Community Dent Oral Epidemiol 2009; 37: 399404  2009 John Wiley & Sons A/S

All rights reserved

Michele Baffi Diniz1,2, Jonas Almeida

Reproducibility and accuracy of Rodrigues1,2, Isabel Hug2, Rita de Cassia
Loiola Cordeiro1 and Adrian Lussi2

the ICDAS-II for occlusal caries

1
Department of Pediatric Dentistry, School of
Dentistry of Araraquara, Sao Paulo State
University (UNESP), Araraquara, SP, Brazil,
2
Department of Preventive, Restorative and
detection Pediatric Dentistry, School of Dental
Medicine, University of Bern, Bern,
Switzerland

Diniz MB, Rodrigues JA, Hug I, Cordeiro RCL, Lussi A. Reproducibility and
accuracy of the ICDAS-II for occlusal caries detection. Community Dent Oral
Epidemiol 2009; 37: 399404.  2009 John Wiley & Sons A/S

Abstract Objectives: The aim of this in vitro study was to assess the inter- and
intra-examiner reproducibility and the accuracy of the International Caries
Detection and Assessment System-II (ICDAS-II) in detecting occlusal
caries. Methods: One hundred and sixty-three molars were independently
assessed twice by two experienced dentists using the 0- to 6-graded ICDAS-II.
The teeth were histologically prepared and classified using two different
histological systems [Ekstrand et al. (1997) Caries Research vol. 31, pp. 224231;
Lussi et al. (1999) Caries Research vol. 33, pp. 261266] and assessed for caries
extension. Sensitivity, specificity, accuracy and area under the ROC curve (Az)
were obtained at D2 and D3 thresholds. Unweighted kappa coefficient was used Key words: dental caries; early diagnosis;
to assess inter- and intra-examiner reproducibility. Results: For the Ekstrand professional training; teeth
et al. histological classification the sensitivity was 0.99 and 1.00, specificity 1.00 Michele Baffi Diniz, Faculdade de
and 0.69 and accuracy 0.99 and 0.76 at D2 and D3, respectively. For the Lussi Odontologia de Araraquara, Departamento
de Clnica Infantil, Rua Humaita, 1680,
et al. histological classification the sensitivity was 0.91 and 0.75, specificity
CEP: 14801-903 Araraquara, SP, Brazil
0.47 and 0.62 and accuracy 0.86 and 0.68 at D2 and D3, respectively. The Az Tel: +55 16 3301 6331
varied from 0.54 to 0.73. The inter- and intra-examiner kappa values were Fax: +55 16 3301 6329
0.51 and 0.58, respectively. Conclusions: ICDAS-II presented good e-mail: mibdiniz@hotmail.com
reproducibility and accuracy in detecting occlusal caries, especially caries Submitted 17 August 2008;
lesions in the outer half of the enamel. accepted 20 May 2009

The detection of caries is a challenge in dentistry,
especially regarding the occlusal surfaces. Incipient
occlusal caries have proved difficult to detect
because of the widespread use of fluorides and its
superficial remineralization potential, which allows
the development of dentinal caries under a macro-
scopically intact surface (1). For this reason, early
detection is important to establish adequate pre-
ventive measures and avoid premature tooth
treatment by restorations.
Dentists have several options at their disposal for
the clinical detection of dental caries on occlusal
surfaces, such as visual or visualtactile examina-
tion, radiographic examination, fluorescence-based
methods, and electrical conductance measurements
(2). Visual inspection and radiographic examina-
tion have been commonly used in clinical practice
in the past, but these techniques are capable of
detecting occlusal caries lesions only at an ad-
vanced stage (3). Besides, a systematic review has
shown that the use of the laser fluorescence devices
can lead to false-positive results related to its low
specificity (4).
In 2001, after the analysis of a systematic review
presented in a conference in the USA, it was
concluded that the reliability and reproducibility of
currently available caries detection diagnostic sys-
tems, including visual and visualtactile criteria,
were not strong (5). Besides, in 2002, a document
from the International Consensus Workshop on
Caries Clinical Trials held in Scotland agreed with
this statement (6). Based on these findings, a new
visual criterion has been introduced for caries
detection.

