The Effect of Varying Diagnostic Thresholds

upon Clinical Caries Data for a Low Prevalence Group

N. B. PIUTS and H. E. FYFFE
Dental Health Services Research Unit, Department of Periodontology and Community Dentistry, Dental School,
Park Place, Dundee DD1 4HR, Scotland

This study investigated the impact of employing differing diagnostic

thresholds on clinical caries data in studies of groups with low caries
prevalence. Data from clinical examinations of287HongKong dental
students were analyzed by means of the CARIES microcomputer software package. This software allows for re-calculation of raw data
according to three different diagnostic thresholds (D3, D2, and Dl).
When "enamel" and "initial" lesions (as defined by WHO criteria)
were included in the calculation of DMFT, its value increased from
3.0 (D3) to 5.9 (DI), while the percentage of individuals considered
"caries-free" decreased from 28.2% to 7.0%. Little change was found
in the magnitude of the intra-examiner reproducibility, when calculated at each threshold, for a random 10% of the subjects. It was
unfortunately not possible to calculate inter-examiner reproducibility
in this study. The use of criteria which might be misinterpreted as
being similar, but which use differing effective diagnostic thresholds,
can dramatically influence the reported level ofdental caries. In view
of these findings, it may be necessary for the question of diagnostic
thresholds to be re-examined and to receive greater emphasis in future
studies.
J Dent Res 67(3):592-596, March, 1988

Introduction.
Most epidemiological caries studies employ criteria in which
a tooth, or tooth surface, is only recorded as decayed when
cavitation is obvious, and which ignore all caries present at a
less severe level (Klein et al., 1938; Todd et al., 1982; Downer
and Teagle, 1979). In 1981, the Federation Dentaire Internationale (FDI) adopted a number of "global goals for oral health"
which proposed that by the year 2000 the global average for
Decayed, Missing, and Filled teeth (DMFT) in 12-year-olds
should be no more than 3 (FDI, 1982). Here, clinical caries
was to be diagnosed at the level at which clinical intervention
was required, which is commonly taken to mean when clinical
cavitation has occurred. The workshop on Epidemiology of
Dental Caries set up by the British Association for the Study
of Community Dentistry in 1982 also recommended one, relatively gross, level of diagnosis: "caries at the cavitation level,
i.e., involving dentine", for prevalence studies, since this would
conform to the criteria in current use and, they hoped, allow
for a higher degree of reproducibility between and among examiners (Palmer et al., 1984). Few studies have considered
the extent to which inclusion or exclusion of pre-cavitation
lesions ["initial" and "enamel" lesions, to use the World
Health Organization terminology (WHO, 1979)] may affect
DMF counts, particularly after the recent decline in caries
prevalence.
In cases where the presence of "early" lesions as well as
cavities has been scored and reported, it has been shown that
large differences may occur between DMFT calculated incluReceived for publication July 28, 1987
Accepted for publication November 19, 1987
Financial support for this study came from the HKU Dental Faculty
Research Committee and latterly from the Chief Scientist Organisation
of the Scottish Home and Health Department.
592

ding early lesions and the DMFT calculated when the criteria
for recognition of D teeth are limited to cavitation (Marthaler,
1963). These differences, if not considered, can hide or confuse important findings. In a fluoridation study, for example,
there appeared to be a large disparity between the total number
of caries lesions recorded in test and control groups when only
relatively gross lesions were recognized. When, however, all
enamel lesions were included in the calculations, the total numbers of lesions in both the test and control groups at the end
of the experiment were shown to have been similar (Groeneveld, 1985). This has led to a re-examination of previous concepts of the mode of action of fluoride in caries prevention.
Rather than completely preventing the formation of a number
of lesions in the test group, it would seem that fluoride acted
by preventing the progression of many of the pre-cavitation
lesions to a more severe state (Groeneveld, 1985).
A recent preliminary report of the caries status of a group
of Hong Kong University dental undergraduates (Pitts, 1983)
found a "low" caries prevalence. A mean DMFT of 2.8 was
found when the conventional diagnostic threshold (D3), which
excludes all pre-cavitation lesions, was employed. This group
of students can therefore be considered to have already exceeded the FDI goal for the year 2000. In view of the muchdocumented recent decline in caries prevalence in many countries throughout the world (Glass, 1982; Allan et al., 1983;
Renson et al., 1985), this type of "low caries" data may
become more common in future caries studies in many developed countries. The principal aim of this study was to investigate the impact of the inclusion (or, conversely, exclusion)
of "initial" and "enamel" lesions on the results of a clinical
caries examination of a low-caries-prevalence group. Secondary aims of this study were to assess the feasibility of doing
this using a microcomputer running the CARIES software
package which re-calculates the raw DMF data according to
three different diagnostic thresholds, and to examine the extent
to which the percentage of a group identified as "caries-free"
changed when the sensitivity of the diagnostic threshold employed was increased.

