caries classification system

The ADA's 2015 Caries Classification System (CCS) for Clinical Practice

Dental caries are a continuum of net mineral loss. From a sound surface containing little to no mineral loss (Sound) to severe cavitation lesions containing a lot of mineral loss (Advanced).

All teeth and tooth surfaces should be visually inspected for lesions and can be scored using the table below (CCS). Not all carious lesions are active. Once a lesion has been identified and determined to be an Initial, Moderate or Advanced lesion then each lesion should evaluated using Table 1 to determine if the lesion is active or inactive. Treatment decisions can then made based on the CCS scoring and if the lesion is active or inactive. Definitions of tooth surface site definitions are below in Table 2.

2015 ADA Dental Caries Classification System (CCS)*
	Sound	Initial	Moderate	Advanced
Clinical Presentation	No clinically detectable lesions, Dental hard tissue appears normal in color, translucency and gloss.	Earliest clinically detectable lesion compatible with mild demineralization. Lesion limited to enamel or to shallow demineralization of cementum/dentin. Mildest forms are detectable only after drying. Established and active lesions may be white or brown and enamel has lost its gloss.	Visible signs of enamel breakdown or signs the dentin is moderately demineralized.	Enamel is fully cavitated and dentin is exposed. Dentin lesion is deeply/severely demineralized.
Other Labels	No surface change or adequately restored	Visually noncavitated	Established early cavitated, shallow cavitation, or microcavitation	Spread/disseminated, late cavitated, deep cavitation
Infected Dentin	None	Visually noncavitated	Possible	Present
Appearance of Occlusal sufaces (Pit and Fissure or Smooth surfaces including Cervical and Root)	ICDAS 0**	ICDAS 1 or ICDAS 2	ICDAS 3 or ICDAS 4	ICDAS 5 or ICDAS 6
Radiographic Presentation of the Approximal Surface	E0*** or R0# No radiolucency	E1 or RA1 OR E2 or RA2 OR D1 or RA3 Radiolucency may extend to the dentinoenamel junction or outer one-third of the dentin. Note: radiographs are not reliable for mild occlusal lesions.	D2 or RB4 Radiolucency extends into the middle one-third of the dentin.	D3 or RC5 Radiolucency extends into the inner one-third of the dentin.
For ICDAS system click here. *E0-E2, D1-D3 notation system; E0 (no lesion), E1 (lesion within the outer half of enamel), E2 (inner half of enamel), D1 (outer third of dentin), D2 (middle third of dentin), and D3 (inner third of dentin); click here for article (Anusavice K. Present and future approaches for the control of caries. J Dent Educ. 2005;69(5):538-854.) #R0,RA-1-RA-3, RB4, and RC5-RC6 is the ICCMS radiographic scoring system (RC-6 = into pulp; https://www.icdas.org/uploads/ICCMS-Guide_Full_Guide_US.pdf . Accessed 9/22/16)

Table 1: Characteristics of Active and Inactive Caries Lesions*
Activity Assessment Factor	Caries Lesion Activity Assessment Descriptions
Activity Assessment Factor	Likely to be Inactive or Arrested	Likely to be Active
Location of the lesion	Lesion is not in a plaque stagnation area	Lesion is in a plaque stagnation area (pit/fissure, approximal, gingival area)
Plaque over the lesion	Not thick or sticky	Thick and/or sticky
Surface appearance	Shiny; color: brown-black	Matte/opaque/loss of luster; color: white-yellow
Tactile feeling	Smooth, hard enamel/hard dentin	Rough enamel/soft dentin
Gingival status (if lesion is near the gingiva)	No inflammation, no bleeding on probing	Inflammation, bleeding on probing
*Ekstrand KR, Zero DT, Martignon S, Pitts NB. Lesion activity assessment. Monogr Oral Sci. 2009;21:63-90.

Table 2: American Dental Association Caries Classification Sytem Tooth Surface Site Definitions*
Site	Definition
Pit and Fissure	The anatomic pits or fissures (clefts or valleys in the tooth surface) of the teeth at the occlusal, facial or lingual surfaces of posterior teeth OR the lingual surfaces of the maxillary incisors or canines
Approximal Surface	The contact point(s) between adjacent teeth OR the surface(s) between adjacent teeth would touch if they were to touch; approximal surfaces may exist on any surface of a tooth.
Cervical and Smooth Surface	The cervical area or any other smooth enamal surface of the anatomic crown adjacent to an edentulous space (toothless space); may exist anywhere around the full circumference of the tooth.
Root	The root surface apical to the anatomic crown
*Ismail AI, Tellez M, Pitts NB, et al. Caries management pathways preserve dental tissues and promote oral health. Community Dent Oral Epidemiol. 2013;41(1):e12-e40.

The American Dental Association Caries Classification System for Clinical Practice

Douglas A. Young, DDS, EdD, MBA, MS, Brian B. Nový, DDS, Gregory G. Zeller, DDS, MS, Robert Hale, DDS, Thomas C. Hart, DDS, PhD, Edmond L. Truelove, DDS, MSD Kim R. Ekstrand, DDS, PhD, John D.B. Featherstone, MSc, PhD, Margherita Fontana, DDS, PhD, Amid Ismail, BDS, MPH, DrPH, MBA, John Kuehne, DDS, MS, Chris Longbottom, BDS, PhD, Nigel Pitts, BDS, PhD, David C. Sarrett, DMD, MS, Tim Wright, DDS, MS, Anita M. Mark, Eugenio Beltran-Aguilar, DMD, DrPH, DABDPH Douglas A. Young, DDS, EdD, MBA, MS, Brian B. Nový, DDS, Gregory G. Zeller, DDS, MS, Robert Hale, DDS, Thomas C. Hart, DDS, PhD, Edmond L. Truelove, DDS, MSD Kim R. Ekstrand, DDS, PhD, John D.B. Featherstone, MSc, PhD, Margherita Fontana, DDS, PhD, Amid Ismail, BDS, MPH, DrPH, MBA, John Kuehne, DDS, MS, Chris Longbottom, BDS, PhD, Nigel Pitts, BDS, PhD, David C. Sarrett, DMD, MS, Tim Wright, DDS, MS, Anita M. Mark, Eugenio Beltran-Aguilar, DMD, DrPH, DABDPH. The Journal of the American Dental Association. Volume 146, Issue 2, Pages 79-86 (February 2015) DOI: 10.1016/j.adaj.2014.11.018

How would you stage these lesions? Light blue arrow, yellow arrow, orange arrow, dark blue arrow, and green arrow.

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