Clinical Study to Evaluate the Safety and Performance of the Calcivis System for Identifying Active Demineralization on Tooth Surfaces
Phase: NA
Conditions: Dental Caries
Sponsor: Calcivis Ltd

CAL-02-2014, Version 6,  08 December 2016                                                                 F-PM-16, v1, March 2013 
 
Page 1 of 48 
 
CLINICAL STUDY PLAN  
 
  Version 6,   08 December 2016 
 
 
Clinical Study to Evaluate the Safety and Performance of the Calcivis® System for Identifying Active 
Demineralization on Tooth Surfaces 
CAL-02-2014 
 
 
CALCIVIS LTD 
NINE, EDINBURGH BIOQUARTER 
LITTLE FRANCE ROAD 
EDINBURGH 
EH16 4UX 
Tel: +44 (0) 131 658 5153 
 
 
 
 
COMPANY CONFIDENTIAL INFORMATION:   
NOTHING HEREIN IS TO BE DISCLOSED IN ANY WAY  
WITHOUT THE PRIOR WRITTEN CONSENT OF CALCIVIS LTD 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 2 of 48 
Revision History  
VERSION / DATE 
REVISION CHANGES 
Version 1 /  11 November 2015 
Original Version 
Version 2, 04 January 2016 
Section 15.3 – Informed Consent 
The sentence regarding “The patients’s General Practitioner will be 
informed of their participation in the study” has been removed further 
to Ethics review 
 
Version 3, 08 February 2016 
Section 1 – Synopsis – Patient Population 
Section 1 -  Inclusion and Exclusion Criteria 
Section 7.4 – Inclusion Criteria and Reference Table 
Inclusion criteria no. 2 changed to include inscisors 
Version 4, 03 May 2016 
All pages - Footers - changed on every page to reflect amended   
version and date 
 
Page 1 – Front Page – version number and date changed       
 
Page 3 - Investigator Signature Page -  reference to version and date 
changed in Investigator declaration 
 
Page 9 – 1. Synopsis – Study Device - Intended Use and Indications 
and Page 18 – 5.2 General Description  -  changes to description of 
Calcivis Disclosing Solution Kit to reflect syringe needles replaced by 
needleless adaptors  
 
Page 24 – 5.9 Device Labelling and Storage - changes to description of 
contents of Calcivis Disclosing Solution Kit and Calcivis Application Kits 
and change of storage condtions for the Calcivis Disclosing Solution Kit 
from 2 to 80C to Room Temperature 
 
Page 29 – 8.2 Study Visit 1 – Preparation Procedures for Teeth and 
Page 48 -  Appendix 2 – Tooth Cleaning Protocol – amended from 
cleaning teeth with prophylaxix paste to cleaning teeth with water or 
dental paste 
 
 
Version 5, 19 October 2016 
All pages - Footers - changed on every page to reflect amended   
version and date 
 
Page 1 – Front Page – version number and date changed       
 
Page 3 - Investigator Signature Page -  reference to version and date 
changed in Investigator declaration 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 3 of 48 
Page 9 – 1. Synopsis – Study Device - Intended Use and Indications 
and Page 19 – 5.2 General Description  addition of description of 
Calcivis Disclosing Solution (Photoprotein) multi-use format, and 
clarification to description of Calcivis Disclosing Solution single-use 
format and Calcivis Application Kit.  
 
Page 25 – 5.9 Device Labelling and Storage – addition of description 
of contents of Calcivis Multi-use Disclosing Solution (photoprotein)  
Kit and corresponding storage condtions. 
 
Page 26 – 6.1 Risk Analysis - addition of possible safety concerns and 
mitigations of multi-use format of Photoprotein 
 
Page 30 – 8.2 Study Visit 1 – Preparation of the Calcivis System -
clarification of storage conditions for the Calcivis multi-use Disclosing 
Solution (Photoprotein) 
 
 
Version 6, 08 December 2016 
All pages - Footers - changed on every page to reflect amended   
version and date 
 
Page 1 – Front Page – version number and date changed       
 
Page 4 - Investigator Signature Page -  reference to version and date 
changed in Investigator declaration 
 
Page 13 – Study Investigators – removal of Site 02 ( Charles Ormond) 
and addition of Site 05 (Agnieszka Nohawica)  
 
Page 31 – 8.5 Independent Investigator Review – Table amended to 
take into account removal of Site 02 and addition of Site 05 

CAL-02-2014, Version 6,  08 December 2016                                                                 F-PM-16, v1, March 2013 
 
Page 4 of 48 
 
 

CAL-02-2014, Version 6,  08 December 2016                                                                 F-PM-16, v1, March 2013 
 
Page 4 of 48 
 

CAL-02-2014, Version 6,  08 December 2016                                                                 F-PM-16, v1, March 2013 
 
Page 4 of 48 
 

CAL-02-2014, Version 6, 08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 4 of 48 
 
 

CAL-02-2014, Version 6, 08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 4 of 48 
 
 

CAL-02-2014, Version 5, 19 October 2016 
 
F-PM-16, v1, March 2013 
 
Page 5 of 48 
SPONSOR STUDY CONTACTS  
 
Study Sponsor 
 
 
Adam Christie (CEO) 
Calcivis Ltd 
Nine, Edinburgh Bioquarter 
Little France Road 
Edinburgh 
EH16 4UX 
Tel: +44 (0) 131 658 5153 
 
Sponsor Medical Director: 
James Browning  
Calcivis Ltd 
 
Tel: +44 (0) 131 658 5153 
Mob: +44 (0)7850839999 
 
Sponsor Dental Advisors: 
Christopher Longbottom  
 
Tel: +44 (0) 131 658 5153 
 
Nigel Pitts 
 
Tel: +44 (0) 131 658 5153 
 
Clinical Research Manager: 
Marjory Willins  
Calcivis Ltd 
 
Tel: +44 (0) 131 658 5153 
Mob: +44 (0) 7917 784 626 
 
Statistics and Data  
Management: 
DataTrial Ltd 
Flemming Business Centre 
Burdon Terrace, Jesmond 
Newcastle upon Tyne 
 
Tel: +44 (0) 191 212 8200 
 
 
 
 
 
 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 6 of 48 
TABLE OF CONTENTS  
Page 
Front Title Page 
1 
Revision History 
2 
Investigator Signature Page 
4 
Sponsor Study Contacts 
5 
Table of Contents 
6 
1. Synopsis 
9 
2. Schedule of Events 
15 
3. Introduction  
16 
3.1.         Background 
16 
3.2.         General overview of the technology 
16 
3.3.         Risk / benefit analysis 
17 
3.4.         Rationale for study 
18 
4. Study Objectives and Endpoints 
18 
4.1.         Primary objective and endpoints 
18 
4.2.         Secondary objective(s) and endpoints 
18 
5. Study Device  
18 
5.1. 
Intended Use 
18 
5.2. 
General Description 
19 
5.3. 
Device Use 
20 
5.4. 
Device Technology 
20 
5.5. 
Device Manufacture 
21 
5.6. 
Regulatory Status 
22 
5.7. 
Device Safety 
23 
5.8. 
Device Accountability 
24 
5.9. 
Device Labelling and Storage       
25 
5.10 
Device Training 
25 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 7 of 48 
6. Risks and Benefits 
26 
6.1.       Risks Analysis 
26 
6.2.       Potential Risks 
26 
6.3.       Potential Benefits 
26 
7. Study Design 
27 
7.1. 
  Overview 
27 
7.2.       Patient Selection and Confidentiality 
27 
7.3.       Study Duration 
27 
7.4.       Inclusion and Exclusion Criteria 
28 
8. Study Procedures 
29 
8.1. 
Screening Procedures 
29 
8.2. 
Study Visit 1 
29 
8.3. 
Study Visit 2 
31 
8.4. 
Future Dental Care 
31 
8.5. 
Independent Investigat or Image Review 
31 
9. Adverse Events 
32 
9.1. Definitions 
32 
9.2. Collection and Reporting of Adverse Events 
33 
10. Statistics 
34 
10.1. Sample size Calculations 
34 
10.2. Statistical Analysis 
35 
11. Data Management 
36 
12. Study Data Reporting and Study Report 
36 
13. Publication of Results 
36 
14. Regulatory, Administrative and Contractual Information 
37 
14.1. 
Sponsor’s Responsibilities 
37 
14.2. 
Amendments 
37 
14.3. 
Deviations 
37 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 8 of 48 
14.4. 
Monitoring Procedures and Source Documents 
38 
14.5. 
Data Recording 
38 
14.6. 
Maintenance , Retention and Archiving of Study records 
39 
14.7. 
Investigator and Site Personnel Training 
39 
14.8. 
Study Termination 
39 
14.9. 
Financing and Insurance 
39 
14.10. Investigator Responsibilities 
40 
15. Ethical Considerations 
41 
15.1. 
Standards and Guidelines 
41 
15.2. 
Research Ethics Committee and Other Approvals 
41 
15.3. 
Informed Consent 
41 
15.4. 
Disclosure and Confidentiality 
42 
16. References 
43 
17. Appendices 
44 
                 Appendix 1 – ICDAS Conventions – Decision Tree 
45 
                 Appendix 2 – Tooth Cleaning Protocol 
47 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 9 of 48 
1. 
SYNOPSIS   
Study Name and Unique 
Number 
Clinical Study to Evaluate the Safety and Performance of the Calcivis 
System for Identifying Active Demineralization on Tooth Surfaces  
– CAL-02-2014 
Study Objectives 
Primary Objectives 
Performance of the Calcivis System, as measured by the presence or 
absence of elevated luminescence on the surface of the tooth 
determined from intra-oral image mapping of that surface (with or 
without a visible lesion).  
 
