The aims of this study were: (1) to evaluate the overall reproducibility and accuracy of the International Caries Detection and Assessment System (ICDAS) for assessing coronal caries lesions, and (2) to investigate the use of systems associated with the ICDAS for activity assessment of coronal caries lesions. Specific search strategies were adopted to identify studies published up to 2016. For the first objective, we selected studies that assessed primary coronal caries lesions using the ICDAS as a reference standard. A total of 54 studies were included. Meta-analyses summarized the results concerning reproducibility and accuracy (correlation with histology, summary ROC curves [SROC], and diagnostic odds ratio [DOR]). The latter 2 were expressed at D1/D3 levels. The heterogeneity of the studies was also assessed. Reproducibility values (pooled) were > 0.65. The ICDAS mostly presented a good overall performance as most areas under SROC were > 0.75 at D1 and > 0.90 at D3; DOR ≥6. For the second objective, we selected studies investigating activity assessment associated with the ICDAS. The meta-analyses pooled results based on the same methodology and parameters as above. Longitudinal findings regarding caries progression were described to estimate the validity of these systems. On average, the systems for activity assessment of caries lesions showed moderate values concerning reproducibility and overall performance. Active caries lesions were more prone to progress than inactive ones after 2 years. In conclusion, the ICDAS presented a substantial level of reproducibility and accuracy for assessing primary coronal caries lesions. Additional systems associated with the ICDAS that classify caries lesion activity can be useful as they are moderately reproducible and accurate.

Achilleos EE, Rahiotis C, Kakaboura A, Vougiouklakis G: Evaluation of a new fluorescence-based device in the detection of incipient occlusal caries lesions. Lasers Med Sci 2013; 28: 193–201.
Agustsdottir H, Gudmundsdottir H, Eggertsson H, Jonsson SH, Gudlaugsson JO, Saemundsson SR, Eliasson ST, Arnadottir IB, Holbrook WP: Caries prevalence of permanent teeth: a national survey of children in Iceland using ICDAS. Community Dent Oral Epidemiol 2010; 38: 299–309.
Bader JD, Shugars DA, Bonito AJ: Systematic reviews of selected dental caries diagnostic and management methods. J Dent Educ 2001; 65: 960–968.
Baelum V, Heidmann J, Nyvad B: Dental caries paradigms in diagnosis and diagnostic research. Eur J Oral Sci 2006; 114: 263–277.
Bornmann L, Mutz R, Daniel HD: A reliability-generalization study of journal peer reviews: a multilevel meta-analysis of inter-rater reliability and its determinants. PLoS One 2010; 5:e14331.
Braga MM, Ekstrand KR, Martignon S, Imparato JC, Ricketts DN, Mendes FM: Clinical performance of two visual scoring systems in detecting and assessing activity status of occlusal caries in primary teeth. Caries Res 2010; 44: 300–308.
Braga MM, Mendes FM, Martignon S, Ricketts DN, Ekstrand KR: In vitro comparison of Nyvad's System and ICDAS-II with lesion activity assessment for evaluation of severity and activity of occlusal caries lesions in primary teeth. Caries Res 2009a; 43: 405–412.
Braga MM, Morais CC, Nakama RC, Leamari VM, Siqueira WL, Mendes FM: In vitro performance of methods of approximal caries detection in primary molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009b; 108:e35–41.
Bussaneli DG, Boldieri T, Diniz MB, Rivera LM, Santos-Pinto L, Cordeiro Rde C: Influence of professional experience on detection and treatment decision of occlusal caries lesions in primary teeth. Int J Paediatr Dent 2015; 25: 418–427.
Castilho LS, Cotta FV, Bueno AC, Moreira AN, Ferreira EF, Magalhaes CS: Validation of DIAGNOdent laser fluorescence and the International Caries Detection and Assessment System (ICDAS) in diagnosis of occlusal caries in permanent teeth: an in vivo study. Eur J Oral Sci 2016; 124: 188–194.
Chawla N, Messer LB, Adams GG, Manton DJ: An in vitro comparison of detection methods for approximal carious lesions in primary molars. Caries Res 2012; 46: 161–169.