doi: 10.1111/j.1600-0528.2009.00487.x 399

Diniz et al.
The International Caries Detection and Assess-
ment System (ICDAS) was developed in 2002 by an
international group of researchers (cariologists and
epidemiologists) based on a systematic review of
clinical caries detection systems to provide clini-
cians, epidemiologists, and researchers with an
evidence-based system for caries detection. This
method would allow a standardization of data
collection and would also enable better compara-
bility among studies (2, 79).
In 2003, the ICDAS-I was devised based on the
principle that the visual examination should be
carried out on clean, plaque-free teeth, with care-
fully drying of the lesion surface to identify early
lesions. According to this system, the replacement
of the traditional explorers and sharp probes with a
ball-ended periodontal probe would avoid trau-
matic and iatrogenic defects on incipient lesions.
Later, in 2005, this criterion was modified and the
ICDAS-II was created at the ICDAS workshop in
Baltimore. The improvement included an exchange
of codes to insure that the system would reflect
increased severity (7, 8).
There are few studies in the literature concerning
the visual ICDAS-II for occlusal caries detection.
ICDAS-II has good reproducibility and accuracy
for the detection of occlusal caries lesions at
different stages of the disease (2, 7, 8, 10, 11).
However, these studies were performed by exam-
iners who received a special training before using
the ICDAS-II. The aim of this in vitro study was to
assess the inter- and intra-examiner reproducibility
and the accuracy of the ICDAS-II in detecting
occlusal caries when experienced but not ICDAS
specialist were involved.
Materials and methods
Sample selection
One hundred sixty-three permanent human molars,
without sealants or restorations, were selected from
a pool of extracted teeth, which were stored frozen
at )20C until use. Prior to extraction, consent was
obtained and the patients were informed about the
use of their teeth for research purposes. All teeth
had been extracted by dental practitioners in
Switzerland (no water fluoridation, 250 ppm F- in
table salt). The teeth were defrosted for 3 h and the
calculus and debris were removed using a scaler
(Cavitron; Dentsply Professional, York, PA, USA).
The teeth were then cleaned for 15 s with water
and toothbrush (Trisa ultra super-sensitive; Trisa,
400
Triengen, Switzerland) and for 10 s with a water-
powder jet cleaner (PROPHYflex II, KaVo, Biberach,
Germany) with sodium hydrogen carbonate pow-
der. The teeth were rinsed with the three-in-one
syringe for 10 s to remove any possible powder
remainders in the fissure (12).
During the measurements, the teeth were stored
under relative humidity of 100%. Photographs of
the occlusal surfaces were taken (magnification of
6.25) and one spot on each tooth was selected in
the fissure surface (test site). All assessments were
carried out twice by two experienced dentists (A
and B), with previous experience in others caries
detection methods, observing a 1-week interval
between the measurements. Both dentists were
introduced to the ICDAS-II by the supervisor. The
details of each code were discussed until a consen-
sus was reached.
ICDAS-II examination
The visual examination was performed following
the administration of ICDAS-II (2), with direct
visualization of the teeth, guided by black and white
photographs printed in draft quality paper after a
full circle was inserted to cover the entire test site
and coded as shown in Table 1. The teeth were
examined in the same room with the aid of a light
reflector and a three-in-one air syringe. First they
Table 1. ICDAS-II criteria (2)
ICDAS-II
code Clinical criteria description
0 Sound tooth surface: no evidence of caries
after prolonged air drying (5 s)
1 First visual change in enamel: opacity or
discoloration (white or brown) is visible at
the entrance to the pit or fissure after
prolonged air drying, which is not or
hardly seen on a wet surface
2 Distinct visual change in enamel: opacity or
discoloration distinctly visible at the
entrance to the pit and fissure when wet,
lesion must still be visible when dry
3 Localized enamel breakdown due to caries
with no visible dentin or underlying
shadow: opacity or discoloration
wider than the natural fissure fossa
when wet and after prolonged air drying
4 Underlying dark shadow from
dentin localized enamel breakdown
5 Distinct cavity with visible dentin: visual
evidence of demineralization and dentin
exposed
6 Extensive distinct cavity with visible
dentin and more than half of the surface
involved
 ICDAS-II for occlusal caries detection

