two clinical approaches based on visual criteria for secondary caries assessments and treatment decisions in permanent posterior teeth.

Methods

The two clinical visual criteria tested for the assessments of restored teeth were: FDI criteria—based on the caries presence, marginal adaptation and staining criteria, adapted from the FDI (International Dental Federation) criteria and CARS criteria—"Caries Associated with Restorations or Sealants" (CARS) criteria described by the International Caries Classification and Management System. Adults were randomized according to the criteria. One calibrated examiner assessed the restorations and assigned the treatment according to the criteria. The primary outcome was replacement indication.

Results

A total of 185 patients were included, totalling 718 restorations. The strongest correlation founded between the methods was for the presence of caries lesions (Rho = 0.829). A moderate correlation (Rho = 0.420) was founded between the treatment decisions proposed by the CARS and by the FDI criteria. The multilevel regression analysis showed that the FDI criteria indicated five times more replacements when compared to the CARS (< 0.001). Also, using the FDI criteria restorations were 2.7 times more related to caries around restorations (p < 0.001) compared to the other criterion.

Conclusions

The visual criteria used on the restoration's assessment directly influences the treatment decision to intervene or not on the restoration. The use of a minimally invasive based approach for assessing secondary caries may prevent overtreatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02112-6.

Automated caries detection in vivo using a 3D intraoral scanner

The use of 3D intraoral scanners (IOS) and software that can support automated detection and objective monitoring of oral diseases such as caries, tooth wear or periodontal diseases, is increasingly receiving attention from researchers and industry. This study clinically validates an automated caries scoring system for occlusal caries detection and classification, previously defined for an IOS system featuring fluorescence (TRIOS 4, 3Shape TRIOS A/S, Denmark). Four algorithms (ALG1, ALG2, ALG3, ALG4) are assessed for the IOS; the first three are based only on fluorescence information, while ALG4 also takes into account the tooth color information. The diagnostic performance of these automated algorithms is compared with the diagnostic performance of the clinical visual examination, while histological assessment is used as reference. Additionally, possible differences between in vitro and in vivo diagnostic performance of the IOS system are investigated. The algorithms show comparable in vivo diagnostic performance to the visual examination with no significant difference in the area under the ROC curves (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p>0.05$$\end{document}p>0.05). Only minor differences between their in vitro and in vivo diagnostic performance are noted but no significant differences in the area under the ROC curves, (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p>0.05$$\end{document}p>0.05). This novel IOS system exhibits encouraging performance for clinical application on occlusal caries detection and classification. Different approaches can be investigated for possible optimization of the system.

The ADEPT study: a comparative study of dentists' ability to detect enamel-only proximal caries in bitewing radiographs with and without the use of AssistDent artificial intelligence software

Introduction Reversal of enamel-only proximal caries by non-invasive treatments is important in preventive dentistry. However, detecting such caries using bitewing radiography is difficult and the subtle patterns are often missed by dental practitioners.

Aims To investigate whether the ability of dentists to detect enamel-only proximal caries is enhanced by the use of AssistDent artificial intelligence (AI) software.

Materials and methods In the ADEPT (AssistDent Enamel-only Proximal caries assessmenT) study, 23 dentists were randomly divided into a control arm, without AI assistance, and an experimental arm, in which AI assistance provided on-screen prompts indicating potential enamel-only proximal caries. All participants analysed a set of 24 bitewings in which an expert panel had previously identified 65 enamel-only carious lesions and 241 healthy proximal surfaces.

Results The control group found 44.3% of the caries, whereas the experimental group found 75.8%. The experimental group incorrectly identified caries in 14.6% of the healthy surfaces compared to 3.7% in the control group. The increase in sensitivity of 71% and decrease in specificity of 11% are statistically significant (p <0.01).

Conclusions AssistDent AI software significantly improves dentists' ability to detect enamel-only proximal caries and could be considered as a tool to support preventive dentistry in general practice.

Enamel-only proximal caries is often missed by dentists when examining bitewing radiographs.