Cortes DF, Ekstrand KR, Elias-Boneta AR, Ellwood RP: An in vitro comparison of the ability of fibre-optic transillumination, visual inspection and radiographs to detect occlusal caries and evaluate lesion depth. Caries Res 2000; 34: 443–447.
Cortes DF, Ellwood RP, Ekstrand KR: An in vitro comparison of a combined FOTI/visual examination of occlusal caries with other caries diagnostic methods and the effect of stain on their diagnostic performance. Caries Res 2003; 37: 8–16.
Cotta F, de Castilho LS, Moreira AN, Paiva SM, Ferreira EF, Ferreira LC, Magalhaes CS: Lesion Activity Assessment (LAA) in conjunction with International Caries Detection and Assessment System (ICDAS) for occlusal caries diagnosis in permanent teeth. Oper Dent 2015; 40:E189–196.
CRD: Centre for Review and Dissemination’s Guidance for Undertaking Reviews in Health Care. York, University of York, 2009.
Diniz MB, Lima LM, Eckert G, Zandona AG, Cordeiro RC, Pinto LS: In vitro evaluation of ICDAS and radiographic examination of occlusal surfaces and their association with treatment decisions. Oper Dent 2011; 36: 133–142.
Diniz MB, Rodrigues JA, Hug I, Cordeiro Rde C, Lussi A: Reproducibility and accuracy of the ICDAS-II for occlusal caries detection. Community Dent Oral Epidemiol 2009; 37: 399–404.
Duval S, Tweedie R: Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–463.
Ekstrand KR, Luna LE, Promisiero L, Cortes A, Cuevas S, Reyes JF, Torres CE, Martignon S: The reliability and accuracy of two methods for proximal caries detection and depth on directly visible proximal surfaces: an in vitro study. Caries Res 2011; 45: 93–99.
Ekstrand KR, Martignon S, Ricketts DJ, Qvist V: Detection and activity assessment of primary coronal caries lesions: a methodologic study. Oper Dent 2007; 32: 225–235.
Ekstrand KR, Ricketts DNJ, Kidd EAM: Reproducibility and accuracy of three methods for assessment of demineralization depth of the occlusal surface: an in vitro examination. Caries Res 1997; 31: 224–231.
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: 247–254.
Ferreira Zandona A, Santiago E, Eckert GJ, Katz BP, Pereira de Oliveira S, Capin OR, Mau M, Zero DT: The natural history of dental caries lesions: a 4-year observational study. J Dent Res 2012; 91: 841–846.
Floriano I, Bonini GC, Matos R, Novaes TF, Ekstrand KR, Mendes FM, Braga MM: How different do visuo-tactile criteria assess caries lesions activity status on occlusal surfaces? Oral Dis 2015; 21: 299–307.
Freitas LA, Santos MT, Guare RO, Lussi A, Diniz MB: Association between visual inspection, caries activity status, and radiography with treatment decisions on approximal caries in primary molars. Pediatr Dent 2016; 38: 140–147.
Gimenez T, Piovesan C, Braga MM, Raggio DP, Deery C, Ricketts DN, Ekstrand KR, Mendes FM: Visual inspection for caries detection: a systematic review and meta-analysis. J Dent Res 2015; 94: 895–904.
Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PM: The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol 2003; 56: 1129–1135.
Gomez J, Zakian C, Salsone S, Pinto SC, Taylor A, Pretty IA, Ellwood R: In vitro performance of different methods in detecting occlusal caries lesions. J Dent 2013;41:180–186.
Guedes RS, Piovesan C, Ardenghi TM, Emmanuelli B, Braga MM, Ekstrand KR, Mendes FM: Validation of visual caries activity assessment: a 2-yr cohort study. J Dent Res 2014; 93: 101S–107S.
Guedes RS, Piovesan C, Floriano I, Emmanuelli B, Braga MM, Ekstrand KR, Ardenghi TM, Mendes FM: Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study. Int J Paediatr Dent 2016; 26: 116–124.
Hanley JA: Standard error of the Kappa statistic. Psychol Bull 1987; 102: 315–321.
Henderson MC, Tierney LM, Smetana GW: The Patient History. Columbus, McGraw-Hill, 2012.