were analyzed moist and then dried, according to Mariakerke, Belgium) at D2 and D3 thresholds for
Ismail et al. (8) and Jablonski-Moneni et al. (2). The both the histological classifications, using the mode
codes ranged from examination of the first visible value among all examinations. The use of a gold
carious change in enamel to extensive cavitation. standard is a prerequisite in assessing the ROC
curve (16). This analysis involves a plot of pairs of
Validation sensitivity (true positive rate) and 1 ) specificity
After visual examination, the teeth were ground (false-positive rate) for a given cut-off value of a
longitudinally on a Knuth-Rotor polishing machine diagnostic test (17).
(Struers S/A, Ballerup, Denmark) using silicon
carbide paper (60 lm of grain size) cooled under
tap water. Progression of the grinding process
(papers of grain size 30, 18, 8 and 5 lm) was
Results
constantly checked under the microscope (magni- From the 163 occlusal test sites analyzed in this
fication 6.25) until the periphery of the site was study (one site in each tooth), the histological
reached. The teeth surfaces were then colored with examination revealed that seven of them were
saturated rhodamine B (Fluka, Buchs, Switzerland). caries-free, 12 had caries extending up to halfway
For histological assessments, the rhodamine B through the enamel, 67 had caries extending in the
penetration either into the enamel or both the inner half of enamel, 47 had caries in dentin and 30
enamel and the dentin tissues (magnification 10) had deep dentin caries. Table 3 shows the cross
was analyzed. Two different histological classifica- tables with both Ekstrand et al. (13) and Lussi et al.
tion systems Ekstrand et al. (13) and Lussi et al. (1) histological scores for the ICDAS-II.
(1) were used to record caries extension at each
tested site (Table 2).
Table 3. Cross-tabulation for ICDAS-II with the two
histological classification system
Statistical analysis
ICDAS-II
Inter- and intra-examiner reproducibility was
assessed by calculating unweighted kappa coeffi- 0 1 2 3 4 5 6 Total
cient (14). Kappa values above 0.75 denoted excel- Ekstrand et al. (13)
lent agreement, while values between 0.40 and 0.75 0 4 1 2 7
indicated good agreement (15). 1 3 1 3 4 11
2 6 6 42 51 2 107
For each examiner, the relationship between the
3 1 3 12 2 3 21
ICDAS-II criteria and both the histological classifi- 4 2 7 3 5 17
cation systems were determined using the Spear- Total 14 8 50 76 5 10 163
mans correlation coefficient. A correlation Lussi et al. (1)
coefficient of 0.70 or above indicates a strong 0 4 1 2 7
1 3 1 4 4 12
relationship between two variables (2). 2 5 4 31 27 67
Sensitivity, specificity, accuracy, area under the 3 2 2 12 29 2 47
ROC curve (Az) and likelihood ratios (LR+) were 4 3 14 5 8 30
calculated (MedCalc for Windows, version 9.3.0.0, Total 14 8 50 76 5 10 163

Table 2. Criteria used in the histological examination

Criteria proposed by Criteria proposed by
Score Ekstrand et al. (13) Lussi et al. (1)
0 No enamel demineralization Caries free
1 Demineralization limited to the outer Caries extending up to halfway
on e-half of the enamel thickness through the enamel
2 Demineralization between inner one-half Caries extending in the inner half
of the enamel and outer one-third of the enamel
of the dentin
3 Demineralization in the middle third Caries in the outer half of the dentin
of the dentin
4 Demineralization in the inner third Caries in the inner half of the dentin
of the dentin