The use of AssistDent artificial intelligence software results in a 71% increase in ability to detect enamel-only proximal caries accompanied by a 11% decrease in specificity.

Artificial intelligence software could be considered as a tool to support preventive dentistry in general practice.

Intraoral scanner featuring transillumination for proximal caries detection. An in vitro validation study on permanent posterior teeth

OBJECTIVES

To assess the validity of an intraoral scanner system featuring near-infrared (NIR) transillumination to aid the detection of proximal caries lesions, and to compare the diagnostic performance of this system with that of conventional caries detection methods and with that of an intraoral camera featuring NIR transillumination (DIAGNOcam).

METHODS

Ninety-five permanent posterior teeth were examined using a prototype tip functioning with TRIOS 4 intraoral scanner system (3Shape TRIOS A/S, Denmark) and emitting NIR light, DIAGNOcam, and visual and radiographic examination employing ICDAS criteria. One or two approximal surfaces per tooth, sound or with caries lesions at different stages, were examined (N₁=158). Histological assessment was used as the reference standard.

RESULTS

All methods showed excellent intra-examiner reliability (κ_intra ≥0.80). Two independent examiners assessed the NIR images obtained with both devices. The first examiner, who obtained and assessed the images, showed improved diagnostic performance than the second examiner, who only had access to the images. The inter-examiner agreement between the two examiners assessing the NIR images was substantial (κ_inter 0.57-0.72). The intraoral scanner and DIAGNOcam showed similar diagnostic performance. Regarding initial caries lesions, the NIR image assessment resulted in equal or improved sensitivity (SE 0.50-0.89) compared to radiographic assessment (SE 0.49-0.51) and higher than visual examination (SE 0.28-0.39). Radiographic and NIR image assessment resulted in similar SE in detecting moderate-extensive dentin caries lesions (SE 0.59-0.70), while visual examination showed an inferior value (SE 0.30).

CONCLUSIONS

The intraoral scanner system featuring NIR transillumination and DIAGNOcam showed an overall good diagnostic performance. The conventional caries detection methods showed inferior sensitivity at initial caries lesion stages.

CLINICAL SIGNIFICANCE

Considering the promising diagnostic performance of the intraoral scanner featuring transillumination and the advantages offered by combining the NIR images with the 3D models of the teeth, this system has the potential to contribute towards more reliable caries detection and monitoring in clinical practice without the use of ionizing radiation.

Visual or visual-tactile examination to detect and inform the diagnosis of enamel caries

BACKGROUND

The detection and diagnosis of caries at the initial (non-cavitated) and moderate (enamel) levels of severity is fundamental to achieving and maintaining good oral health and prevention of oral diseases. An increasing array of methods of early caries detection have been proposed that could potentially support traditional methods of detection and diagnosis. Earlier identification of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol-generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.

OBJECTIVES

To determine the diagnostic accuracy of different visual classification systems for the detection and diagnosis of non-cavitated coronal dental caries for different purposes (detection and diagnosis) and in different populations (children or adults).

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 April 2020); Embase Ovid (1980 to 30 April 2020); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 April 2020); and the World Health Organization International Clinical Trials Registry Platform (to 30 April 2020). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared a visual classification system (index test) with a reference standard (histology, excavation, radiographs). This included cross-sectional studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were considered. Studies that explicitly recruited participants with caries into dentine or frank cavitation were excluded. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.

DATA COLLECTION AND ANALYSIS

We extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on QUADAS-2 specific to the review context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence intervals (CIs) and regions, and 95% prediction regions. The comparative accuracy of different classification systems was conducted based on indirect comparisons. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