Materials and methods.

Subjects and examinations. -The subjects consisted of four
successive intakes of dental undergraduates at the University
of Hong Kong. The group consisted of 238 males and 49
females, with a mean age of 20.6 years.
Clinical caries examinations were carried out on the 287
students during the academic years 1981 to 1984. The method
employed was based upon the guidelines laid down by the
World Health Organization (WHO) Manual on Oral Surveys
and the WHO Guide to Oral Health Epidemiological Investigations (WHO, 1977, 1979). Immediately prior to the examination, each student cleaned his or her teeth with a toothbrush
to remove the majority of debris and plaque. The examination
took place with the student supine in a dental chair and the
operator seated. Compressed air was used to dry the teeth,
while the use of a dental operating light ensured adequate il-

Vol. 67 No. 3

EFFECT OF DIAGNOSTIC THRESHOLDS ON LOW CARIES DATA

rumination. A plane mouth mirror and an Ash sickle probe No.

54 were used by the examiner. Where necessary, the probe
was used to clean gross debris from fissures.
During the examinations, all lesions (including "enamel"
and "initial" caries) were recorded. The diagnostic criteria
employed are listed in Table 1. The only modification made
to the WHO criteria, after a pilot study, was to allow slight
staining in an otherwise sound-looking fissure to be scored as
sound, since this type of slight staining was found to be exceedingly common and was not felt by the examiners to represent initial lesions. The WHO criteria applied to the other
categories for permanent teeth were as follows: "extracted due
to caries" and "lost due to other reasons", "filled", "filled
with primary caries", "filled with secondary decay", "unerupted", and "excluded" teeth. In line with WHO recommendations, only teeth extracted due to caries were counted
as missing.

The examinations were conducted by three dentists from the

Faculty of Dentistry of the University of Hong Kong. One
dentist carried out the examinations of the 1980 and 1981 intakes, while the other two dentists each examined just one
annual intake. Each had previously studied the criteria, and
two examiners were trained and calibrated using volunteer patients by the third, one of the authors. A scribe recorded the
scores for each tooth on a prepared form (since the software
to allow for direct input was not available at the start of the
study), and the examinations were tape-recorded so that checks
for recording errors could be made on completion of each
session. Approximately 10% of the subjects were randomly
selected to undergo a repeat examination (by the examiner
responsible for that particular student intake) to allow for assessment of intra-examiner reproducibility (Horowitz, 1972).
Unfortunately, due to the timing of the departure of the examiners from the University staff and from Hong Kong, it was
not feasible to calculate inter-examiner reproducibility using
the same subjects.
CARIES software package. -The data were analyzed by use
TABLE 1
DIAGNOSTIC CRITERIA
Criteria
Code
Category
No evidence of treated or untreated clinical
0 Surface Sound
caries (slight staining allowed in an otherwise sound fissure).
No clinically detectable loss of substance.
I Initial Caries
For pits and fissures, there may be significant staining, discoloration, or rough spots
in the enamel that do not catch the explorer,
but where loss of substance cannot be positively diagnosed. For smooth surfaces, these
may be white, opaque areas with loss of luster.
Demonstrable loss of tooth substance in pits,
2 Enamel Caries
fissures, or on smooth surfaces, but no softened floor or wall or undermined enamel.
The texture of the material within the cavity
may be chalky or crumbly, but there is no
evidence that cavitation has penetrated the
dentin.
3 Caries of Dentin
Detectably softened floor, undermined
enamel, or a softened wall, or the tooth has
a temporary filling. On approximal surfaces,
the explorer point must enter a lesion with
certainty.
4 Pulpal Involvement* Deep cavity with probable pulpal involvement. Pulp should not be probed.
* Included with D3 in computations.

