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ICCMS Guide forPractitioners and EducatorsNigel B. Pitts, FRSE BDS PhD FDS RCS (Eng) FDS RCS (Edin) FFGDP (UK) FFPH1Amid I. Ismail, BDS, MPH, Dr. PH, MBA2Stefania Martignon, BDS, PhD1,3Kim Ekstrand, BDS, PhD4Gail V. A. Douglas, BMSc, BDS, MPH, FDS, PhD, FDS (DPH) RCS5Christopher Longbottom, BDS, PhD1Contributing co-authors*Christopher Deery, University of Sheffield, UKRoger Ellwood, University of Manchester, UKJuliana Gomez, University of Manchester, UKJustine Kolker, University of Iowa, USADavid Manton, University of Melbourne, AustraliaMichael McGrady, University of Manchester, UKPeter Rechmann, University of California San Francisco, USADavid Ricketts, University of Dundee, UKVan Thompson, Kings College, London, UKSvante Twetman, University of Copenhagen, DenmarkRobert Weyant, University of Pittsburgh, USAAndrea Ferreira Zandona, University of North Carolina, USADomenick Zero, Indiana University School of Dentistry, USAOn behalf of the Participating Authors of the International Caries Classification andManagement System (ICCMSTM) Implementation Workshop, held June 2013**December 20141King’s College London Dental Institute, Dental Innovation and Translation Centre, Guy’s Hospital, London, UK2Maurice H. Kornberg School of Dentistry, Temple University, Philadelphia, USA3UNICA Caries Research Unit, Universidad El Bosque, Bogotá, Colombia4University of Copenhagen, Denmark5School of Dentistry, University of Leeds, UK1

*Contact details for all authors and contributing co-authors can be found in Appendix A1.**For a list of contributors from the ICCMS Implementation Workshop and developmentmeetings since, please see Appendix A2.Amid Ismail and Nigel Pitts are the co-Directors of ICDAS/ICCMS and are assisted by StefaniaMartignon, the ICCMSTM Coordinator. Modifications, questions, and suggestions relating to theICCMSTM Consensus Core resource document and this ICCMSTM Guide for Practitioners andEducators should be directed to Stefania Martignon ([email protected]) who alsoworks with the current ICDAS coordinator Gail Douglas ([email protected]) as well asthe ICDAS Coordinating Committee and the Global Collaboratory for Caries Management(GCCM), formed at King’s College London under the supervision of Professor Nigel Pitts, withthe aim of initiating comparative studies of the proposed systems and evaluate the process andoutcomes of its implementation. Further details can be found in the webpages www.icdas.organd l-caries-management.aspx.AcknowledgementsThe Authors are indebted to the marvelous contributions made by all of the internationally mixedgroups who attended the launch meeting of the Global Collaboratory for Caries Management atKings College London in June 2013 and the many who have helped since at meetings inLiverpool, Seattle, Philadelphia, London, Capetown, Greifswald, Delhi and Tokyo to drive thisinitiative forward. We are also exceedingly grateful to all the Organizations and Companies whohave supported this work and enabled the progress to date. A list of Supporting Organizationsand Companies can be found in Appendix M.Correspondence:Stefania MartignonKing’s College London Dental Institute, Dental Innovation and Translation CentreGuy’s HospitalRoom 38, Tower WingSE1 9RT, London, [email protected]: ICCMS is trademarked by the ICDAS Foundation in order that the International Caries Classification andManagement System can remain open and available to all.2