Safety of the Calcivis System, as measured by the collection of all adverse 
events  
   
The Secondary Objective of the study is: 
 
To assess the usefulness of the Calcivis System images, as a 
communication tool between patient and dentist, as measured by 
Questionnaires and  / or Patient Visual Analogue Scales. 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 10 of 48 
Study Device  - Intended Use 
and Indications 
The Calcivis Caries Activity Imaging System comprises: 
Calcivis Imaging Kit - Administration and Imaging device 
Consists of:   
 
Calcivis Intra-oral Imaging Device 
 
Device cradle 
 
Calcivis (Imaging) Software on DVD/CD 
 
Calcivis Instruction Manual 
Accessory - Calcivis Disclosing Solution Kit – single use 
Consists of:   
 
Calcivis Disclosing Solution (Freeze dried in vials) 
 
Water for reconstitution 
 
Syringe  
 
Needleless adaptors  
and / or 
 
Accessory – Calcivis Disclosing Solution (Photprotein) Kit - Multi-use 
Consists of: 
 
Calcivis Photoprotein (Disclosing Solution) - Freeze dried in a vial 
 
Vial of Calcivis Diluent (Water for reconstitution) 
 
Single-use Device Syringes (sterile prior to opening) 
 
Vial Adaptors x 2 
 
Accessory – Calcivis Application Kit 
Consists of: 
 
Single-use Calcivis Applicators x10 
 
The Calcivis Caries Activity Imaging System is intended to be used by 
dental healthcare professionals on patients (6 years and older) with, or at 
risk of developing, caries lesions on coronal tooth surfaces.  
The Calcivis Caries Activity Imaging System is indicated for use to provide 
images of active demineralization on tooth surfaces, as an aid to the 
assessment and diagnosis of caries lesions.  
Study Design 
Prospective, multi-site, non-randomised, post-approval clinical study 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 11 of 48 
Patient Population: 
Eligible patients will be recruited from routine, general dental practices 
who have one unrestored, accessible, free smooth buccal surface on a 
canine or incisor , away from the gingival surface,  identified with no 
visible lesion (coded ICDAS 0),  and / or  one unrestored, accessible, 
erupting or erupted molar or pre-molar with a visible lesion identified 
(coded ICDAS 2 or 3) in a plaque stagnation area.  
Inclusion and Exclusion 
Criteria  
Inclusion criteria 
 
1. Patient must be ≥ 6 years old 
 
2. Patient must have one unrestored, accessible, free smooth 
buccal surface on a canine or incisor, away from the gingival 
surface  identified with no visible lesion (coded ICDAS 0) – ref. 
table on page 27 
 
               and / or 
3. Patient must have one unrestored, accessible, erupting or 
erupted molar or pre-molar with a visible lesion identified 
(coded ICDAS 2 or 3) in a plaque stagnation area – ref. table on 
page  27  
 
4. Patient and  / or parent or guardian must be willing and able to 
give written informed consent 
 
5. Patient and  / or parent or guardian must be willing and able to 
adhere to study schedule 
 
Exclusion criteria 
 
1. Any Patient with recent tooth bleaching (within previous two 
weeks of imaging with the Calcivis System) 
 
2. Any Patient having on-going re-mineralization treatment 
including, but not limited to high concentration prescription 
fluoride toothpaste  
 
3. Any patient with a fixed orthodontic appliance 
 
4. Any patient currently taking part in a clinical research study, or 
has taken part in a clinical research study in the previous three 
months 
 
5. Pregnant and / or nursing mothers 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 12 of 48 
Statistical Rationale 
The study will assess the agreement between the Calcivis System and 
dentist rating of suitable teeth into two categories: ‘no visible lesions’ or 
‘active lesions’. Based on previous study data and expert opinion, ‘No 
visible lesions’ are expected to correspond to ‘no luminescence’ in at 
least 70% of cases. Similarly, ‘active lesions’ are expected to correspond 
to ‘luminescence’ in at least 70% of cases. 
For the purpose of sample size calculations, the percentage agreement 
for each of the two categories are jointly considered as measures of 
agreement. That is, both measures will need to show statistically 
significant agreement for the study to be considered successful. 
The study is sized to provide at least 90% power to reject the null 
hypothesis of chance agreement (50%). Statistical hypothesis tests will be 
1-sided and conducted at the 2.5% significance level.  
This requires a mimimum of 81 evaluable teeth of each category. 
Number of Patients / 
Investigator 
A minimum of 17 and a maximum of 18 teeth from each tooth 
population are required from each Investigator (a total of 85 to 90 teeth 
from each tooth population). 
Therefore per Investigator - if all patients have one of each tooth 
population, a minimum of 17 patients per Investigator will be recruited 
and if all patients only have one of each tooth population, a maximum of 
36 patients will be recruited.  
Therefore the number of patiens recruited to the study will range from 
85 to 180. 
Number of Sites 
Four (4) 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 13 of 48 
Sites and Investigators 
Site 01:      Neil Shanks (Chief Investigator) 
Downie, Harper & Shanks Dental Practice 
55 Captains Road 
Edinburgh, EH17 8HP 
Scotland 
Tel: 0131 664 2184 
 
                    Elaine Downie (Investigator) 
Downie, Harper & Shanks Dental Practice 
55 Captains Road 
Edinburgh, EH17 8HP 
Scotland 
                    Tel: 0131 664 2184 
 
Site 03:     Fraser Morrison  (Investigator) 
                  Bathgate Smile Centre 
                  Whitburn Road 
                  Bathgate, EH48 2SS 
                  West Lothian 
                  Scotland 
                  Tel: 01506 656563 
 
Site 04:     Steve Martin (Investigator) 
                   Marchmont Periodontics 
                   18 Thirlestane Road 
                   Edinburgh, EH9 1AN 
                    Scotland 
                    Tel: 0131 447 4159  
 
Site 05:      Agnieszka Nohawia (Investigator) 
                    Bosco Dental Studio 
                    3/25 Thorny Crook Terrace 
                    Dalkeith, EH22 2RF 
                    Scotland 
                    Tel: 0131 654 9316                      
 
 
Duration of Procedure 
 
Preparation for Imaging is expected to take approximately one minute 
per tooth with imaging itself taking less than one second. All  eligible 
teeth per patient will be imaged at the same dental visit 
Follow-Up  
7 to 14 days post imaging 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 14 of 48 
Duration of Study 
The overall study period is expected to take 10 months - 3 months for 
Ethics Committee and R & D approval, 2 to 3 months for recruitment and 
study procedures, and 4 months for final follow up, data collection and 
analysis.  
 
Regulatory Status 
The Calcivis System is a Class IIa Medical Device which is CE marked in 
the EU.  

CAL-02-2014, Version 5, 19 October 2016 
 
 
  
F-PM-16, v1, March 2013  
Page 15 of 48 
2. SCHEDULE OF EVENTS 
 
      
Screening  
Visit 1 
Visit 2 
Indendent 
Review 
Pre-Imaging 
 
Pre-
Imaging 
Imaging 
 
Post-Imaging 
Post-Imaging 
(7 to 14 days) 
 
Identification of patients / issue of Patient Information Sheet 
X 
 
 
 
 
 
Written Informed Consent 
 
X 
 
 
 
 
Demographics 
 
X 
 
 
 
 
Inclusion / Exclusion Criteria 
 
X 
 
 
 
 
Oral Hygiene information 
 
X 
 
 
 
 
Tooth ID (ICDAS score / activity status) and cleaning 
 
X 
 
 
 
 
Intra-oral colour photographs – tooth surface only 
 
X 
 
 
 
 
Calcivis System - Images / disclosing solution / images 
 
 
X 
 
 
 
Adverse Events (intra-oral colour photograph if relevant) 
 
X 
X 
X 
X 
 
Image interpretation – Dentist  
 
 
X 
 
 
 
Image review – Dentist and Patient 
 
 
X 
 
 
 
Patient Questionnaire / Visual Analogue Scale 
 
 
X 
 
 
 
User Questionnaire 
 
 
X 
 
 
 
Second Investigator / Dentist Image Review 
 
 
 
 
 
X 

CAL-02-2014, Version 5, 19 October 2016 
 
F-PM-16, v1, March 2013 
 
Page 16 of 48 
3.    INTRODUCTION  
3.1  Background 
Dental caries (tooth decay) is a significant clinical and public health problem. Caries is associated with 
localised demineralization of the tooth surface which may lead to progressive loss of tooth structure 
and associated pain and morbidity (Selwitz et al, 20071). The development of caries lesions involves a 
net mineral loss of dental tissue, (mediated by the acid in dental bacterial plaque on the surface of the 
tooth), in what is initially principally a sub-surface phenomenon. Detecting, assessing, diagnosing and 
treating such hard tissue lesions is a core activity in dentistry. (Pitts NB, 20092; Fejerskov O, et al 20083; 
Paris S, 20134). The main detection and diagnostic aids for caries have long been visual inspection and 
the use of a probe, together with X-ray images. 
While a number of technologies have been developed to aid caries lesion detection, this step 
represents only part of the problem for clinicians in relation to clinical decision-making. Determination 
of the activity status of a lesion is required in order to assess the treatment needs for this lesion. 
Current methods of clinical assessment of lesion activity are problematic and involve the clinician’s 
subjective assessment and/or the monitoring of lesion behaviour over time using a specific detection 
technique such as radiography and/or a combination of factors involved in caries aetiology to produce 
an algorithm weighted in an attempt to discriminate between active and inactive lesions. The 
assessment of the activity status of a specific lesion in a single patient visit remains difficult (Ekstrand K 
et al, 20095; Ekstrand K, Martignon S, 20136) since it currently involves the visual assessment of the 
subtle differences in the physical characteristics of the lesion surface. Not all dental caries lesions 
progress to cavitation. The determination of which early ‘white spot’ lesions will progress can currently 
only be achieved with any significant degree of accuracy by monitoring over time. Such observing of a 
lesion risks its progression beyond the stage where preventive interventions are appropriate to a point 
at which more complex treatments are involved. There are significant differences in the treatment 
requirements for active and inactive caries lesions, with consequent marked differences in costs and 
outcomes for the patient, dentist and third-party payer. There is thus a need to develop a technique to 
aid dentists in identifying the activity status of caries lesions at a single visit in order to optimise the 
use of non-invasive preventive therapies, as compared to operative / surgical interventions, which 
tend to be more expensive and can have long-term negative clinical consequences (Qvist V 20087; 
Longbottom C et al, 20098; Meyer-Lueckel H et al, 20139)  
3.2  Overview of Technology 
The technology underlying the Calcivis System was developed to help address the unmet need in 
relation to the determination of caries lesion activity status. The Calcivis system combines a sensitive 
custom intraoral imaging device and a bioluminescent marker which produces light in the presence of 
free calcium ions as they are released from actively demineralizing areas of a tooth surface. The 
images produced by the system are effectively maps of demineralization activity across that surface. 
This information is potentially valuable in the context of a systematic approach to caries detection and 
assessment such as ICDAS (International Caries Detection and Assessment System) – Appendix 2. This 
study will therefore be set within the ICDAS framework. (Pitts NB and Ekstrand KR, 201310; 
www.icdas.org).  
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 17 of 48 
Figure 1. Overview of ICDAS Caries Management Process 
 