401
Diniz et al.

The agreement assessed by calculating the complex invaginated anatomy of the pits and
unweighted kappa was 0.51 for inter-examiner fissures and to the difficulty in plaque removal,
reproducibility. For intra-examiner reproducibility, which makes caries detection more difficult. For
the values were 0.58 and 0.59 for examiner A and B, this reason, the importance of early occlusal caries
respectively. The Spearmans correlation was 0.49 detection has increased now (1820). There are
for examiner A and 0.42 for examiner B considering some methods aimed at aiding clinicians in detect-
the Ekstrand et al. (13) histological classification, and ing caries lesions and in deciding the most appro-
0.53 for examiner A and 0.46 for examiner B, priate treatment. This study assessed the visual
considering the Lussi et al. (1) histological classifi- examination and stressed the importance of early
cation. Table 4 presents the inter- and intra-examiner caries detection. In this way, the advantage of the
reproducibility and Spearmans correlation values. ICDAS-II is its ability to detect the first changes in
Specificity, sensitivity, accuracy, area under the dental surfaces because of caries development.
ROC curve (Az) and likelihood ratios (LR+) are To date, few studies are available researching the
shown in Table 5, where the accuracy of the tested reproducibility of ICDAS-II. Other scoring systems
method can be observed. The best value of sensi- have been used previously, such as the five-point
tivity (1.00) was observed at threshold D3 of scoring system proposed by Ekstrand et al. (13) and
Ekstrand et al. (13) histological classification. For the four-point system proposed by Souza-Zaroni
specificity, the ICDAS-II compared with the Lussi et al. (21), who found good to excellent reproduci-
et al. (1) histological classification showed values of bility.
0.47 and 0.62 and with the Ekstrand et al. (13) The kappa values for ICDAS-II found in this study
histological classification showed values of 1.00 were lower than those found by Ekstrand et al. (7) in
and 0.69 for D2 and D3, respectively. an in vitro study, for both intra- and inter-examiner
reproducibility. In another in vitro study also similar
lower kappa values for ICDAS-II reproducibility
were observed when no training was given to the
Discussion examiners (11). However, Jablonski-Momeni et al.
Occlusal surfaces are the most caries-affected sites (2), after a training session in an in vitro study,
in children and adolescents. This is related to the found unweighted kappa values ranging from 0.32
to 0.61 for inter-examiner reproducibility and from
Table 4. Inter- and intra-examiner reproducibilities and 0.54 to 0.65 for intra-examiner reproducibility,
Spearmans correlation for ICDAS-II examinations which are similar to the values found in our study.
Spearmans Ismail et al. (8) showed higher weighted kappa
correlation values for intra-examiner (varying from 0.59 to
Intra-examiner
unweighted Ekstrand Lussi 0.82) and inter-examiner reproducibility (varying
Examiner kappa et al. (13) et al. (1) from 0.63 to 0.75). However, this was an in vivo
study performed in Detroit, Michigan. The differ-
A 0.58 0.49 0.53
B 0.59 0.42 0.46 ences among the present investigation and those
Inter-examiner 0.51 studies could be explained by the subjective
unweighted kappa aspects involved in visual examination, such as
knowledge and clinical experience of the examiners
Table 5. Specificity, sensitivity, accuracy, area under the (22). Besides, it is important to stress that some
ROC curve (Az) and LR+ of ICDAS-II and each corre- investigations were performed in vivo, and others
sponding histological system at D2 and D3 thresholds in vitro, and these could be an explanation of the
D2 D3 different reproducibility values found among the
studies. The methodological difference between
Ekstrand Lussi Ekstrand Lussi
et al. (13) et al. (1) et al. (13) et al. (1) our study and the others is due to the examiners
training. According to Ismail et al. (8), the ICDAS-II
Specificity 1.00 0.47 0.69 0.62
presents good to excellent reproducibility, even
Sensitivity 0.99 0.91 1.00 0.75
Accuracy 0.99 0.86 0.76 0.68 when used by examiners who have no previous
Az 0.63 0.73 0.54 0.73 experience in epidemiological dental examina-
LR+ 1.50 1.96 1.08 1.73 tion. This is in contrast to this study, as shown
D2: codes 01 = sound; codes 26 = decayed. by the lower kappa values for intra- and inter-
D3: codes 02 = sound; codes 36 = decayed. reproducibility. The examiners of this study were