MAIN RESULTS

We included 71 datasets from 67 studies (48 completed in vitro) reporting a total of 19,590 tooth sites/surfaces. The most frequently reported classification systems were the International Caries Detection and Assessment System (ICDAS) (36 studies) and Ekstrand-Ricketts-Kidd (ERK) (15 studies). In reporting the results, no distinction was made between detection and diagnosis. Only two studies were at low risk of bias across all four domains, and 15 studies were at low concern for applicability across all three domains. The patient selection domain had the highest proportion of high risk of bias studies (49 studies). Four studies were assessed at high risk of bias for the index test domain, nine for the reference standard domain, and seven for the flow and timing domain. Due to the high number of studies on extracted teeth concerns regarding applicability were high for the patient selection and index test domains (49 and 46 studies respectively). Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies: sensitivities ranged from 0.16 to 1.00 and specificities from 0 to 1.00. For all visual classification systems the estimated summary sensitivity and specificity point was 0.86 (95% CI 0.80 to 0.90) and 0.77 (95% CI 0.72 to 0.82) respectively, diagnostic odds ratio (DOR) 20.38 (95% CI 14.33 to 28.98). In a cohort of 1000 tooth surfaces with 28% prevalence of enamel caries, this would result in 40 being classified as disease free when enamel caries was truly present (false negatives), and 163 being classified as diseased in the absence of enamel caries (false positives). The addition of test type to the model did not result in any meaningful difference to the sensitivity or specificity estimates (Chi2(4) = 3.78, P = 0.44), nor did the addition of primary or permanent dentition (Chi2(2) = 0.90, P = 0.64). The variability of results could not be explained by tooth surface (occlusal or approximal), prevalence of dentinal caries in the sample, nor reference standard. Only one study intentionally included restored teeth in its sample and no studies reported the inclusion of sealants. We rated the certainty of the evidence as low, and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and inconsistency of results.

AUTHORS' CONCLUSIONS

Whilst the confidence intervals for the summary points of the different visual classification systems indicated reasonable performance, they do not reflect the confidence that one can have in the accuracy of assessment using these systems due to the considerable unexplained heterogeneity evident across the studies. The prediction regions in which the sensitivity and specificity of a future study should lie are very broad, an important consideration when interpreting the results of this review. Should treatment be provided as a consequence of a false-positive result then this would be non-invasive, typically the application of fluoride varnish where it was not required, with low potential for an adverse event but healthcare resource and finance costs. Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Wherever possible future studies should be carried out in a clinical setting, to provide a realistic assessment of performance within the oral cavity with the challenges of plaque, tooth staining, and restorations, and consider methods to minimise bias arising from the use of imperfect reference standards in clinical studies.

Development of a Fluorescence-Based Caries Scoring System for an Intraoral Scanner: An in vitro Study

OBJECTIVES

To develop an automated fluorescence-based caries scoring system for an intraoral scanner and totest the performance of the system compared to state-of-the-art methods.

METHODS

Seventy-three permanent posterior teeth were scanned with a three-dimensional (3D) intraoral scanner prototype which emitted light at 415 nm. An overlay representing the fluorescence signal from the tissue was mapped onto 3D models of the teeth. Multiple examination sites (n = 139) on the occlusal surfaces were chosen, and their red and green fluorescence signal components were extracted. These components were used to calculate 4 mathematical functions upon which a caries scoring system for the scanner prototype could be based. Visual-tactile (International Caries Detection and Assessment System, ICDAS), radiographic (ICDAS), and histological assessments were conducted on the same examination sites.

RESULTS

Most index tests showed significant correlation with histology. The strongest correlation was observed for the visual-tactile examination (rs = 0.80) followed by the scanner supported by the caries classification function that quantifies the overall fluorescence compared to sound surfaces (rs = 0.78). Additionally, this function resulted in the highest intra-examiner reliability (κ = 0.964), and the highest sum of sensitivity (SE) and specificity (SP) (sum SE-SP: 1.60-1.84) at the 2 histological levels where the comparison with visual-tactile assessment was possible (κ = 0.886, sum SE-SP = 1.57-1.81) and at the 3 out of 4 histological levels where the comparison with radiographic assessment was possible (κ = 0.911, sum SE-SP = 1.37-1.78); the only exception was for the lesions in the outer third of dentin, where the radiographic assessment showed the highest sum SE-SP (1.78).