The ICDAS concept is that the use of a standardised system, based on best available evidence for 
detecting early and later stage caries severity, should lead to the acquisition of better quality 
information which could then be used to inform decisions about appropriate diagnosis, prognosis, and 
clinical management of dental caries at both the individual and public health levels. 
The Calcivis System provides information that informs Lesion Activity Assessment (in yellow with Red 
border), in Figure 1 above. An active lesion is a lesion that is actively deteriorating (demineralization is 
outstripping remineralization). Currently there are no marketed products that allow direct assessment 
of active demineralization at a single patient visit.  
The device is intended to be used on visually accessible occlusal and free smooth surfaces and to 
provide the dental professional with additional information to the clinical visual (and other clinical, 
radiographic and additional technology-derived) data in order to help enable the clinician to assess / 
determine the caries activity status of a tooth site / surface. This assessment will aid the clinician in 
determining the management option for each caries lesion. Fundamentally, a clinician has three 
possible options when confronted with a caries lesion – he can: 1) monitor it, 2) apply preventive 
treatments such as sealants and remineralization therapies 3) drill and fill it. The combination of the 
assessment of the extent of the lesion, in terms of its depth towards the dental pulp, and its activity 
status will be critical in determining the clinician’s treatment decision from these 3 options.  
3.3  Risk / Benefits Rationale 
The potential benefits from using the Calcivis System relate to the clinician being able  to make a more 
informed decision about lesion activity status – the more accurate the information relating to lesion 
activity status, the more likely an appropriate treatment decision will be made. The potential risks 
from using the device relate to the device providing a false positive signal with the consequent 
increased potential for the clinician deciding the lesion requires either non-operative preventive 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 18 of 48 
therapy or a restoration / filling, i.e. drilling, (the latter being unlikely since, if there is no cavitation 
present, the current guidelines indicate a restoration is not required).  
Previous laboratory research on recently extracted teeth has demonstrated that there is strong 
correlation between positive light signals generated by the early Calcivis technology and caries lesion 
activity status, as assessed by a clinician, as well as the physical characteristics of the surface of active 
lesions.    
The results of the previous clinical study on the advanced prototype of the Calcivis System confirmed 
the device to be safe in clinical use, and provided an acceptable level of “correlation” between the 
Investigators rating of sound and unsound teeth using ICDAS coding and the Calcivis System. In 
particular the results showed a higher level of correlation for the sound teeth, (83.9%) meaning the 
chances of false positives are low. It may be that some of the teeth considered sound had sub-clinical 
but actively demineralizing lesions.  
The feedback from both user and patient questionnaires, provided useful information on some of the 
design features, which have now been incorporated in to the commercial device which will be easier to 
use. 
3.4  Study Rationale 
Therefore the purpose of this clinical study is to evaluate both the clinical safety and performance of 
the next generation Calcivis System for identifying active demineralisation on the surfaces of teeth on 
a patient population ≥ 6 years old. 
4.    STUDY OBJECTIVES AND ENDPOINTS  
4.1  Primary Objectives 
Performance of the Calcivis System, as measured by the presence or absence of elevated luminescence 
on the surface of the tooth determined from intra-oral image mapping of that surfaces of teeth (with 
or without a visible lesion).  
 
Primary Safety Objective 
 
Safety of the Calcivis System, as measured by the collection of all adverse events  
   
4.2  Secondary Objective  
To assess the usefulness of the Calcivis System images, as a communication tool between patient and 
dentist, as measured by Questionnaires and  / or Patient Visual Analogue Scales. 
5. 
STUDY DEVICE  
5.1  Intended Use 
The Calcivis Caries Activity Imaging System is intended to be used on patients by dental healthcare 
professionals on patients (6 years and older) with, or at risk of developing, caries lesions on coronal 
tooth surfaces. 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 19 of 48 
The Calcivis Caries Activity Imaging System is indicated for use to provide images of active 
demineralization on tooth surfaces, as an aid to the assessment and diagnosis of caries lesions.  
5.2  General Description 
The Calcivis Caries Activity Imaging System comprises: 
Calcivis Imaging Kit - Administration and Imaging device 
Consists of:   
 
Calcivis Intra-oral Imaging Device 
 
Device cradle 
 
Calcivis (Imaging) Software on DVD/CD 
 
Calcivis Instruction Manual 
The software main functions are; to initiate imaging (visible and luminescent), to save and retrieve 
digital images for display, and the overlaying of black and white images with luminescence images to 
map location of luminescence, representing elevated calcium levels, to the tooth surface. 
 
The software requirements are detailed in the Instructions For Use.  
  
Figure 2: Calcivis Intra-oral Imaging Device  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Accessory - Calcivis Disclosing Solution Kit – single-use 
Consists of:   
 
Calcivis Disclosing Solution (Freeze-dried in vials) 
 
Water for reconstitution 
 
Syringe  
 
Needleless adaptors  
 
 
Applicator 
Device Actuator Button 
Intra-oral Camera 
Syringe Cover 
Device Syringe 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 20 of 48 
and / or 
 
Accessory – Calcivis Disclosing Solution (Photprotein ) Kit - multi-use   
Consists of: 
 
Calcivis Photoprotein (Disclosing Solution) - Freeze dried in a vial 
 
Vial of Calcivis Diluent (Water for reconstitution) 
 
Single-use Device Syringes (sterile prior to opening) 
 
Vial Adaptors x 2 
 
Accessory – Calcivis Application Kit 
Consists of: 
 
Single-use Calcivis Applicators x10 
 
5.3  Device Use 
The device can be used for screening purposes but in this study the device will be used as a site specific 
technique intended to be used where a dentist has already detected a potential carious lesion. The 
dentist will have carried out a standard oral examination to detect and assess potential caries lesions. 
Where a potential lesion is detected and the dentist would like more information about that lesion, i.e. 
is there on-going active loss of calcium ions (de-mineralization) from that lesion, use of the Calcivis 
System may be appropriate. In normal operation, the dentist will image a tooth before application of 
the Disclosing Solution using the Calcivis intraoral camera. The Disclosing Solution will then be applied 
to the same tooth and another image will be taken with the Calcivis camera. The image is processed by 
the software then displayed on a PC monitor and can then be printed and / or stored to hard disk or 
incorporated on to dental practice imaging management systems. The system is fully automated so 
that both images are taken within less than 0.5 seconds (including the automated application of the 
disclosing solution). 
Full details for the operation of the Calcivis System is supplied in the Instructions For Use.  
5.4  Device Technology 
The Calcivis System technology involves imaging localised calcium loss from demineralizing tooth 
surfaces, as evidenced by the luminescence, or light emission (low level in visible spectrum), produced 
from the ionic calcium interacting with the Disclosing Solution (containing photoprotein), after it is 
applied to the tooth surface. The light emission results from a chemical reaction between the 
photoprotein and free Calcium, in contrast to fluorescence based technologies which require an 
excitatory light source. 
The Disclosing Solution is placed on to a tooth and where ionic calcium is present light is generated 
which the intraoral camera detects and records. The majority of the light signal is captured in less than 
0.1 second. Software is used to overlay the visible and luminescent images in order to highlight regions 
where calcium ions are present, providing an easy to use interface, thereby providing de-
mineralization maps of the tooth surfaces which are interpreted by the Dentist. Figure 3 below 
summarizes this process. 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 21 of 48 
Figure 3: Summary of visualization of free calcium by Calcivis System 
 
Typical white spot lesions can be seen on the visible images of freshly 
extracted teeth (1A to3A – black and white images). 
 
Luminescent images of the same three teeth (1B to 3B) and false-coloured 
luminescent images (1C to 3C). Both these types of images show the 
observed pattern of luminescence from the tooth surface after the addition 
of disclosing solution 
Merged images of the black and white images with the false-coloured 
luminescent images (1D to 3D) which show the positioning of the 
luminescent pattern on the tooth surface for each of the three teeth. 
5.5  Device Manufacture  
The Calcivis system intra-oral imaging device will not normally come into contact with the skin, teeth 
or mucosa of the patient. It will be covered by a single use, disposable applicator, which may come into 
contact with the skin, teeth and mucosa of the patient, to protect the patient from any possible cross-
contamination from the multi-use camera unit. The imaging unit will be cleaned thoroughly between 
use with hospital grade disinfectant wipes. The camera connects directly with the USB of a PC and 
incorporates a CMOS system, Light Emitting Diode (LED) – visible light and a lens to capture the image. 
Images can be transferred to the PC for display by the software. 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 22 of 48 
The Disclosing Solution comprises a lyophilized, powdered recombinant bioluminescent protein. By 
supplying the disclosing solution lyophilized, it maximizes the shelf life and specificity of the 
bioluminescent capability. The powder will be supplied non-sterile but low bioburden and will be 
reconstituted immediately before use with deionized water (also supplied). A total of 2.5 µg (100µg/ml 
in 25 µl application) of photo-protein is dispensed per application in the disclosing solution. 
5.6  Regulatory Status 
EU 
The Calcivis System is classified in the EU as a Class IIa Medical Device according to the Medical Device 
Directive.  
The Calcivis System comprises three components as follows: 
Device (Intra-oral Camera) - administration and Imaging device 
 
Class IIA Rule 11 for administration of disclosing solution, 
Class I Active Rule 12 for imaging 
Class I Active Rule 12 for Software 
(Therefore the highest class is Class IIA Rule 11) 
 
Disclosing Solution – lyophilised protein and water for reconstitution 
 
Class I Rule 5 invasive (via natural orifice) and transient. Intended to bind with free calcium ions at the 
tooth surface and emitted light (in visible spectrum) captured by the imaging system. 
 
Disposables – applicator, syringe and needle 
 
Class I Rule 5 invasive (via natural orifice). Syringe and needle to be provided sterile until open. 
 