ICDAS – International Caries Detection and Assessment System (homepage). Leeds, ICDAS, 2017. (accessed June 1, 2017).
Ismail AI, Pitts NB, Tellez M: The International Caries Classification and Management System (ICCMS): an example of a caries management pathway. BMC Oral Health 2015; 15(suppl 1):S9.
Ismail AI, Sohn W, Tellez M, Amaya A, Sen H, Hasson H, Pitts NB: The international caries detection and asssessment system (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol 2007; 35: 170–178.
Jablonski-Momeni A, Stachniss V, Ricketts DN, Heinzel-Gutenbrunner M, Pieper K: Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro. Caries Res 2008; 42: 79–87.
Jallad M, Zero D, Eckert G, Ferreira Zandona A: In vitro detection of occlusal caries on permanent teeth by a visual, light-induced fluorescence and photothermal radiometry and modulated luminescence methods. Caries Res 2015; 49: 523–530.
Juni P, Holenstein F, Sterne J, Bartlett C, Egger M: Direction and impact of language bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol 2002; 31: 115–123.
Ko HY, Kang SM, Kim HE, Kwon HK, Kim BI: Validation of quantitative light-induced fluorescence-digital (QLF-D) for the detection of approximal caries in vitro. J Dent 2015; 43: 568–575.
Kuhnisch J, Goddon I, Berger S, Senkel H, Bucher K, Oehme T, Hickel R, Heinrich-Weltzien R: Development, methodology and potential of the new Universal Visual Scoring System (UniViSS) for caries detection and diagnosis. Int J Environ Res Public Health 2009; 6: 2500–2509.
MacGregor AB: The extent and distribution of acid in carious dentine. Proc R Soc Med 1962; 55: 23–26.
McGee S: Simplifying likelihood ratios. J Gen Intern Med 2002; 17: 646–649.
Mitropoulos P, Rahiotis C, Stamatakis H, Kakaboura A: Diagnostic performance of the visual caries classification system ICDAS II versus radiography and micro-computed tomography for proximal caries detection: an in vitro study. J Dent 2010; 38: 859–867.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006–1012.
Moher D, Pham B, Lawson ML, Klassen TP: The inclusion of reports of randomised trials published in languages other than English in systematic reviews. Health Technol Assess 2003; 7: 1–90.
Neuhaus KW, Ciucchi P, Rodrigues JA, Hug I, Emerich M, Lussi A: Diagnostic performance of a new red light LED device for approximal caries detection. Lasers Med Sci 2015a; 30: 1443–1447.
Neuhaus KW, Jost F, Perrin P, Lussi A: Impact of different magnification levels on visual car ies detection with ICDAS. J Dent 2015b; 43: 1559–1564.
Neuhaus KW, Rodrigues JA, Hug I, Stich H, Lussi A: Performance of laser fluorescence devices, visual and radiographic examination for the detection of occlusal caries in primary molars. Clin Oral Investig 2011; 15: 635–641.
Novaes TF, Matos R, Braga MM, Imparato JC, Raggio DP, Mendes FM: Performance of a pen-type laser fluorescence device and conventional methods in detecting approximal caries lesions in primary teeth – in vivo study. Caries Res 2009;43:36–42.
Novaes TF, Matos R, Gimenez T, Braga MM, DE Benedetto MS, Mendes FM: Performance of fluorescence-based and conventional methods of occlusal caries detection in primary molars – an in vitro study. Int J Paediatr Dent 2012;22:459–466.
Nyvad B, Machiulskiene V, Baelum V: Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res 1999; 33: 252–260.
Oliveira RS, Zenkner JE, Maltz M, Rodrigues JA: Association between two visual criteria in assessing non-cavitated caries lesion activity on occlusal surfaces of permanent molars. Clin Oral Investig 2015; 19: 565–568.
Ozkan G, Kanli A, Baseren NM, Arslan U, Tatar I: Validation of micro-computed tomogra phy for occlusal caries detection: an in vitro study. Braz Oral Res 2015; 29:S1806-83242015000100309.