TABLE OF CONTENTSPageOverview . 5Introduction 1.1.11.21.36History and Development of the ICCMSTM . . . 9ICCMSTM’s Goals for Caries Management . . . 10Principles for Implementing ICCMS . . 11ICCMSTM Caries Management Pathway 122.ICCMSTM Elements and the supporting evidence . 132.1Element 1- History-:Patient Level Caries Risk Assessment . . 142.2Element 2- Classification: Caries Staging and Lesion Activity Assessment . . 152.2.1 Assessment of Caries Risk Factors Intraorally . 162.2.2 Staging lesions 182.2.2.1 Staging coronal caries lesions clinically . 182.2.2.2 Staging coronal caries lesions radiographically . 202.2.2.3 Combining clinical and radiographic information . 222.2.2.4 Lesion activity assessment . 222.3Element 3- Decision Making: Synthesis of information to reach Diagnoses . . 242.3.1 ICCMS caries diagnosis . . 242.3 2 ICCMS caries risk analysis to assess likelihood of new lesions or cariesprogression . 252.4Element 4- Management: Personalized Caries Prevention, Control & Tooth PreservingOperative Care . . . 272.4.1 Managing a patient’s risk factors . . 282.4.2 Managing individual lesions . . 302.5Recall interval, Monitoring and Review . 333.Outcomes of Caries Management using ICCMSTM . 344.ICCMSTM in Practice . 355.5.15.25.35.4Related Developments 35New Evidence on Current or Emerging Technology 35Research Agenda for ICCMS and the GCCM . 36Integrated eLearning and Data Management Software . 37Implementation for ICCMS – GCCM . 37References . 383

List of TablesTable 1. Risk status of the patient 17Table 2. Definition of ICCMSTM Caries categories (merged codes) 19Table 3. ICDAS/ICCMS radiographic scoring system . 21Table 4. Combination of clinical and radiographic information 22Table 5. Characteristics of lesion activity across the ICCMSTM coronal caries stages 23Table 6. ICCMS caries diagnosis (staging and activity status per lesion) . 25Table 7. ICCMS Caries Risk and Likelihood Matrix . 25Table 8. Managing individual lesions in permanent teeth . 31Table 9. Managing individual lesions in primary teeth . 32List of FiguresFigure 1.Identification of the ICCMS Practice and Education Domains relating to thisManual 7Figure 2. Overview of the ICCMS Elements and Outcomes . . 8Figure 3. The Four Elements of ICCMS linked by risk based recall . 12Figure 4. Detailed overview of ICCMS Elements and their components . . 13Figure 5. Element 1- History- Patient-level Caries Risk Assessment . . 14Figure 6. Element 2- Classification: Caries Staging and Lesion Activity Assessment withIntraoral Caries Risk Factors . . 16Figure 7. Element 3- Decision Making: Synthesis of information to reach Diagnoses andRisk Status . 24Figure 8. Element 4- Management: Personalized Caries Prevention, Control & ToothPreserving Operative Care . . 27Figure 9. Managing patient’s risk factors 29Figure 10. Detailed Outcomes of Caries Management using ICCMS . . . 34List of BoxesBox 1. Patient level caries risk factors . . . 15Box 2. Intraoral level caries risk factors . . 16List of AppendicesAppendix A: List of Contributing and Participating Authors . . . . 47Appendix B: Scottish Intercollegiate Guidelines Network’s (SIGN) Grading of the Evidence . 50Appendix C: Patients’ caries risk factors. A consideration . 51Appendix D: Full Definition of ICCMS Caries categories (merged codes) . 54Appendix E: Root caries: Staging of lesions clinically, activity assessment andmanagement options . 55Appendix F: Some considerations on Caries Associated with Restorations orSealants (CARS) and Non carious changes . . 58Appendix G: Evidence considerations for managing patients’ risk factors . . 60Appendix H: Level of evidence for individual lesions’ interventions . . 62Appendix I: New Evidence on Current or Emerging Technology . 63Appendix J: Glossary for key words . . 64Appendix K: ICCMSTM Caries Staging Photographs and Radiographs 66Appendix L: ICCMS Clinical Case Example . 77Appendix M: Supporters of ICCMS and the Global Collaboratory for Caries Management . 844