USA 
The Calcivis System falls under ‘diagnosis, prevention, monitoring, treatment or alleviation of disease, 
and does not achieve its action by pharmacological, immunological or metabolic means’. The Calcivis 
technology involves the detection and display of a chemical reaction as part of caries lesion activity 
assessment, which includes imaging localised calcium loss from demineralizing surfaces. This is only 
one of several factors which can be used to diagnose caries. Elevated levels of calcium ions can also be 
a result of a number of different causes (dental erosion, dental fluorosis and enamel 
hypomineralisation). The dentist therefore has to consider all potential causes before making a 
diagnosis. Thus, the Calcivis System has the potential for showing activity of caries and is an aid to the 
dentist, and not diagnostic per se.  
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 23 of 48 
5.7  Device Safety 
Clinical and Pre – Clinical Data  
As the mode of action of the Calcivis Device is detection of free calcium on the tooth surface it is 
relatively simple to check this function using calcium solutions of varying concentration in wells and 
confirm using extracted teeth. Release testing of the disclosing solution includes a functional assay 
employing stopped-flow technology. The stopped flow process uses fixed syringes to rapidly (within a 
few nanoseconds) dispense set volumes of known concentration of the luminescent marker and 1mM 
calcium chloride to a mixing chamber, from which light output is collected and assessed. The intra-oral 
imaging device can be set up in a dark box or “mock mouth” with either wells of calcium solution or 
extracted teeth to confirm detection of calcium and expected demineralization maps on carious teeth. 
A Clinical Evaluation was  performed, taking into account the “mock-mouth” bench-top studies, pre-
clinical studies on extracted teeth and clinical studies of similar comparator devices. In addition, pre-
clinical toxicology studies on the Disclosing Solution (cytotoxicity, oral toxicity, oral irritation and 
sensitisation tests) were also carried out according to ISO10993 and American Dental Association 
guidelines. The Clinical Evaluation Report concluded that sufficient clinical data was available to 
support the safety and performance of the Calcivis System, without the need for a specific clinical 
study.  
The Calcivis System was CE marked in December 2013, following submission of the Technical File. 
In May 2014, the first formal Post-Approval Clinical Study was performed in adults (16 to 25 yrs old) 
using the advanced prototype Calcivis System. The Primary Objectives of the study were to assess the 
Performance and Safety of the Calcivis System, and the Secondary Objective was to assess user 
experience with the Calcivis System (both User and Patient). A total of 42 patients were recruited to 
the study from three UK, General Dental Practices, to obtain a total of 31 evaluable patients. Eligible 
patients were those with interpretable images of both a tooth with no visible lesion identified (ICDAS 
Code 0) and a tooth with a suspected visible lesion identified (ICDAS Code 1, 2 or 3). Images from 11 
patients were not eligible for interpretation due to confounding factors including ambient light ingress, 
gross saliva contamination and poor disclosing solution coverage on the tooth surface. All these issues 
have been addressed in the design phase for the new commercial Calcivis System which is the subject 
of this study. 
All 42 patients were included in the Safety Population – two adverse events were recorded – bleeding 
gums and slight gum abrasion – both were device-related, non-serious and asymptomatic to the 
patients with no action required. One other adverse event was recorded as a device deficiency when 
the device jammed and did not dispense fluid.  
31 patients were included in the Agreement Population – analysis of the level of agreement between 
the ICDAS scores and elevated luminscence, (Y/N) as defined by the Investigators. 
For the primary study objectives, the study results concluded that: -  
1. The Calcivis System was safe in clinical use as determined by the low number and minor nature 
of the adverse events recorded. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 24 of 48 
2. Analysis of the overall level of agreement between elevated luminescence and the presence of 
lesions predicated as active by the Investigators showed agreement in 47 of the 65 teeth 
imaged (72.3 %) which was statistically significant, not due to chance and above the expected 
level of 70%. 
 
       (Of the 31 teeth identified by the Investigators with no visible lesions, 26 showed no elevated  
luminescence using the Calcivis System – corresponding to a negative percentage agreement 
of 83.9%. Of the 34 teeth with visible lesions identified by the Investigators, 21 showed 
elevated luminescence using the Calcivis System – corresponding to a positive percentage 
agreement of 61.8%). 
A recent paper by Alves et al (11) indicates an association between the stage of eruption and activity 
status of caries. As summarized in table below: 
Stage of Eruption 
1 
2 
3 
4 
sound 
526 
108 
814 
694 
inactive non-cavitated 
9 
5 
148 
164 
active non-cavitated 
184 
43 
179 
48 
Total caries non-cavitated 
193 
48 
327 
212 
% act non- cavitated 
95 
90 
55 
23 
 
stage 1, partially erupted occlusal surface;  
stage 2, fully erupted occlusal surface, <1/2 crown exposed; and  
stage 3, fully erupted occlusal surface, >1/2 crown exposed 
stage 4. Full occlusion  
The teeth examined in the clinical study were predominantly stage 3 i.e. fully erupted occlusal surface, 
with greater than half the crown exposed with expected activity in approx. 55% of lesions.  
For the secondary study objective, the study results concluded that: -  
Although one patient recorded ‘marked pain’ on the Patient Questionnaire, the overall feedback was 
positive with 91.4% of patients recording their experience with the Calcivis System as ‘good’ or ‘very 
good’. 88.1% of patients reported that seeing the images of their teeth and having the dentist explain 
their situation was ‘helpful’ or ‘very helpful’. 65% of the dentists recorded their overall user experience 
with the Calcivis® System to be ‘good’. 
5.8  Device Accountability  
All study devices will be accounted for. Master Device Accountability records will be maintained by the 
Sponsor for all device components – intra-oral imaging device kit, disclosing solution kits and 
application kits.  

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 25 of 48 
Each site will be provided with one intra-oral imaging device for use in the study, and a sufficient 
number of disclosing solution kits and application kits, for the target number of patients to be 
recruited. Additional supplies of all three components will be available, should they be required.  
Each site will maintain Device Delivery and Return documentation. All intra-oral imaging devices, and 
unused disclosing solution kits and application kits will be returned to Calcivis Ltd at the end of the 
study period. 
Returned study devices / components will be checked against the Master Device Accountability 
records by the Sponsor. Any discrepancies will be documented and investigated. 
5.9  Device Labelling and Storage  
The Intra-Oral Imaging Device Kit will be supplied as a single unit, non-sterile and will be identified by a 
unique serial number. 
The single-use Disclosing Solution Kits will be supplied non-sterile in boxes, each box containing 10 
vials of the freeze-dried protein, water for reconstitution, individually wrapped, sterile, off- the- shelf 
syringes, and individually wrapped, sterile, off- the- shelf needless adaptors. Each vial will be identified 
by a unique lot number. 
The Calcivis multi-use format will be supplied in a non-sterile in box, containing 1 x 5ml vial of freeze-
dried photoprotein and individualy wrapped adaptor,  1 x 5ml vial of diluent and individually wrapped 
adaptor, 10 x individulally wrapped sterile, off-the-shelf single-use syringes and 10 x individually 
wrapped single-use applicators. 
The Application Kits will be supplied in boxes of ten, each kit containing an individually wrapped 
applicator. The individual Applicators will be identified by a unique lot number. 
The Intra-Oral Imaging Device and the Application Kits will be stored at room temperature.  The 
Disclosing Solution Kits, containing the lyophilised protein and de-ionised water for reconstitution, will 
be stored in a secure area not above 250 C  For the Calcivis multi-use format, once reconstituted the 
vial of Photoprotein will be stored at 2 to 80 C, up to a maximum of 4 weeks. 
5.10 Study / Device Training 
Full training on all aspects of the study will be provided by the Sponsor as follows: 
 
Identification of teeth according to ICDAS caries scoring system and caries lesion activity 
assessment 
 
Tooth cleaning protocol 
 
Imaging with standard Intra-oral camera 
 
Full preparation and use of the Calcivis Sytem according to the manufacturer’s Instructions For 
Use, to include –  
o preparation of the disclosing solution and syringe loading and device activation 
o laptop set-up and image interpretation and storage 
 
Study procedures and data recording 
 
Adverse event collection, recording and reporting  
 
Informed Consent Process 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 26 of 48 
All training will be fully documented for Investigators / Dentists and Dental Nurses. In addition 
technical support will be available on the study visit days, if required. 
6. 
RISKS AND BENEFITS  
6.1 
Risk Analysis  
Extensive risk analyses have highlighted the following potential areas of safety concern (high impact 
risks):  
1. Integrity of the single use Applicators 
2. Deterioration of the Disclosing Solution throughout its shelf life 
3. Toxicity of the Disclosing Solution  
4. Contamination of vial from re-use (multi-use format only) 
These are all considered very low likelihood and have all been adequately addressed by:    
1. Integrity testing of applicators in addition to breach requiring a triple fault condition in that 
previous patient would need to be carrying disease, main device would have to not be cleaned 
between uses and any contaminant on device would need to penetrate to subsequent 
patients. 
2. Extensive stability studies on the Disclosing Solution 
3. ISO 10993 compliant pre-clinical toxicological study and recent clinical study on Disclosing 
Solution shows no sign of toxicity 
4. The multi-use reconstituted solution contains an anti-microbial preservative. In addition , 
wiping top of Photoprotein vial with alcohol wipes between uses  and drawing up of 
phototprotein with single-use syringes. 
6.2 
Potential Risks 
The Calcivis system has been designed and tested in compliance with ISO 13485 and will only be used 
by fully trained dental professionals. Any risks associated with the use of the Calcivis System have been 
analysed as above, and provision made to either reduce or eliminate these risks. Potential risks to the 
patient include:  
- cross-contamination between patients, if not used according to manufacturer’s instructions 
- hypersensitivity of patient  to protein or other components in Disclosing Solution 
- over  / under application of Disclosing Solution leading to necessity for repeat procedure 
- discomfort and / or soft tissue trauma due to presence of intra-oral imaging device in mouth 
6.3  Potential Benefits  
This study is intended to show the safety and performance of the Calcivis System for evaluating active 
demineralization on tooth surfaces in a clinical setting. When used to characterise de-mineralization in 
teeth, it is anticipated that the Calcivis System will benefit both the user (dentist) and patient. 
Potential benefits to the patient are: 
- treatment of early lesions with re-mineralization therapies or sealants to prevent progression 
to cavitation 
- enhanced clinical decision making  
- reducing the need for X-rays 
- improved communication between dentist and patients and improved potential for prevention 
of caries  