Ozturk E, Sinanoglu A: Histological validation of cone-beam computed tomography versus laser fluorescence and conventional diagnostic methods for occlusal caries detection. Photomed Laser Surg 2015; 33: 61–68.
Parviainen H, Vahanikkila H, Laitala ML, Tjaderhane L, Anttonen V: Evaluating performance of dental caries detection methods among third-year dental students. BMC Oral Health 2013; 13: 70.
Piovesan C, Ardenghi TM, Guedes RS, Ekstrand KR, Braga MM, Mendes FM: Activity assessment has little impact on caries parameters reduction in epidemiological surveys with preschool children. Community Dent Oral Epidemiol 2013; 41: 204–211.
Piovesan C, Moro BL, Lara JS, Ardenghi TM, Guedes RS, Haddad AE, Braga MM, Mendes FM: Laboratorial training of examiners for using a visual caries detection system in epidemiological surveys. BMC Oral Health 2013; 13: 49.
Pitts N: “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: 193–198.
Pitts N: Monographs in Oral Science – Detection, Assessment, Diagnosis and Monitoring of Caries. Basel, Karger, 2009.
Pitts NB, Stamm JW: International Consensus Workshop on Caries Clinical Trials (ICW-CCT) – final consensus statements: agreeing where the evidence leads. J Dent Res 2004; 83:C125–C128.
Ricketts DN, Ekstrand KR, Kidd EA, Larsen T: Relating visual and radiographic ranked scoring systems for occlusal caries detection to histological and microbiological evidence. Oper Dent 2002; 27: 231–237.
Rodrigues JA, de Oliveira RS, Hug I, Neuhaus K, Lussi A: Performance of experienced dentists in Switzerland after an e-learning program on ICDAS occlusal caries detection. J Dent Educ 2013; 77: 1086–1091.
Rodrigues JA, Hug I, Diniz MB, Lussi A: Performance of fluorescence methods, radiographic examination and ICDAS II on occlusal surfaces in vitro. Caries Res 2008; 42: 297–304.
Schwarzer G: Meta: an R package for meta-analysis. R News 2007; 7: 40–45.
Shoaib L, Deery C, Ricketts DN, Nugent ZJ: Validity and reproducibility of ICDAS II in primary teeth. Caries Res 2009; 43: 442–448.
Song F, Khan KS, Dinnes J, Sutton AJ: Asymmetric funnel plots and publication bias in meta-analyses of diagnostic accuracy. Int J Epidemiol 2002; 31: 88–95.
Souza JF, Boldieri T, Diniz MB, Rodrigues JA, Lussi A, Cordeiro RC: Traditional and novel methods for occlusal caries detection: performance on primary teeth. Lasers Med Sci 2013; 28: 287–295.
Soviero VM, Leal SC, Silva RC, Azevedo RB: Validity of MicroCT for in vitro detection of proximal carious lesions in primary molars. J Dent 2012;40:35–40.
Teo TK, Ashley PF, Louca C: An in vivo and in vitro investigation of the use of ICDAS, DIAGNOdent pen and CarieScan PRO for the detection and assessment of occlusal caries in primary molar teeth. Clin Oral Investig 2014; 18: 737–744.
Tikhonova SM, Feine JS, Pustavoitava NN, Allison PJ: Reproducibility and diagnostic outcomes of two visual-tactile criteria used by dentists to assess caries lesion activity: a cross-over study. Caries Res 2014; 48: 126–136.
Topping GV, Pitts NB; International Caries Detection and Assessment System Committee: Clinical visual caries detection. Monogr Oral Sci 2009; 21: 15–41.
Viechtbauer W: Conducting meta-analyses in R with the metafor package. J Stat Softw 2010; 36: 1–48.
Whiting P, Rutjes AW, Reitsma JB, Glas AS, Bossuyt PM, Kleijnen J: Sources of variation and bias in studies of diagnostic accuracy: a systematic review. Ann Intern Med 2004; 140: 189–202.
Zandona AG, Al-Shiha S, Eggertsson H, Eckert G: Student versus faculty performance using a new visual criteria for the detection of caries on occlusal surfaces: an in vitro examination with histological validation. Oper Dent 2009; 34: 598–604.
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