Diagnostic Criteria for Assessing Coronal Caries Lesion Activity

Based on the outcome of numerous symposia on the topic of caries diagnostics and assessment, ICDAS criteria were developed to describe various aspects of caries activity. The following figure and tables provide a summary of these criteria, along with the six different ICDAS codes used to identify each occlusal condition.

Figure 1. The International Caries Detection and Assessment System (ICDAS).³⁶

In general, the following criteria apply:

An Active Lesion is considered to have a greater likelihood of transition (progression, arrest or regression) than an inactive lesion.
An Inactive (arrested) Lesion is considered to have a lesser likelihood of transition than an active lesion.

In alignment with Figure 1, the characteristics of active coronal lesions (not all characteristics need to be present to decide activity status) are as follows.³³

Table 1. Characteristics of Active Coronal Lesions

ICDAS Code	Characteristics of Lesion
ICDAS Code	Signs of Active Lesion	Signs of Inactive Lesion
Initial to Moderate Stage Caries (1-4)	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. Lesion is in a plaque stagnation area, i.e. in the entrance of pits and fissures, or near the gingiva, and in approximal surfaces below the contact point. Lesion was covered by thick plaque prior to cleaning.	Surface of enamel is whitish, brownish or black. Enamel may be shiny and feels hard and smooth when the tip of the probe is moved gently across the surface. For smooth surfaces, the caries lesion is typically located at some distance from the gingival margin. Lesion was not covered by thick plaque prior to cleaning.
Extensive Stage Caries (5-6)	Dentin feels soft or leathery on probing	Dentin is shiny and hard on probing

For the purpose of caries management, individual tooth surfaces are categorized and described, based on an evaluation of each surface affected, using the following criteria:

For pits and fissures, the evaluation criteria are as follows:

Table 2. Pits and Fissures Evaluation Criteria.

Tooth Surface Description	Evaluation Criteria	ICDAS Code
Sound surfaces	No visible caries when viewed clean and dry. Non-carious white or brown marks on tooth surfaces must be differentiated from early caries lesions.	0
Initial stage caries	Characterized by the first visual change in enamel (seen only after prolonged air drying or restricted to the confines of a pit or fissure). OR A distinct visual change in enamel (seen on a wet or dry surface).	1 2
Moderate stage caries	Characterized visually by either localized enamel breakdown (without visual signs of dentinal exposure). • Enamel breakdown is often viewed best when the tooth is air dried. OR An underlying dark shadow from dentin. • Shadowing from dentinal caries is often best seen with the tooth surface wet.	3 4
Extensive stage caries	Characterized by distinct cavitation exposing visible dentin. • Lesions exhibiting cavitation involving less than half the tooth surface. • Lesions involving half of the tooth surface or more.	5

For mesial and distal surfaces, the evaluation criteria are as follows:

Table 3. Mesial and Distal Surfaces Evaluation Criteria.

Tooth Surface Description	Evaluation Criteria	ICDAS Code
Sound surfaces	No visible caries when viewed clean and dry. Non-carious white or brown marks on tooth surfaces must be differentiated from early caries lesions.	0
Initial stage caries	Characterized by the first visual change in enamel (seen only after prolonged air drying). OR A distinct visual change in enamel (seen on a wet or dry surface). • These lesions are usually seen directly from the lingual or buccal directions but may be viewed from the occlusal direction as a shadow confined to enamel.	1 2
Moderate stage caries	Characterized visually by either localized enamel breakdown (without visual signs of dentinal exposure). • Enamel breakdown is often viewed best when the tooth is air dried. OR An underlying dark shadow from dentin. • Shadowing from dentinal caries is often best seen with the tooth surface wet.	3 4
Extensive stage caries	Characterized by distinct cavitation exposing visible dentin. • Lesions exhibiting cavitation involving less than half the tooth surface. • Lesions involving half of the tooth surface or more.	5 6

For buccal-lingual smooth surfaces, the evaluation criteria are as follows:

Table 4. Buccal-lingual Smooth Surfaces Evaluation Criteria.

Tooth Surface Description	Evaluation Criteria	ICDAS Code
Sound surfaces	No visible caries when viewed clean and dry. Developmental defects like enamel hypoplasias, fluorosis, tooth wear (attrition, abrasion and erosion), and extrinsic or intrinsic stains should be recorded as sound in the absence of other signs of caries lesions, as described below.	0
Initial stage caries	Characterized by the first visual change in enamel (seen only after prolonged air drying). OR A distinct visual change in enamel (seen on a wet or dry surface). • Initial stage lesions on free smooth surfaces are located in close proximity (in touch or within 1 mm) to the gingival margin or adjacent to orthodontic or prosthetic attachments on a tooth surface.	1 2
Moderate stage caries	Characterized visually by either localized enamel breakdown (without visual signs of dentinal exposure). • Enamel breakdown is often viewed best when the tooth is air dried. OR An underlying dark shadow from dentin. • Shadowing from dentinal caries is often best seen with the tooth surface wet.	3 4
Extensive stage caries	Characterized by distinct cavitation exposing visible dentin. • Lesions exhibiting cavitation involving less than half the tooth surface. • Lesions involving half of the tooth surface or more.	5 6

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