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 27 of 48 
It is therefore anticipated that the overall benefits will outweigh any risks associated with the use of 
the Calcivis System. 
7. 
STUDY DESIGN  
7.1  Overview 
This is a prospective, multi-site, non-randomised, post-approval clinical study to assess the use of the 
Calcivis System for assessing  active demineralization on tooth surfaces of teeth in patients 6 years and 
older. This post-approval clinical study will be conducted under the controlled conditions of this clinical 
study plan, on eligible patients, in a general dental practice setting. 
From the Expert Paper on Caries Activity Assessment, Longbottom C, 2015 (12) it concludes that the 
prevalence of active lesions found on the occlusal surfaces of erupting teeth is affected by the erupting 
stage status of the teeth –  with the prevalence of active lesions greater in the earlier eruption stages. 
As a result of these and similar findings the choice of teeth for identifying visible lesions which are 
potentially ‘active’ has been limited to erupting and erupted molars and premolars (in which case 
occlusal surface must be such that, apart from minimal presence of an operculum over the distal 
marginal ridge, it is clear of the gingivae (gum)).  
7.2  Patient Selection and Confidentiality 
To ensure poolability of the data from each Investigator, up to 36 patients may be recruited to the 
study (to obtain a minimum of 17 evaluable images of each tooth population ) by five Investigators 
from four general dental practices. Patients will be identified and selected according to the Inclusion / 
Exclusion criteria listed below. All patients and  / or parent or guardian  must provide written informed 
consent and be willing to adhere to the study schedule, before being entered in to the study.  
Patients will be encouraged to complete both Study Visits, however, patients are free to withdraw 
Consent at any time, irrespective of their initial consent.  
Patients may also be withdrawn from the study by the Investigator on the grounds of safety. Any 
patients who withdraw or are withdrawn from the study will be replaced.  
All patients recruited to the study will be identified by a unique study number, comprising the site 
number and a patient number, to allow any data collected on them to be anonymized. The investigator 
will maintain a confidential patient identification list of all patients enrolled in the study (by name and 
patient number). The list will be maintained at the site and will not be retrieved by the Sponsor. There 
is no randomization required in this clinical study.  
7.3  Study Duration 
The overall study period is expected to take  10 months - 3 months for Ethics Committee and NHS,  
R & D approval, 2 to 3 months for recruitment and study procedures, and 4 months for final follow up, 
data collection and analysis.  
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 28 of 48 
7.4  Inclusion and Exclusion criteria 
Inclusion criteria 
1. 
Patient must be ≥ 6 years old 
2. 
Patient must have one unrestored, accessible, free smooth buccal surface on a canine or 
incisor, away from the gingival surface  identified with no visible lesion (coded ICDAS 0) – ref. 
table below 
and / or 
3. 
Patient must have one unrestored, accessible, erupting or erupted molar or pre-molar with a 
visible lesion identified (coded ICDAS 2 or 3) in a plaque stagnation area – ref. table below  
4. 
Patient and / or parent or guardian must be willing and able to give written informed consent 
5. 
Patient and  / or parent or guardian must be willing and able to adhere to study schedule 
 
Tooth status population 
Exemplar tooth type and location 
Additional criteria 
Sound tooth 
Canine or incisor 
Away from gingival margin 
 
 
Enamel should be shiny and feels hard 
and smooth when the tip of a probe is 
moved gently across the surface 
Active Lesion 
Erupting or erupted Molars 
Fissure pits of occlusal surface 
 
 
 
Surface of enamel should be 
whitish/yellowish opaque with loss 
of luster; feels rough when the tip of a 
probe is moved gently across the surface. 
Lesion should be in a plaque stagnation 
area 
i.e. pits and fissures; approximally, near 
the gingival surface below the contact 
point. 
Inactive Lesion 
Molars and pre-molars 
Smooth surface away from 
gingival margin 
 
 
 
 
Surface of enamel should be whitish, 
brownish or black. Enamel should be 
shiny and feels hard and smooth when 
the tip of a probe is moved gently across 
the surface. For smooth surfaces, the 
caries lesion will be typically located at 
some distance from the gingival margin. 
 
Exclusion criteria 
1. 
Any Patient with recent tooth bleaching (within previous two weeks of imaging with the 
Calcivis System) 
2. 
Any Patient having on-going re-mineralization treatment including, but not limited to high 
concentration prescription fluoride toothpaste  
3. 
Any patient with a fixed orthodontic appliance 
4. 
Any patient currently taking part in a clinical research study, or has taken part in a clinical 
research study in the previous three months 
5. 
Pregnant and / or nursing mothers 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 29 of 48 
8. 
STUDY PROCEDURES  
8.1  Screening  Procedures 
Patients attending routine dental appointments who are identified by the Investigator as meeting all 
the inclusion / exclusion criteria, will be approached to discuss their possible participation in the study. 
Initial approach will be by the Dental Nurse to ask the patient and / or parent or guardian, if they 
would be interested in participating in the study. The study will be explained to them and each patient 
and / or parent or guardian will be given a copy / copies of the relevant Patient Information Sheet and 
Consent Forms to read and discuss with others if required. The patient and / or parent or guardian will 
be asked to confirm their interest in participating in the study by contacting the Dental Practice (no 
less than 24 hours after being given the Patient Information and Consent Form). They will be given the 
opportunity to discuss their participation in the study with the Investigator and ask any questions. If 
the patient and / or parent or guardian is still willing for the patient to participate in the study, they 
will be asked to return to the dental practice for Study Visit 1, when written Informed Consent will be 
taken by the Investigator. Patient availability for Study Visit 2 (7 to 14 days post-imaging) will also be 
checked.  
The Site will document all patients and / or parent or guardian provided with the Patient Information 
Sheet and the outcome, (whether or not recruited to the study) on a Patient Screening  / Recruitment 
Log. 
8.2  Study Visit 1 
At this visit, written Informed Consent (ref. 15.3) will be taken by the Investigator and the following 
information collected and procedures carried out. 
Pre-Imaging Information collected 
Demographics – DoB,  ethnicity, relevant medical history and medications 
Oral hygiene information - brushing regime, toothpaste and any other dental products used 
Preparation of the Calcivis System 
The Calcivis System must be prepared according to the manufacturer’s Instructions For Use. Single-use  
Disclosing Solution (Photoprotein) should not be reconstitued more than 2 hours before the first tooth 
is imaged. Once reconstituted, the multi-use vial of Disclosing Solution (Photoprotein) should be stored 
at 2 to 80 C, up to a maximum of 4 weeks. 
Preparation Procedures for Teeth 
Relevant teeth will be identified and recorded for assessment using the Calcivis System as per Inclusion 
/ Exclusion criteria. 
All teeth surfaces to be imaged will be cleaned by the Dentist, by brushing with water or dental paste 
and rinsing with water and an air-water spray from a conventional dental 3-in-1 device, according to 
the Tooth Cleaning Protocol (Appendix 2). Patients will be asked to rinse out thoroughly with tap 
water. 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 30 of 48 
Immediately following thorough air-drying of each tooth surface to be imaged, the Investigator will 
take a colour photograph with a standard intra-oral camera and record the ICDAS score  /activity 
status.  
Preparation Procedures for imaging with the Calcivis device 
Care must be taken to ensure the surface of the tooth and surrounding area are free from saliva before 
imaging by the use of appropriate moisture control aids.  
Each tooth will be air-dried for 5 to 10 seconds immediately before application of the disclosing 
solution and Calcivis System imaging.  
Imaging with the Calcivis System 
For teeth from each category (no lesions, and active lesions) a maximum of one tooth per patient can 
be imaged. 
If a patient has more than one tooth of a particular category (sound tooth [no visible lesion], or tooth 
with active lesion) the investigator will use best clinical judgement to choose a tooth that most clearly 
fits the criteria of that particular population tooth type, for example if there is the choice of 2 teeth 
displaying lesions considered active, each identical except one of the teeth has a lesion in a plaque 
stagnation area (e.g. pits and fissures) and one more distant from plaque stagnation area, the tooth 
with the lesion in a plaque stagnation area will be chosen. 
If the first image of a selected tooth is not clear for interpretation, it is acceptable to take a second 
image of that tooth, however no more than two images of any one tooth can be taken.  
Recruitment will be stopped for each Investigator when a minimumof 17 evaluable images (as 
determined by the Investigators) from each tooth population have been obtained. 
After all imaging has been completed, patients will be asked to rinse out with tap water. 
Any adverse events observed or volunteered by the patient will be recorded. If appropriate a colour 
photograph will be taken of the adverse event with a standard intra-oral camera. 
The images generated with the Calcivis System will be stored digitally on the laptop provided. The 
software will allow overlay of the two sets of images (before and after application of the disclosing 
solution) and interpretation of the resulting demineralization map of each imaged tooth will be carried 
out by the Investigator at the end of imaging.  
At the end of the imaging procedures, the Investigator will share the images of the teeth with the 
patient. 
The Calcivis System will be dismantled and cleaned according to the Instructions For Use. All 
consumables will be disposed according to the Instructions For Use. 
Representatives of the Sponsor, Calcivis Ltd, will be available throughout Visit 1 to provide technical 
support for the use of the Calcivis System, as and when required. Consent will be sought from the 
patient and / or parent or guardian. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 31 of 48 
Post-Imaging Questionnaires / Visual Analogue Scales 
At the end of the imaging procedures, patients will be asked to remain at the dental practice to 
complete a Patient Questionnaire / Visual Analogue Scale. Visit 1 is then complete.  
In addition, at the end of each imaging study visit, the Investigator and Dental Nurse will each 
complete relevant sections of a User-Questionnaire  
8.3  Study Visit 2 – 7 to 14 days post-imaging  
At this visit, a final oral examination will be performed by the Investigator and any adverse events 
observed or volunteered by the patient will be recorded. If appropriate a colour photograph will be 
taken of the adverse event with a standard intra-oral camera. 
8.4  Future Dental Care 
Depending on the results, the Investigator may provide caries preventive advice to the patient and / or 
parent or guardian. The Investigator will not suggest further dental treatment based on the result of 
the images alone. 
8.5  Independent Investigator Image Review 
After all the images have been taken and verified as acceptable by the originating Investigator, and the 
CRFs collected, an indpendent review of the Calcivis images will be undertaken to assess the presence 
or absence of elevated luminescence on the surface to the teeth imaged with the Calcivis System.  
This will be carried out by one of the other Investigators as follows: 
Site  
Original Investigator 
Independent 
Investigator 
1 
Neil Shanks 
Fraser Morrison 
1 
Elaine Downie 
Steve Martin 
3 
Fraser Morrison 
Agnieszka Nohawica 
3 
Steve Martin 
Niel Shanks 
5 
Agnieszka Nohawica 
Elaine Downie 
 
The independent reviewer will be provided with evidence of both the original investigator’s decision 
on tooth classification (i.e. no lesion, or active lesion, based on ICDAS coding / activity status) along 
with documented evidence of the clinician’s intended location for assessment (this is all documented 
by the original Investigator prior to imaging using the Calcivis System). In addition, photographic 
evidence of the actual location of the luminescence will be provided. The determination by the 
independent reviewer will be made off-site, using the visible and Calcivis images along with copies of 
the original Investigator’s documentation. The data from the independent reviewer will be used for 
the Primary analysis. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 32 of 48 
9. 
ADVERSE EVENTS  
9.1  Definitions 
Adverse Event (AE) – any untoward medical occurrence, unintended disease or injury, or untoward 
clinical signs (including abnormal laboratory findings) in subjects, users or other persons, whether or 
not related to the investigational medical device. 
This definition includes events related to the investigational device and comparator and events related 
to the procedures involved.  
For users or other persons, this definition is restricted to events related to the investigational medical 
devices. 
A Serious Adverse Event (SAE) – is an adverse event that – 
o 
Led to death 
o 
Led to a serious deterioration in the health of a subject that –  
o 
resulted in a life-threatening illness or injury 
o 
resulted in a permanent impairment of a body structure or a body function 
o 
required in-patient hospitalization or prolongation of existing hospitalization 
o 
resulted in medical or surgical intervention to prevent a permanent impairment of a 
body structure or a body function 
o 
Led to foetal distress, foetal death or a congenital abnormality or birth defect 
 
Planned hospitalisation for a pre-existing condition, or a procedure required by the CIP, without 
serious deterioration in health, is not considered a serious adverse event 
Adverse Device Effect (ADE) – an adverse event related to the use of an investigational medical device.  
This definition includes any events resulting from insufficient or inadequate instructions for use, 
deployment, implantation, installation, or operation, or any malfunction of the investigational device.  
This definition also includes any event resulting from user error or form intentional misuse of the 
investigational device. 
Serious Adverse Device Effect (SADE) – adverse device effect that has resulted in any of the 
consequences characteristic of a serious adverse event.  
Anticipated Serious Adverse Device Effect (ASADE) - an effect which by its nature, incidence, severity 
or outcome has been identified in the risk analysis report 
Unanticipated Serious Adverse Device Effect (USADE) - serious adverse device effect which by its 
nature, incidence, severity or outcome has not been identified in the current version of the risk report. 
Device Deficiency – inadequacy of a medical device with respect to its identity, quality, durability, 
reliability, safety or performance. 
Device deficiencies include malfunctions, use errors and inadequate labelling. 
Device deficiencies which result in SADEs or USADEs, will be managed as detailed below.  