OverviewThe aim of this Guide is to describe the structure and facilitate the implementation of the InternationalCaries Classification and Management System (ICCMS ), which the authors propose to be used inthe daily handling of our patients for caries prevention and management and also in the teachingundertaken at dental schools around the world.The ICCMS is a health outcomes focused system that aims to maintain health and preservetooth structure. Staging of the caries process and activity assessment is followed by riskadjusted preventive care, control of initial non-cavitated lesions, and conservative restorativetreatment of deep dentinal and cavitated caries lesions.There are four elements in the ICCMS , the two key aspects are: Classification - Caries Staging & Activity Assessment: this comprizes (i) staging of caries lesionseverity (‘initial’/’moderate’/’extensive’) and (ii) caries activity assessment (likelihood of progression orarrest/reversal of lesions: ‘active’/’inactive’). [Note that during the intraoral assessment phaseinformation is also collected on oral risk factors; e.g. oral hygiene, dry mouth]Management - Personalized Caries Prevention, Control & Tooth Preserving Operative Care: Thedental team, together with the patient, devise a Personalized Caries Care Plan to manage the cariesrisk status of the patient as well as managing caries lesions appropriately. (i) Management of the riskstatus is based on both home care advice, as well as clinical activities; those with low risk gettinggeneral information on how to maintain teeth as sound, those with moderate and high risk withincreasing focus on behavior changes and short periods between recalls to the clinic. (ii) Themanagement of the lesions is related to the diagnosis of the individual lesions: ‘initial’ active lesions ingeneral are managed with non-operative care (NOC) whilst moderate/extensive lesions are in generalmanaged operatively with tooth preserving operative care (TPOC).In order to devise an optimal Personalized Caries Management Plan, two other elements are alsoneeded (please note that the chronological sequence and the method of integration of patient andclinical information may vary according to local preferences): History - Patient-level Caries Risk Assessment: collation of risk information at the patient level (tobe integrated with clinical and tooth level information).Decision Making - Synthesis and Diagnoses: (i) classification of individual lesions combininginformation about their stage and activity (e.g. ‘initial’ active lesion), and (ii) an overall caries risklikelihood status combining information about presence/absence of active lesion/s and patient’s risk(‘low’, ‘moderate’ or ‘high’ risk of getting future caries and/or of lesion progression).The risk-based recall interval, including monitoring and review, then allows this caries managementpathway to become a cycle, facilitating the achievement of optimal long-term health outcomes. Outcomes - are considered across: health maintenance, disease control, patient-centered qualitymetrics, as well as the wider impacts of using the ICCMS System.The authors hope that this Guide will be useful in bringing the International Caries Classification andManagement System - ICCMS - to the attention of many more clinicians and educators around theworld. We also hope that it will provide an indication of one way to operationalize the System. Thecharacteristics of ICCMS are the delivery of effective, risk based caries care that prevents newlesions, controls initial caries non-operatively and preserves tooth tissue at all times.The authors gratefully acknowledge the tremendous contributions of all the many parties who havecontributed to both the ICDAS Foundation and to the development of ICCMS .5

IntroductionThe International Caries Classification and Management System - ICCMSTM - deliberatelyincorporates a range of options designed to accommodate the needs of different usersacross the ICDAS (International Caries Detection and Assessment System) domains ofclinical practice, dental education, research and public health (see Figure 1). The ICCMSTMsystem seeks to provide a standardized method for comprehensive caries classification andmanagement, but recognizes fully that there are different ways for implementing suchsystems locally. ICCMS builds on the evidence-based ICDAS system for the staging ofcaries. It also maintains the flexible approach of the ICDAS “wardrobe” which providesseveral approved options for categorising the disease according to local and/or specificneeds, preferences and circumstances.It must be appreciated that this Guide relates only to the use of the System in the domains ofPractice and Education; there are a range of considerations and applications ofICDAS/ICCMS in Research and in Public Health that are important, but are beyond thescope of this Guide (see Figure 1).The system outlined in this document is based on best evidence and consensus. Themethodology used was wherever possible to use “SIGN” grading of the evidence with rapidreviews an