593

of part of the suite of programs contained in the Clinical and

Radiographic Information from Epidemiological Surveys
(CARIES) software package. This software, which was written
with the assistance of the Dental Data Processing Unit of the
University of Hong Kong, is written in Microsoft BASIC, runs
on IBM PC-compatible microcomputers, and requires that WHO
diagnostic criteria and scoring codes be used for the clinical
examination. The package includes programs to validate input
data (to reject impossible or inappropriate values) and to calculate DMFT and DMFS and their components for every subject in the examination and for the group as a whole. The
software can also re-calculate the DMF indices and their components according to three different diagnostic thresholds, D1,
D2, and D3 (as detailed in Table 2), thus allowing for inclusion
or exclusion of "enamel" and "initial" lesions in the computations. Although radiographic data can be utilized by the
package (either in conjunction with corresponding clinical data
or on its own), for this study the package was employed solely
to process clinical data.
Intra-examiner reproducibility. -To calculate intra-examiner reproducibility, we used the following methods: Dice's
coincidence index for both 'sound to sound' and 'decay to
decay' (Dice, 1945); kappa (Cohen, 1960); the modified percentage reproducibility index (Shaw and Murray, 1975); and
finally Pearson's correlation coefficient (Rugg-Gunn et al.,
1976).

Results.
Mean DMF.-The average time for an examination (all of
which were carried out at the D1 threshold) to be carried out
was approximately three minutes, with a range of 2-5 minutes.
Table 3 shows the mean decayed, missing, and filled teeth and
surface counts from the same data (for all of the 287 students)
calculated at each of the three diagnostic thresholds. For both
DMFT and DMFS, it is evident that, as the sensitivity of the
diagnostic threshold was increased from D3 (least sensitive) to
D1 (most sensitive), the value of the calculated index almost
doubled.
When the separate components of the indices are considered,
it becomes obvious that, as expected, the decay component is
the one most affected by the imposed thresholds. An increased
sensitivity of diagnostic threshold had no effect on the M component, which remained at 0.29 missing teeth (or 0.86 missing
surfaces) per person. Similarly, filled surfaces remained constant at 2.97 per person regardless of threshold. There was a
TABLE 2

DIAGNOSTIC THRESHOLDS WHICH CAN BE APPLIED TO THE

DATA VIA THE CARIES SOFTWARE PACKAGE
Threshold
D3
excludes (W.H.O.) "enamel" and "initial" lesions
excludes (W.H.O.) "initial" lesions
D2
D1
includes all clinically detected lesions
TABLE 3
MEAN DECAYED, MISSING, AND FILLED TOOTH AND
SURFACE COUNTS FROM THE SAME GROUP OF 287 HONG
KONG DENTAL STUDENTS AT EACH OF THE THREE
DIAGNOSTIC THRESHOLDS.
Mean DMFS (SEM)
Mean DMFT (SEM*)
Threshold
Diagnostic
4.75 (0.32)
D3
3.01(0.19)
6.12 (0.33)
4.16 (0.21)
D2
8.40 (0.37)
Dl
5.91(0.23)
*SEM = Standard error of the mean.

594

PITTS & FYFFE

J Dent Res March 1988

slight decrease in the filled tooth count, from 1.97 (D3) to

1.78 (Dl). This was the result of five subjects in whom a tooth
had both a restoration and a code 1 or 2 lesion. When this
occurred, the tooth was counted as filled until the lesion was
recognized by the diagnostic threshold, at which point the tooth
was classed as decayed.
The mean DT component itself increased from 0.75 at
threshold D3, to 1.96 at D2, and to 3.84 at threshold D1.
Similarly, for mean DS there was a marked increase from 0.92
at threshold D3, to 2.29 at D2, and to 4.58 at threshold D1.
"Caries-free".-Table 4 shows the percentage of the group
which had a D component of zero and the percentage in which
DMFT equaled zero. If one considers the decay component
alone, 61.0% of the group showed no decay at threshold D3;
this figure was almost halved by application of threshold D2
and further reduced to approximately one-quarter of its D3
value on application of threshold D1. Looking at this in a
slightly different way, although 61.0% of the group were classified as currently free of decay at D3, 76.0% of these individuals had "initial" or "enamel" lesions.
A similar trend is observed when one considers the percentage of the group classified as free of decay experience
(i.e., where DMFT = 0); at threshold D1 this percentage is
only one-quarter of that calculated at threshold D3.
Intra -examiner reproducibility. -The overall intra-examiner
reproducibility for all three examiners, for a randomly selected
10% of subjects, is shown in Table 5. Similar calculations
were made for each of the three individual examiners. The
kappa values calculated at diagnostic thresholds D3, D2, and
D1, respectively, for each examiner were: Examiner A-0.60,
0.58, 0.67; Examiner B-0.81, 0.81, 0.82; and Examiner C0.89, 0.92, 0.83. Although the reproducibility between different examiners varied quite considerably, there was little
change within an individual examiner's reproducibility when
the three different thresholds were used. This finding was repeated with the other indices calculated.