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 33 of 48 
Device deficiencies that did not lead to an adverse event, but could have led to a medical occurrence if 
suitable action had not been taken, or intervention had not been made or if circumstances had been 
less fortunate will also be managed as detailed below. 
Use error – act or omission of an act that results in a different medical device response than intended 
by the manufacturer or expected by the user. 
Use error includes slips, lapses and mistakes. 
An unexpected physiological response of the subject does not itself constitute a use error. 
Severity Definitions – the following definitions will be used to determine the severity rating for all SAEs 
o 
Mild – awareness of signs or symptoms, that does not interfere with the subject’s usual 
activity, or is transient which resolves without treatment and with no sequelae 
o 
Moderate – a sign or symptom which interferes with the subject’s usual activity 
o 
Severe – incapacity with inability to do work or usual activities 
9.2  Collection and Reporting of Adverse Events  
It is the responsibility of the Investigator at the site to ensure that all adverse events (AEs, SAEs, ADEs, 
SADEs (ASADEs and USADEs) and device deficiencies) occurring during the course of the study are 
recorded on the Adverse Event Form. Details recorded should include the following information: 
 
A description of the event 
 
The dates of the onset and resolution 
 
Any action taken 
 
The outcome 
 
The relationship to the device 
 
Whether or not the adverse event is serious 
 
Whether the adverse events arises from insufficiencies in the IFU 
 
Whether the adverse event arises from user error 
Any adverse events that occur during the course of the study should be treated by established 
standards of care that will protect the life and health of the study patients. 
Adverse events can be observed directly by the site Investigator or staff, or can be spontaneously 
reported by the patient. In addition each patient should be questioned about adverse events at each 
study visit. In all cases it is the responsibility of the site Investigator to collect the information and 
record as outlined above. All adverse events should be followed up for the duration of the study. 
In the case of SAEs, SADEs (ASADEs and USADEs) – including those resulting from device deficiencies), 
these must be reported to the study Sponsor and to the relevant Ethics Committee according to the 
term of approval and in addition, any local adverse event reporting guidelines should be followed. 
Anticipated Adverse Events are as follows: 
 
Infection due to cross-contamination from other patient 
 
Irritation / erythema due to reaction to Disclosing Solution 
 
Hypersensitivity to the Disclosing Solution 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 34 of 48 
 
Pain or discomfort due to presence of intra-oral imaging device in mouth 
 
Damage/ trauma to soft tissue due to presence of intra-oral imaging device in mouth 
 
Choking hazard from patient biting down on Applicator 
Serious Adverse Events, Serious Adverse Device Effects and Unanticipated Adverse Device Effects must 
be reported to the Sponsor, within 24 hours of becoming aware of the event. In addition a written 
report is to be provided by the Investigator within 5 working days.  
SAEs, SADEs and UDAEs should be sent by email within the specified timelines to:  
mwillins@calcivis.com and bvernon@calcivis.com 
On receipt of any SAE, SADEs and UADEs, Calcivis Ltd will initiate a Safety Panel review within two 
working days of becoming aware of the adverse event, with Calcivis Management and Medical / Dental 
advisors, to determine if there is any safety requirement to stop the clinical study. Any such decision 
will be communicated to the Investigators as soon as reasonably possible. 
10. 
STATISTICAL ANALYSIS  
10.1  Sample size 
The study will assess the agreement between the Calcivis System and dentist rating of suitable teeth in 
two teeth populations: ‘no visible lesions’, and ‘active lesions’. Based on previous study data and 
expert opinion, ‘No visible lesions’ are expected to correspond to ‘no luminescence’ according to the 
Calcivis system in at least 70% of cases. Similarly, ‘active lesions’ are also expected to correspond to 
‘luminescence’ in at least 70% of cases.  
Subjects will provide no more than one tooth of each tooth population. The study sample size is 
calculated in terms of the number of teeth of each tooth population required. The number of subjects 
required is then at most the total number of teeth required. 
For the purpose of sample size calculations, the percentage agreement for each of the two tooth 
populations are jointly considered as measures of agreement. That is, the study will be deemed a 
success if the percentage agreement in both of the tooth status populations is statistically significant at 
the 2.5% level when compared to chance agreement (50%). 
Expressed in terms of hypothesis tests, the null and alternative hypotheses are: 
H0: pa,i=0.5 vs. H1: pa,i>0.5 for each tooth status population i 
where pa,i is the percentage agreement in tooth status population i. 
To achieve at least 90% power overall, a power of 94.9% has been used for each tooth status 
population individually. The planned method of analysis is an exact binomial test and this has been 
used to derive a required sample size of 81 for each of the tooth status populations. This is the first 
sample size after which all subsequent sample sizes provide at least 94.9% power. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 35 of 48 
10.2  Statistical Analysis 
General Considerations 
The planned statistical analysis will be fully described in a Statistical Analysis Plan, which will be 
finalised prior to the locking of the study database. The main details of the planned analysis are 
described below. 
The statistical analysis will be performed using SAS version 9.2 or higher. 
All statistical tests will be conducted one-sided with a 2.5% level of significance and no adjustment will 
be made for multiple testing. 
Analysis Populations 
All patients on whom the Calcivis System is used will be included in the Safety Population. 
The Agreement Population will include all teeth on which there is a dentist ICDAS score.  
Analysis  
The percentage agreement of the original dentist ICDAS score and the independent reviewer Calcivis 
finding (‘no luminescence’ or ‘luminescence’) will be presented along with an exact one-sided 97.5% 
confidence interval and p-value comparing the percentage agreement to 0.5 for the following: 
 
Teeth rated with ‘no visible lesion’ that are assessed as ‘no luminescence’ by the Calcivis 
System; 
 
Teeth rated with an ‘active lesion’ that are assessed as ‘luminescence’ by the Calcivis System. 
 
The analysis of agreement will be performed on the Agreement Population.  
 
The agreement between the original dentist ICDAS score and Calcivis finding will be analysed in the 
same manner. 
User and patient questionnaire data and adverse events will be summarised descriptively for the 
Safety Population. 
Missing Data 
Missing data arising from teeth where the Calcivis System assessment is uninterpretable for reasons 
that are thought unrelated to the assessment outcome, will not be imputed. The reasons will be pre-
defined in the Statistical Analysis Plan. Otherwise missing data will be considered as a disagreement in 
the calculation of agreement. Secondary analyses based on imputing all missing data as a 
disagreement will be conducted, if appropriate. 
Otherwise missing data will not be imputed. 
Interim Analysis 
No interim analysis is planned for this study. 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 36 of 48 
11. 
DATA MANAGEMENT  
All data collected on the Case Report Forms will be 100% verified against source data (Patient’s Dental 
/ Medical Records and Source Document Worksheets) by the monitoring staff. The data from the CRFs 
will be entered on to a validated Database. Quality control of the data entry process will be performed 
and any resulting discrepancies adjudicated against the CRFs. The data will then be subjected to 
validation checks and any resulting Data Queries will be resolved at site with the assistance of the 
monitoring staff. Once all Data Queries are resolved, critical data will be 100% verified (including 
adverse events), comparing the Database against the CRF. 
The database will then be locked and the study data prepared for statistical analysis.  
Any data existing for patients who withdraw voluntarily or are withdrawn from the study, will be used 
in the study analysis, unless the patient states this is contrary to their wishes. 
Details of the data to be presented will be outlined in the Statistical Analysis Plan. 
12. 
STUDY DATA REPORTING AND STUDY REPORT  
A final Clinical Study Report of the results will be complied by Calcivis Ltd which will be approved and 
signed off by each participating Investigator. A copy will be made available to each Investigator. In 
addition, a lay summary report of the clinical study results will be produced and made available for any 
patients who request a copy. 
Copies of the final Clinical Study Report will be provided to the Research Ethics Committee, NHS R & D 
and any other local approvers. 
13. 
PUBLICATION OF RESULTS  
Calcivis Ltd commits to communicating or otherwise making available for public disclosure the results 
of the study regardless of the outcome. Public disclosure includes publication of a paper in a scientific 
journal, abstract submission with a poster or oral presentation at a scientific meeting, or by other 
means. 
At the end of the study, one or more manuscripts for publication will be prepared in collaboration 
between the all Investigator(s) and Calcivis Ltd on the collective study results. Calcivis Ltd will not 
suppress or veto publications, however Calcivis Ltd reserves the right to postpone publication and / or 
communication for 180 days to protect intellectual property. 
Any subsequent publications, (journal submissions, posters, white papers, marketing literature etc.) 
will be covered in a separate Publication Strategy document provided by Calcivis Ltd. 
Calcivis Ltd will register this clinical study on www.clinicaltrials.gov website and report the study 
results accordingly. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 37 of 48 
14. 
REGULATORY, ADMINISTRATIVE AND CONTRACTUAL INFORMATION 
14.1  Sponsor’s Responsibilities  
 
The Sponsor, (Calcivis Ltd) is responsible for providing Investigators with the information and training 
they need to conduct the clinical study properly and in accordance with the Clinical Study Plan. The 
Sponsor must ensure proper monitoring of the Clinical Study, that Research Ethics Committee 
approval, NHS, R & D approval and any other required local approvals are obtained and remain 
current, and that the Research Ethics Committee, NHS, R & D and other local approvers are informed 
of significant new information about the clinical study as required.  
This information should include the following:  
 
A current signed copy of the Clinical Study Plan and any amendments 
 
A signed copy of the signed Clinical Investigation Agreement or equivalent Contract - for 
each participating Investigator / Site 
 
All information pertaining to Research Ethics Committee review and approval of this clinical 
study including a copy of the REC Letter of Favourable Opinion and a blank copy of the 
approved Patient Information / Consent Form for all sites involved. 
 