CONCLUSION

A fluorescence-based caries scoring system was developed for the intraoral scanner showing promising performance compared to state-of-the-art caries detection methods. The intraoral scanner accompanied by an automated caries scoring system may improve objective caries detection and increase the efficiency and effectiveness of oral examinations. Furthermore, this device has the potential to support reliable monitoring of early caries lesions.

The impact of ICDAS on occlusal caries treatment recommendations for high caries risk patients: an in vitro study

Background

The diagnostic criteria and tools used in caries lesion detection have been shown to affect the decision-making for caries treatment. Compared to other diagnostic criteria/classifications, ICDAS has been shown to provide a more accurate method for the detection of occlusal caries lesions. The influence of using ICDAS on caries treatment recommendations has received increasing attention in recent years. Therefore, the aim of this study was to assess the impact of ICDAS on dentists’ occlusal caries lesions’ treatment decisions for patients at high risk for caries.

Methods

Five dentists examined the occlusal surfaces of 270 extracted premolars and permanent molars. For a predetermined clinical scenario, the examiners were asked to indicate their treatment recommendations for each tooth. Four weeks later, all the examiners were trained and calibrated for the use of ICDAS. Then the investigators examined the same 270 teeth independently and indicated their treatment recommendations using the same clinical scenario. Histological validation was used to determine the caries lesions detection performance of the examiners using ICDAS and to assess the relationship between the presence of dentin caries and treatment recommendations for each examiner before and after ICDAS training. Specificity, sensitivity, area under the receiver operating characteristic curve (AUC), and Spearman’s correlation coefficients were calculated. The Wilcoxon two-related sample rank test was used to test for differences between treatment recommendations.

Results

The strongest correlation for inter-examiner reproducibility was found between the ICDAS D2 cut-off point (ICDAS codes 3–6 as dentin caries) and histologic dentin caries. Treatment recommendations among different examiners before and after ICDAS training demonstrated a statistically significant increase in operative intervention and an increase in the percentage of overtreatment recommendations for two examiners.

Conclusions

The impact of ICDAS on the examiners’ caries lesion treatment recommendations varied among the dentists in this study. Treatment decision-making can be influenced by the caries lesion’s detection and classification system used.

Clinical management and prevention of dental caries in athletes: A four-year randomized controlled clinical trial

The aims of this four-year randomized controlled clinical trial were to gain insights into management and prevention of dental caries and the effect of stannous fluoride products in athletes. Fifty-four participants were randomized into test and control groups. The test group used special stannous fluoride products. The primary endpoint dental caries was assessed by the ICDAS-II-System and analyzed both by a linear mixed model for repeated measures and a generalized linear mixed model. During the observation period an increase in caries-free surfaces from 64.91 ± 6.42 at baseline to 73.22 ± 4.43 was observed. In surfaces with caries superficialis and caries media, a decrease from 13.94 ± 5.70 and 2.96 ± 2.55 surfaces at baseline to 7.89 ± 3.18 and 0.46 ± 0.78 after 2.5 years was noted, respectively. The analysis showed no effect of stannous fluoride products, but a significant difference for the time of examination (p < 0.0001). In addition, it could be shown that at any time of examination, the odds of developing caries media on a new surface was significantly lower than at baseline (up to 25-times). Due to biannual dental examinations, professional tooth cleaning and restorative treatment the number of caries-free surfaces increased and the odds of a new surface to be afflicted with caries media decreased 25-fold.

Decision-making of general practitioners on interventions at restorations based on bitewing radiographs

OBJECTIVE

The aim of this study was to compare decision-making based on bitewing analysis of restored proximal surfaces by general dental practitioners (GDPs) with diagnossis and clinical decisions made by experts in cariology and restorative dentistry.

METHODS

This practice-based study used a database of 7 general dental practices. Posterior bitewing radiographs were selected from the electronic patient files of patients, and 770 cases of proximal restored surfaces were selected. Fifty percent of the cases which lead to the restorative decision, and the other half were cases decided for monitoring by the GDPs. Three experts performed radiographic assessment. The outcome variables were agreement of diagnosis and decision of treatment. Cohen's kappa statistic was used.