Discussion.
Microcomputers with the appropriate software enjoy a number of features which are theoretically desirable for the hanTABLE 4
PERCENTAGES OF A GROUP OF 287 HONG KONG DENTAL
STUDENTS CONSIDERED CURRENTLY FREE OF DECAY
(DECAYED TEETH = 0), OR FREE OF DECAY EXPERIENCE
(DMF TEETH = 0), AT EACH OF THE THREE DIAGNOSTIC
THRESHOLDS
DMF Teeth = 0
Diagnostic Threshold
Dacayed Teeth = 0
D3
61.0%
28.2%
D2
33.5%
15.0%
DI
14.3%
7.0%
TABLE 5
OVERALL INTRA-EXAMINER REPRODUCIBILITY FOR ALL
THREE EXAMINERS, AT THE THREE DIAGNOSTIC
THRESHOLDS, FOR A RANDOMLY SELECTED 10% OF

SUBJECrS

Diagnostic Threshold

Reproducibility Index
Coincidence Index (sound to sound)
Coincidence Index (decay to decay)
Kappa
Modified percentage reproducibility
Correlation
coefficient

D3
0.999
0.841
0.789
99.7%
0.98

D2
0.996
0.812
0.818
99.2%
0.94

D1
0.992
0.809

0.795
98.4%
0.92

dling of epidemiological caries data. Although the software

was not finalized in time to allow for chair-side input in this
study, many powerful microcomputers are now available as
portable versions, which facilitate immediate entry of data during a clinical examination. This reduces the need to fill out
separate record forms or cards for each individual, reduces
problems of record storage, and also reduces the risk of error
during transcription of data into computer files. The automatic
checking facility which ensures that only appropriate codes can
be entered by the scribe at the time of examination should also
minimize errors. Although data could be uploaded directly onto
a mainframe computer, the attraction of using a microcomputer
(particularly one which is IBM PC-compatible) is that workers
who have no ready access to comprehensive computing facilities may well be able to acquire or borrow an 'office' desktop
computer.
Another benefit of the CARIES software package is the centralized storage of data in a systematic manner, which allows
for efficient access and rapid re-calculation of raw results according to different thresholds. This makes it feasible to select
appropriate sets of results from a study to deal with different
situations. For example, the appropriate diagnostic threshold
must be employed when comparisons are made with the results
of other studies if valid conclusions are to be drawn. It may,
however, also be useful to examine a different facet of the
caries pattern by the additional reporting of results computed
with a different threshold.
As caries prevalence decreases, it is becoming increasingly
difficult to demonstrate differential effects between different
formulations of caries-preventive agents in clinical trials. Some
now suggest that the sensitivity of the diagnostic criteria used
should be increased (Glass et al., 1983), since much of the
beneficial effect of fluoride in toothpaste, for example, is in
preventing the progression of pre-cavitation lesions to cavitated
ones and 'reversing' incipient lesions. A proportion of this
cariostatic action may be missed if pre-cavitation lesions are
ignored by the diagnostic threshold employed (Pitts, 1983).
Similarly, in epidemiologic surveys the relative contribution
made by pre-cavitation and initial lesions to the total caries
experience (which may change with falling prevalence) will
be unknown unless sensitive thresholds are employed.
When compared with data available for children, there is a
scarcity of corresponding information for young adults with
which to compare these Hong Kong DMF figures, although
the DMF results appear to be low in comparison with those
recently reported for Denmark, Finland, Israel, Japan, and the
U.S.A. by Gordon and Newbrun (1986). In a national survey
in Britain, a DMFI' of 14.9 for the 16-24-year age group,
based on the D3 threshold, was reported (Todd et al., 1982).
This is approximately five times that of the Hong Kong group.
More recently, however, a national survey of UK children
reported (with the D3 threshold) a mean DMFT of 3.1 and 5.9
for 12- and 15-year-olds, respectively (Todd and Dodd, 1985).
The Hong Kong data (which used the same diagnostic threshold) showed a mean DMFF of 3.01, indicating that the caries
prevalence in this group of 20-year-olds was, in the early 1980's,
on a par with that of British 12-year-olds and considerably
lower than that of British 15-year olds.
Many workers have refrained from including pre-cavitation
lesions in DMF counts, since it has been suggested that the
benefits derived from the extra information may be outweighed
by an increased examiner and method error. The results of a
number of studies do not, however, support this contention
(Backer-Dirks, 1964; Haugejorden and Slack, 1975; Espelid
and Tveit, 1986). While the logistics of this study precluded
an assessment of inter-examiner reproducibility, it was possible to record intra-examiner reproducibility for each examiner.