All information pertaining to NHS, R & D or other local approvals / notifications of this 
clinical study including a copy of the approval letter for each site. 
 
Copies of current signed and dated Curriculum Vitae’s of the Investigator and all relevant 
site personnel  
14.2  Amendments 
Any change or addition to this Clinical Study Plan requires a written amendment which must be 
approved by the Sponsor before the change or addition can be considered effective. Where Research 
Ethics Committee approval is required, the Principal Investigator must submit the appropriate 
documentation to the main Research Ethics Committee, and obtain written approval for the 
amendment before it can be implemented at the investigative site(s). A copy of the written approval 
must be provided to the Sponsor. All Investigators must submit relevant documentation to each site’s 
NHS, R & D or other relevant local approver and obtain approval before the Amendment can be 
implemented. Copies of the written approvals must be submitted to the Sponsor. Amendments will be 
circulated promptly to all investigators by the Sponsor. 
 
14.3  Deviations 
A Deviation is a failure to comply with the requirements specified within this Clinical Study Plan 
without adequate justification. Examples of deviations may include enrolment of a study patient who 
does not meet all of the inclusion / exclusion criteria specified in the Clinical Study Plan, or missed 
study visits without adequate documentation.  
All deviations must be documented on the appropriate forms and reported to the Sponsor. All 
deviations will be reviewed and assessed for their impact on patient safety by Calcivis Ltd. 
The investigators shall conduct this Clinical Study in accordance with this Clinical Study Plan and any 
conditions of approval / notification imposed by the Research Ethics Committee, NHS, R & D and / or 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 38 of 48 
other local approvers. Failure to comply with and / or inability to meet these regulations may 
jeopardise further participation of the Investigator or Investigative Site in this and future clinical 
studies.  
14.4  Monitoring Procedures and Source Documents 
A clinical monitor will be appointed by the Sponsor for each investigative site. The monitor is 
responsible for assessing the Investigator’s compliance with the Clinical Study Plan and for performing 
Source Document Verification. The monitor is also responsible for reporting to the Sponsor on the 
progress of the Clinical Study.  
Source documents include all information, original records of clinical findings, observations, or other 
activities in a clinical study necessary for the reconstruction and evaluation of the study e.g. patient’s 
dental / medical records, dental charts, photographs, patient diaries or questionnaires, device 
accountability records, recorded data from automated instruments, copies or transcriptions certified 
after verification as being accurate and complete, and any certification from medico-technical 
departments involved in the clinical study. 
At the Site Initiation Visit the monitor will review the Clinical Study Plan, Case Report Forms and all 
associated study documentation and procedures with the Investigator and study personnel. During the 
course of the study, the monitor will maintain regular contact with the investigative site and conduct 
on-site monitoring visits and source data verification on a regular basis to ensure compliance with this 
Clinical Study Plan. The number and frequency of the visits for each site, will be determined by the rate 
of patient recruitment. During monitoring visits the monitor will require access to the patient’s dental 
/ medical records in order to carry out source document verification to ensure all data recorded in the 
study records is accurate and complete and the data can be submitted to the Sponsor in a timely 
manner, and to verify that the investigative site facilities continue to be adequate. Throughout the 
study the monitor must check that all adverse events have been collected, recorded and reported as 
required and discuss the implication of all Serious Adverse Events with the site Investigator. 
The Investigator must set aside a reasonable amount of his / her time for these visits and the time of 
any relevant site personnel. 
14.5  Data Recording  
All patients recruited to the study will be identified by a unique study number, comprising the site 
number and patient number, in order data collected on them will be anonymized. The investigator will 
maintain a confidential patient identification list of all patients enrolled in the study (by name and 
patient number). The list will be maintained at the site and will not be retrieved by the Sponsor. 
The sites will adhere to all appropriate national and local regulations to protect health information and 
maintain patient confidentiality.  
All evaluations and procedures indicated in this Post-Approval Clinical Study Plan must be performed. 
All data generated during the course of this Clinical Study will be recorded on standardised 3-part NCR, 
paper Case Report Forms. CRFs should be completed as soon after the patient visit as possible and only 
the Principle Investigator may sign and date the designated pages of the CRF for their patients. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 39 of 48 
14.6  Maintenance, Retention and Archiving of Study Records 
Investigators are to maintain all source documents required by regulation, including diagnostic test 
reports, laboratory results, completed case report forms, supporting medical records and informed 
consents. The source documents will be referenced during regular monitoring visits to verify the 
information documented on the case report forms.  
The Investigator will retain records for a period of ten years following the date a marketing application 
is approved for the study device for the indication for which it is being investigated; or, if no 
application is to be filed or if the application is not approved for this indication, until ten years after the 
investigation is discontinued. 
Arrangements for archiving of all study documentation will be discussed between the Sponsor and the 
site. 
14.7  Investigator and Site Personnel Training 
All key site personnel (Investigators / Dentist and Dental Nurses) must undergo full training on the use 
of the Calcivis System, Image Interpretation, ICDAS scoring system and Study Procedures as applicable. 
A record of all training will be maintained.  
In addition, Investigators / Dentist and Dental Nurses must undergo GCP training in advance of the Site 
Initiation Visit unless they have done so already. Such training will be documented. 
14.8  Study Termination 
The study will be terminated upon completion of follow-up of the last patient recruited. Any decision 
to either terminate the study early or to increase the patient numbers or follow-up periods will be by 
mutual agreement between Sponsor, the Investigators and approval by the Research Ethics 
Committee. Notification will be made of any such decisions to NHS, R & D and other local approvers for 
each site. 
14.9  Financing and Insurance 
Financial arrangements will be defined in a Clinical Investigation Agreement or equivalent Contract  
between Calcivis Ltd and each Investigative site. 
Patients and / or parents or guardians will be paid a total Patient Inconvenience Payment (PIP) of £50, 
to compensate for the time involved in their participation in the study on completion of both study 
Visits 1 and 2. For patients who have parental / guardian Consent, a payment of £25 in the form of a 
store voucher or gift card will be made to the patient plus a payment of £25 to the parent or guardian, 
on completion of both study visits. For all other patients, a payment of £50 will be made on 
completion of both study Visits 1 and 2. No other payments for expenses will be paid. 
Calcivis Ltd as the Sponsor of this Clinical Study will compensate any patient for any injury caused by 
taking part in this study according to the Association of British HealthCare Industries (ABHI) guidelines. 
Broadly speaking this means the Sponsor will compensate the patient, without the patient having to 
prove they are at fault, for any injury as a result of the study device or study procedures. Additional 
healthcare will be provided for any patients who suffer from an adverse event as a result of 
participation in this study. The limit for insurance will be £2.5 million. 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 40 of 48 
14.10  Investigator Responsibilities 
The Investigator is responsible for ensuring that this clinical study is conducted according to the Clinical 
Study Plan, the Clinical Investigation Agreement or equivalent Contract, all conditions of appropriate 
Research Ethics Committee approval, NHS, R & D approval and / or other local approval and any 
applicable national regulations.  
 
Written confirmation of Research Ethics Committee approval, and any relevant local approvals (e.g. 
NHS, R & D) must be provided to Calcivis Ltd prior to the enrolment of any subject in the clinical study.  
The Investigator is responsible for ensuring that written Informed Consent is obtained from all patients 
prior to any procedures, tests or treatments that are outside the standard course of treatment that 
would be followed if this patient were not being considered for enrolment in this clinical study. The 
Investigator is responsible for informing patients that Calcivis Ltd, and its authorized designees (the 
study monitor, dental advisor) may have access to their dental / medical records for the purpose of the 
study. Patients must be informed that they are free to refuse to participate in this clinical study 
without any impact on their medical treatment and that if they choose to participate, they may 
withdraw at any time without prejudice to future care. The Research Ethics Committee approved 
Informed Consent must be signed and dated prior to study participation.  
While awaiting for approvals, the Investigator may discuss with a patient their interest in participating 
in the clinical study, but shall not request the written informed consent nor allow any patient to 
participate in the clinical study before all relevant approvals are received. 
Upon completion of the clinical study or the Investigator’s participation in the clinical study, or at the 
Sponsor’s request, the Investigator must return any remaining devices to Calcivis Ltd.  
It is the responsibility of the Investigator to maintain complete, accurate and current study records. 
Each Investigator will be provided with an Investigator Site File, and paper Case Report Forms and 
other associated study specific documentation by the Sponsor. Such records will be maintained during 
the course of the clinical study and for ten years following the date on which the study is terminated or 
completed. Investigator records shall include, but not be limited to the following: 
 
A current copy of the Clinical Study Plan and any amendments 
 
A copy of the signed Clinical Investigation Agreement or equivalent Contract 
 
All information pertaining to Research Ethics Committee Review and approval of this clinical 
study including a copy of the Research Ethics Committee Letter of Favourable Opinion and a 
blank copy of the approved Patient Information Sheet and Consent Form on dental practice 
headed paper. 
 