RESULTS

For the experts, moderate to substantial intraexaminer agreement was observed for the diagnostic criteria, and kappa values of 0.77, 0.79, and 0.88 were obtained for each expert regarding the treatment assignment. Agreement between GDPs and the majority of experts for secondary caries varied between 67 and 83%. One hundred seventy-three out of 385 cases that were treated by GDPs were decided for monitoring by the experts, while 8 cases that were decided for monitoring by the GDPs were decided for treatment. The agreement between experts and GDPs was moderate for secondary caries detection, and fair for treatment decision.

CONCLUSION

The GDPs tend to have a less conservative approach regarding the decision to intervene or not concerning the reassessment of restorations, showing moderate agreement with the experts for secondary caries detection and fair agreement regarding the treatment decision.

CLINICAL SIGNIFICANCE

This study highlights that GDPs tend to have a less conservative approach to the decision to intervene or not in posterior restorations, compared to experts in cariology and restorative dentistry. Efforts should be made to reduce these differences based on minimally invasive dentistry.

Clinical effectiveness of fluorescence, digital images and ICDAS for detecting occlusal caries

Abstract Introduction The detection of small caries lesions is still a challenge for dental professionals who in their clinical practice have a wide variety of methods to detect caries on occlusal surfaces. Objective To clinically assess the effectiveness of the Vista Proof fluorescence camera, the Vista Cam digital intraoral micro camera and the International Caries Detection and Assessment System (ICDAS) visual criterion for detecting caries lesions on occlusal surfaces of permanent teeth. Material and method One hundred and seven posterior teeth from adult patients were examined visually and by means of digital radiographs by an examiner who rated them according to the presence or absence of occlusal caries. The teeth were then assessed by the other examiner using ICDAS, fluorescence and magnified digital images. The effectiveness of the methods was measured based on sensitivity, specificity, positive and negative likelihood ratio. For each method, the Receiver Operating Characteristic (ROC) curve and the Area Under the ROC curve (AUROC) were estimated. Result There was exceptional discrimination capacity for the intraoral images (AUROC=.93) and the ICDAS (AUROC=.91), with no significant statistical difference between them (z=.35, p=.73). The fluorescence exhibited an acceptable discrimination capacity (AUROC=0.78), although it was lower than the others. The positive likelihood ratio for the fluorescence was only 2.32, compared to 20.58 for the intraoral image and 58.11 for the ICDAS. Conclusion Both methods and the ICDAS exhibited an adequate clinical performance, although the ICDAS and intraoral image were more effective than the fluorescence.

Comparison of occlusal caries detection using the ICDAS criteria on extracted teeth or their photographs

BACKGROUND

Using photographs of occlusal surfaces instead of extracted teeth for the detection of caries can be useful in multicenter studies or education. Using a panel of observers, ICDAS scores on teeth or photographs were evaluated against the histological gold standard. The hypothesis was that both outcomes were equivalent.

METHODS

Four examiners with different experience in ICDAS scored photographs of occlusal surfaces of 100 extracted teeth on a monitor using ICDAS criteria. Two of the examiners had previously scored extracted teeth prior to photography. Digital images of histological sections of the teeth were observed by all examiners and consensus scores were given for each investigation site (gold standard). Kappa statistics and Spearman correlation coefficients as well as repeated measure ANOVA were performed. ROC curves were constructed for each examiner and the areas under the ROC-curves (AUC) of both scoring techniques (extracted teeth, digital images) were compared (α = 0.05).

RESULTS

Intra- and inter-rater kappa for ICDAS on teeth were 0.81-0.94 and on photographs 0.54-0.88, respectively. Correlation with histology was 0.58- 0.61 for the teeth and 0.50-0.62 for the photographs. AUC of ICDAS scores of extracted teeth (mean 0.89) were slightly higher than those for photographs (mean 0.84). However, both AUC values were not statistically significant (p = 0.38).

CONCLUSION

Using photographs to assess occlusal surfaces with the ICDAS criteria was not statistically different from scoring the extracted teeth.