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EFFECT OF DIAGNOSTIC THRESHOLDS ON LOW CARIES DATA

There are many suggested methods of calculating reproducibility (Shaw and Murray, 1975), the choice of the most appropriate method(s) being to an extent governed by survey/
study design and objectives, as well as by personal preference.
While the use of Pearson's correlation coefficient is well-established, it was considered that the Kappa statistic and Dice's
coincidence index also have a number of advantages (Nuttall
and Paul, 1984). Many methods give few guidelines for interpretation of values. Landis and Koch (1977), however, proposed a scale for interpreting Kappa results. At each of the
three diagnostic thresholds employed here, the mean Kappa
values lie at the top of the "substantial agreement" range.
When the individual examiners are considered, it is evident
that examiner A's kappa values were at the borderline between
"moderate" and "substantial" agreement (with the D1 agreement being higher), while examiners B and C's values were
either at the borderline of, or within, the "almost perfect"
agreement range. The important point to be made, however,
is that although the individual examiners showed differences
in intra-examiner reproducibility according to the index calculated, little difference was found in their ability to diagnose
with a similar level of reproducibility at each diagnostic threshold. Fears of loss of intra-examiner reproducibility when the
more sensitive thresholds are used might, therefore, have been
overstated. Further studies of inter-examiner reproducibility
with low-prevalence groups are, however, still required.
Although the lower caries levels encountered in this group
may have played a part in the reproducibility achieved, it might
be postulated that the presence of fewer, less severe lesions
would result in a greater number of more difficult, borderline
decisions than at times of higher caries activity. There was a
slight deterioration in reproducibility from D3 to D1, but the
magnitude of this, as demonstrated in the small changes in the
various reproducibility indices and the relatively small increase
in the standard error of the mean of the DMF values (Table
3), is, we would submit, insufficient to warrant exclusion of
pre-cavitation lesions from DMF counts in all situations. It is
possible that the pre-examination self-cleaning and good examining conditions (dental light and availability of compressed
air) contributed to the reproducibility observed. These conditions can be provided quite readily -even, where necessary,
with portable equipment.
Although it is obvious that increasing the sensitivity of any
diagnostic threshold will give a different interpretation to the
results of an examination, the aim of this study was to assess
the magnitude of this effect when applied to epidemiological
caries data. The results show that the use of such thresholds
can have a dramatic effect on the reported level of dental caries. DMFT and DMFS indices were almost doubled by inclusion of "enamel" and "initial" lesions, while the "cariesfree" percentage was decreased to approximately one-quarter
of its D3 value by inclusion of these lesions (Tables 3 and 4).
In view of these findings, it may be necessary for the question
of choosing a diagnostic threshold which is appropriate to the
survey objective(s) to be re-examined and to receive greater
emphasis in future studies. There is a chance that the apparent
underestimation of disease prevalence which arises when insensitive thresholds are used may be misinterpreted by research
workers, dentists, and health planners.
From the results of this study, it would seem that it is feasible and potentially advantageous to use a microcomputer with
software suitable for storage of raw epidemiological caries data
recorded at the D1 threshold to calculate DMFT and DMFS at
differing diagnostic thresholds. It is evident that the use of
criteria which might be misinterpreted as being similar, when
in fact they use differing effective diagnostic thresholds, can
dramatically influence the reported level of dental caries, and

595

considerable care should therefore be taken in use of the term

"caries-free" when diagnostic thresholds which ignore precavitation lesions have been employed. Finally, calculation of
various reproducibility indices suggests that there may be only
minimal loss of intra-examiner reproducibility when the more
sensitive diagnostic criteria are employed on low caries prevalence groups. Further studies in this area, including an assessment of inter-examiner reproducibility, are required and
planned.

Acknowledgments.
We are indebted to the dental students of Hong Kong University (HKU) for agreeing to participate, to all the various
members of the Faculty of Dentistry, HKU, for their cooperation in mounting the caries examinations during the busy Induction and Orientation weeks, and in particular to Dr. C.
Taylor and Dr. W. Yung (formerly HKU) for acting as examiners. We are also grateful to Mr. D. Carthy, Head of HKU's
Dental Data Processing Unit (DDPU), and to Mr. L. Pong
(DDPU) for the assistance in producing the CARIES package.
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