All information pertaining to NHS, R & D or other local approvals / notifications of this clinical 
study including a copy of the approval letter for each site 
 
Copies of current, signed and dated Curriculum Vitae of the Investigator and all relevant site 
personnel 
 
Signed Informed Consent Forms and copies of all completed Case Report Forms and 
supporting documents (source document worksheets, dental / medical records etc) 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 41 of 48 
 
Records of all reports and information pertaining to all serious adverse events 
 
Accountability records of receipt, use and return of all study devices and other study materials 
where relevant 
15. 
ETHICAL CONSIDERATIONS 
15.1  Standards and Guidelines 
This Clinical Study will be performed in accordance with the following standards and guidelines: 
 
Declaration of Helsinki on Biomedical Research involving Human Subjects (64th World Medical 
Association General Assembly, Fortaleza, Brazil, October 2013)   
 
European Standard of BS EN ISO 14155:2011 (E) – clinical Investigation of medical devices for 
human subjects – Good clinical practice 
 
International Conference on Harmonisation Good Clinical Practice guidelines (ICH GCP), where 
applicable 
15.2  Research Ethics and other Approvals 
Before the study can begin the Investigator must have written evidence of Favourable Opinion for the 
Clinical Study Plan and associated relevant documentation from the appropriate Research Ethics 
Committee.  
Once approval has been granted, the Investigator is responsible for ensuring that he / she complies 
with the terms of the approval, namely with adverse event reporting, notification of amendments, 
interim and final reports on the progress of the study. 
Written responses from any other local approvals (e.g. NHS, R & D) must also be obtained prior to 
starting the study. 
15.3  Informed Consent 
Written Informed Consent must be obtained from each potential patient or parent or guardian prior to 
conducting any study assessments or procedures. (In the case of patients aged 6 to 15 years old, 
written consent must be obtained from the parent or guardian on the patients’ behalf, if the patient is 
not competent to give Written Informed Consent themselves). The Investigator must ensure the 
nature of the study is fully explained to each patient and / or parent or guardian, and provide the 
patient and / or parent or guardian with Research Ethics Committee approved copies of the relevant 
Patient Information Sheet(s) to read. Patient Information Sheets will be provided for patients aged 16 
years and older (adults) and for patients aged 12 to 15 years old, a more simplified version will be 
provided. For patients ages 6 to 11 years, the Patient Information Sheet will be provided in picture 
format. The patient and / or parent or guardian should be informed that participation in the study is 
voluntary and by not consenting, it will not affect the patient’s right to the most appropriate dental 
treatment, or affect the dentist / patient relationship. The patient and / or parent or guardian must 
have adequate time (at least 24 hours) to consider their participation in the study and be able to 
discuss with others and ask the Investigator any questions. If the patient and / or parent or guardian 
agrees to participate, a copy of the Research Ethics Committee approved Patient Consent Form must 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 42 of 48 
be signed and dated. A copy of the signed and dated Consent Form (and a copy / copies of the Patient 
Information Sheets) must be given to the patient and / or parent or guardian to keep. The original 
signed copy of the Consent Form must be kept by the Investigator and placed in the patient’s dental / 
medical records or scanned in if electronic records are kept. A further copy (or the original) should be 
placed in the Investigator Site File.  
It is understood that informed consent is a matter entirely between the Investigator and the patient 
and / or parent or guardian. The Sponsor will only confirm that it has been provided; no copy will be 
taken for use by the company.  
Patients and / or parents or guardians are free to withdraw Consent at any time, irrespective of their 
initial consent. Patients who withdraw Consent will be replaced. 
Each patient and  / or parent or guardian must also give permission for the Sponsor’s representatives 
to review their dental / medical records for the purpose of source document verification. 
During the course of the study, the study patient’s details will be kept anonymous (specific study 
identification codes will be used for each study patient). Study patient data will only be made available 
to authorized staff of the study Sponsor, it’s authorized representatives and regulatory authorities if 
applicable. 
15.4  Disclosure and Confidentiality 
By conducting the study, the Investigator agrees that all information provided by the Sponsor will be 
maintained by the Investigator and the site personnel in strict confidence. It is understood that the 
confidential information provided to the Investigator will not be disclosed to others without 
authorization from the Sponsor. 
All patients recruited to the study will be identified by a unique site and patient identification number 
in order data collected on them will be anonymized. The Investigator will maintain a confidential 
patient identification list of all patients enrolled in the study (by name and patient number). The list 
will be maintained at the site and will not be retrieved by the Sponsor. Study patient data will only be 
made available to authorised staff of the Sponsor, it’s authorised representatives and regulatory 
authorities, if applicable. 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 43 of 48 
16. 
REFERENCES  
1. 
Selwitz RH, Ismail AI, Pitts NB: Dental Caries. Lancet 2007;369:51-59.  
Pitts NB. Detection, Assessment, Diagnosis and Monitoring of Caries, Monographs in Oral 
Science, Eds Lussi A, Whitford GM, Karger, Basel,2009, Introduction, p.1-14. 
2. 
Pitts NB, Introduction: How the Detection, Assessment, Diagnosis and Monitoring of Caries 
Integrate with Personalized Caries Management, in 'Detection, Assessment, Diagnosis and 
Monitoring of Caries', Pitts NB, ed., Monographs in Oral Science, pp1-13, Vol. 21, Karger, Basel, 
2009.  
3. 
Fejerskov O, Kidd EAM, Nyvad B, Baelum V. Dental Caries: The disease and its Clinical 
Management. Eds Fejerskov O, Kidd EAM 2nd edition, Blackwell Munksgaard, Oxford, 2008. 
Defining the disease: an introduction, p.4-7 
4. 
Paris S, Meyer-Lueckel H, Ekstrand K. Caries Management –Science and Clinical Practice Eds 
Paris S, Meyer-Lueckel H, Ekstrand K, Thieme, Stuttgart, 2013 From Diagnostics to Therapy, p. 
134-145 
5. 
Ekstrand K, Zero DT, Martignon S, Pitts NB. Lesion Activity Assessment in: Detection, 
Assessment, Diagnosis and Monitoring of Caries, Monographs in Oral Science, Eds Lussi A, 
Whitford GM, Karger, Basel,2009, p63-90. 
6. 
Ekstrand K, Martignon S. Visual-Tactile Detection and Assessment in: Paris S, Meyer-Lueckel H, 
Ekstrand K, Caries Management –Science and Clinical Practice Eds Paris S, Meyer-Lueckel H, 
Ekstrand K, Thieme, Stuttgart, 2013, p. 69-85.   
7. 
Qvist V. Longevity of restorations: the ‘death spiral’ in: Fejerskov O, Kidd EAM, Nyvad B, 
Baelum V. Dental Caries: The disease and its Clinical Management. Eds Fejerskov O, Kidd EAM 
2nd edition, Blackwell Munksgaard, Oxford, 2008, p.444-455. 
8. 
Longbottom C, Ekstrand K, Zero DT. Traditional Preventive Treatment Options in: Detection, 
Assessment, Diagnosis and Monitoring of Caries, Monographs in Oral Science, Eds Lussi A, 
Whitford GM, Karger, Basel,2009, p. 149-155. 
9. 
Meyer-Lueckel H, Tyas Mj, Wicht MJ, Paris S. Decision-Making in Managing the Caries Process 
in: Caries Management –Science and Clinical Practice Eds Paris S, Meyer-Lueckel H, Ekstrand K, 
Thieme, Stuttgart, 2013 From Diagnostics to Therapy, p.286-304.   
10. 
Pitts NB, Ekstrand KR. International Caries Detection and Assessment System (ICDAS) and its 
International Caries Classification and Management System (ICCMS™) – methods for staging of 
the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 
2013; 41: e41–e52.  
11. 
Alves LS, Zenker JEA, Wagner MB, Dame-Teixeira N, Susin C and Maltz M. Eruption Stage of 
Permanent Molars and Occlusal Caries Activity / Arrest – JDR Clinical Research  Supplement, 
July 2014, p114S-118S. 
12. 
Longbottom C. Expert Paper on Caries Activity Assessment - 2015 
 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 44 of 48 
18. 
APPENDICES 
Appendix 1 - ICDAS Decision Tree for Caries Codes  
Appendix 2 - Tooth Cleaning Protocol 
 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 45 of 48 
 
APPENDIX 1 
ICDAS CONVENTIONS – DECISION TREE 
 
 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 46 of 48 
ICDAS Decision Tree 
 
Use the decision tree below to help you determine the correct caries code  
 
 
 
 
Caries Codes 
0 = Sound tooth surface 
1 = First visual change in enamel 
2 = Distinct visual change in enamel 
3 = Enamel breakdown, no dentine visible 
4 = Dentinal shadow (not cavitated into dentine) 
5 = Distinct cavity with visible dentine 
6 = Extensive distinct cavity with visible dentine 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 47 of 48 
 
 
APPENDIX 2 
TOOTH CLEANING PROTOCOL 
 
 
 
 

 
CAL-02-2014, Version 6,  08 December 2016 
 
F-PM-16, v1, March 2013 
 
Page 48 of 48 
Tooth Cleaning Protocol prior to Imaging with the Calcivis System 
 
Occlusal surfaces: 
 
Remove any dental plaque and debris from the occlusal surface of each molar or premolar which is a 
potential test site for the Calcivis imaging system using the following protocol: 
 
Use a blunt/ball-ended probe to remove gross accumulations of debris and dental plaque from the 
occlusal surface, followed by brushing the entire exposed tooth surface with a toothbrush and water 
(or with a small amount of dental paste at the Investigator’s discretion) which has been rotated 
laterally (horizontally) through 90 degrees to the mesio-distal line of the dental arch and used by 
approaching the surface from the buccal side, completing a series of vigorous bucco-lingual strokes, 
together with brush-head rotations. Try to avoid traumatising any remaining operculum present over 
the occlusal surface. 
 
If  dental paste has been used for cleaning,  repeat the procedure using tap water only on the 
toothbrush, in order to remove any remaining prophylaxis paste then thoroughly rinse the occlusal 
surface with a 3-in-1 (water alone, then air-water spray) to ensure absolutely no prophylaxis paste 
remains on the occlusal surface prior to the Calcivis imaging. After these procedures, should any 
particles of prophylaxis paste remain in the pit and fissure pattern of the molar remove these by gently 
dislodge them with the end of a probe if necessary. 
 
If water only has been used for cleaning, repeat the cleaning with a tooth brush and water only, then 
thoroughly rinse the occlusal surface with a 3-in-1 (water only, then air-water spray).  
 
Free Smooth surfaces: 
 
Remove any dental plaque and debris from the free smooth surface of each tooth which is a potential 
test site for the Calcivis imaging system using the following protocol: 
 
Use a blunt/ball-ended probe to remove gross accumulations of debris and dental plaque from the free 
smooth surface, followed by brushing the entire exposed tooth surface with a toothbrush and water 
(or with a small amount of dental paste at the Investigator’s discretion) which has been rotated 
laterally (horizontally) through 90 degrees to the mesiodistal line of the dental arch and used by 
approaching the surface from the appropriatebuccal or lingual/palatal side, completing a series of 
vigorous cervico-occlusal strokes, together with brush-head rotations. Try to avoid traumatising the 
gingivae and any remaining operculum present over the occlusal surface of the tooth. 
 
If dental paste has been used for cleaning, repeat the procedure using tap water only on the 
toothbrush, in order to remove any remaining prophylaxis paste then thoroughly rinse all of the tooth 
surfaces with a 3-in-1 (water alone, then air-water spray) to ensure absolutely no prophylaxis paste 
remains on the free smooth surface prior to the Calcivis imaging. After these procedures, should any 
particles of prophylaxis paste remain in any pit or fissure pattern on the free smooth surface remove 
these by gently dislodge them with the end of a probe if necessary. 
 
If water only has been used for cleaning, repeat the cleaning with a tooth brush and water only, then 
rinse thoroughly rinse the free smooth surface with a 3-in-1 (water only, then air-water spray).