402

experienced dentists involved in caries research,
concerning different methods of early occlusal
caries detection. The examiners had previously
participated in other dental caries studies, using
different methods and they received a short intro-
duction to the ICDAS-II. Besides, in this study, the
relationship between the ICDAS-II and the both
histological classification systems was not strong
(Spearmans correlation coefficients varied from
0.42 to 0.53). Jablonski-Momeni et al. (2) also found
fair correlation, showing values ranging from
0.48 to 0.72 using Downer histology and from 0.43
to 0.68 for Ekstrand histology. In previous studies
comparing visual examination and histological
classification systems, the relationship was stron-
ger (13, 23).
The method used in this study to validate caries
criteria was based on the quantitative correlation
between the clinical assessment of tooth surfaces
with histological presence and the extent of demin-
eralization in enamel and dentin (3, 13). The
percentage of enamel caries correctly detected by
the ICDAS-II confirmed its good ability to first
detect visual changes in enamel. This good perfor-
mance has also been shown by recent studies
published assessing the ICDAS-II for oclusal caries
detection (7, 8, 11).
Regarding the Lussi et al. (1) histological classi-
fication, the area under the ROC curve (Az) (0.73)
showed good performance of the ICDAS-II in
detecting occlusal caries lesions. Other studies
had shown that the ICDAS-II produced areas
under the ROC curves of 0.70 (2) and 0.75 (11),
which agrees with our results. The advantages of
ROC curve are: (a) it includes several cut-off points;
(b) it shows the relationship between the sensitivity
and specificity; and (c) it is not affect by the
prevalence of disease (17).
In this study, at D2 threshold, the sensitivity and
specificity of the ICDAS-II for Lussi et al. (1)
histological classification were 0.91 and 0.47,
respectively (Table 5). This means that 6% of sound
sites were incorrectly scored as carious, according
to the distribution of caries (Table 2). This situation
must be carefully interpreted in clinical practice in
view of the fact that the amount of sound sites was
short in our study. However, for Ekstrand et al. (13)
histological classification sensitivity and specificity
were higher (0.99 and 1.00, respectively). Different
values were found in a previous study (2), where
the optimal sensitivity (0.69) and specificity (0.82)
achieved by the ICDAS-II was observed at cut-off
12. At D3 threshold, sensitivity was 0.75 and
ICDAS-II for occlusal caries detection
specificity was 0.62 for Lussi et al. (1) histological
classification. These results are very similar with
those observed by Rodrigues et al. (11), who found
sensitivity of 0.73 and specificity of 0.65 when no
training was given to the examiners. Nevertheless,
considering Ekstrand et al. (13) histological classi-
fication, sensitivity was 1.00 and specificity was
0.69. The value of specificity is different from the
value (0.89) found in a recent study concerning the
ICDAS-II (2). This could be due to the different
examiners experience using this new visual crite-
rion. In their study, the examiners were trained and
had experience, which differ from our study,
where the examiners were not trained, but had
clinical experience using a previous visual criterion
for occlusal caries detection (13).
It is important to point out that the values of
sensitivity and specificity obtained in this study for
D2 and D3 thresholds using the cut-off points
proposed by the ICDAS-II matched up to the
optimal values obtained by the highest sum of
sensitivity and specificity. In addition, the ICDAS-
II presented the highest value of LR+ at the D2
threshold, which shows how much the odds of the
disease increase when a test is positive. The
ICDAS-II also showed highest value of accuracy
at the D2 threshold, confirming its ability to detect
enamel changes. At D3 threshold, the lower accu-
racy value presented was similar to that presented
by Rodrigues et al. (11).
The main difference between both histological
classification systems used in the present study is
the caries severity of score 2. For Ekstrand classi-
fication, this score combines deep enamel caries
and caries restricted to outer one-third of dentin. At
D2 threshold, which considers ICDAS-II codes 26
as decayed, the highest values of sensitivity and
specificity were observed for this classification.
This could suggest that when an initial lesion is
observed in a wet surface, one-third of dentin can
be already decayed.
Some meta-analysis reviews have shown that
visual examination is poor for caries detection,
presenting high specificity and low sensitivity (5).
However, recent studies have shown that a
meticulous examination of a clean and dry
surface can improve caries detection, especially
when the examiners are trained with this new
method (2, 7, 8).
This new visual examination criterion seems to
be promising in the case of having to very
accurately examine and closely describe the char-
acteristics of the tooth surface. Furthermore, the
403
Diniz et al.
first enamel changes can be better identified when
the tooth surface is dry and has been cleaned
before, emphasizing the importance of an accurate
examination to improve the diagnosis of caries
lesions. An advantage of this visual criterion is the
possibility to record detailed characteristics of the
teeth and monitor the changes in their surfaces.
It can be concluded that this in vitro evaluation of
the ICDAS-II in detecting occlusal caries lesions
presented good inter- and intra-examiner repro-
ducibility and validity even after non-trained
examinations. Besides, this system is useful, easy
to use, and clearly defined by scores for clinical
visual caries detection. Nevertheless, more research
will be needed to validate this system for caries
activity as well as for caries detection in smooth
surfaces, in vitro and in vivo.
References
1. Lussi A, Imwinkelried S, Pitts NB, Longbotton C,
Reich E. Performance and reproducibility of a laser
fluorescence system for detection of occlusal caries
in vitro. Caries Res 1999;33:2616.
2. 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;42:7987.
3. Ricketts DN, Ekstrand KR, Kidd EA, Larse T.
Relating visual and radiographic ranked scoring
system for occlusal caries detection to histological
and microbiological evidence. Oper Dent
2002;27:2317.
4. Bader JD, Shugars DA. A systematic review of the
performance of a laser fluorescence device for
detecting caries. J Am Dent Assoc 2004;135:141426.
5. Bader JD, Shugars DA, Bonito AJ. Systematic review
of selected dental caries diagnostic and management
methods. J Dent Educ 2001;65:9608.
6. Pitts NB, Stamm JW. Consensus Workshop on Caries
Clinical Trials (ICW-CCT) final consensus state-
ments: Agreeing where the evidence leads. J Dent
Res 2004;83:C1258.
7. Ekstrand KR, Martignon S, Ricketts DNJ, Qvist V.
Detection and activity assessment of primary coronal
caries lesions: a methodologic study. Oper Dent
2007;32:22535.
8. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A,
Hasson H et al. The International Caries Detection
and Assessment System (ICDAS): an integrated
system for measuring dental caries. Community
Dent Oral Epidemiol 2007;35:1708.
404
9. Ismail AI, Sohn W, Tellez M, Willem JM, Betz J,
Lepkowski J. Risk indicators for dental caries using
the International Caries Detection and Assessment
System (ICDAS). Community Dent Oral Epidemiol
2008;36:5568.
10. Sohn W, Ismail A, Amaya A, Lepkowski J. Determi-
nants of dental care visits among low-income
African-American children. J Am Dent Assoc 2007;
138:30918.
11. Rodrigues JA, Hug I, Diniz MB, Lussi A. Perfor-
mance of fluorescence methods, radiographic exam-
ination and ICDAS II on occlusal surfaces in vitro.
Caries Res 2008;42:297304.
12. Lussi A, Reich E. The influence of toothpastes and
prophylaxis pastes on fluorescence measurements
for caries detection. Eur J Oral Sci 2005;113:1414.
13. Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility
and accuracy of three methods for assessment of
demineralization depth of the occlusal surface: an
in vitro examination. Caries Res 1997;31:22431.
14. Lin LIK. A concordance correlation coefficient to
evaluate reproducibility. Biometrics 1989;45:25568.
15. Fleiss IL. Statistical methods for rates and propor-
tions, 2nd edn. New York: Wiley, 1981:21225.
16. Htoon HK, Peng LL, Huak CY. Assessment criteria
for compliance with oral hygiene: application of ROC
analysis. Oral Health Prev Dent 2007;5:838.
17. Obuchowski NA. Receiver operating characteristic
curves and their use in radiology. Radiology
2003;229:38.
18. Sheehy EC, Brailford SR, Kidd EAM, Beighton D,
Zoitopoulos L. Comparison between visual exami-
nation and a laser fluorescence system for in vivo
diagnosis of occlusal caries. Caries Res 2001;35:4216.
19. Diniz MB, Rodrigues JA, Paula AB, Cordeiro RCL.
In vivo evaluation of laser fluorescence performance
using different cut-off limits for occlusal caries
detection. Laser Med Sci 2009;24:295300.
20. Rodrigues JA, Diniz MB, Josgrilberg EB, Cordeiro
RCL. In vitro comparison of laser fluorescence per-
formance with visual examination for detection of
occlusal caries in permanent and primary molars.
Lasers Med Sci 2008; doi: 10.1007/s10103-008-0552-4.
21. Souza-Zaroni WC, Ciccone JC, Souza-Gabriel AE,
Ramos RP, Corona SAM, Palma-Dibb RG. Validity
and reproducibility of different combinations of
methods for occlusal caries detection: an in vitro
comparison. Caries Res 2006;40:194201.
22. Fung L, Smales R, Ngo H, Moun G. Diagnostic
comparison of three groups of examiners using
visual and laser fluorescence methods to detect
occlusal caries in vitro. Aust Dent J 2004;49:6771.
23. Ekstrand KR, Kuzmina I, Bjorndal L, Thylstrup A.
Relationship between external and histologic fea-
tures of progessive stages of caries in the occlusal
fossa. Caries Res 1995;29:24350.