Oral Disease, Treatment Need and Function (ODNF) index for oral health data collection by non-dental assessors in adult population with Intellectual Disabilities (ID): validity, reliability and feasibility study

Abstract

BACKGROUND: The oral health status of adults with intellectual disabilities is poor. In Ireland, there is a paucity of oral health research with this population, largely due to cost of dental surveys and thus there is little re-orientation of services to improve oral health of these individuals. An alternative oral health data collection approach, such as use of non-dental individuals as assessors, has been validated in other groups of population. However, the suitability of the existing tools for use with populations with ID has not been reported. The need for a comprehensive, valid, reliable, inexpensive and acceptable index that can be use by trained non-dental individuals on adults with ID is now recognised. RESEARCH AIM AND OBJECTIVES: Aim: To investigate the feasibility of utilising non-dental individuals to carry out oral health data collection in an adult population with intellectual disabilities (ID). Objectives: 1) To construct an oral health data collection tool that can be used by non-dental individuals. 2) To develop a training programme for the newly constructed tool 3) To establish content validity and to assess concurrent validity for the tool 4) To assess inter-rater and test-retest reliability of the tool 5) To determine the feasibility of the tool; the time taken to carry out assessment, the cost of utilizing non-dental individuals for data collection and the acceptability of this tool by participants with ID and non-dental assessors MATERIALS AND METHODS: 1. This study was completed in two phases; non-clinical and clinical. The construction of the Oral Disease, Treatment Need and Function (ODNF) index and its content validation was carried out during the non-clinical phase; meanwhile, the clinical phase investigated the concurrent validity, reliability and feasibility of the newly constructed tool. 2. The construction of the ODNF tool for people with an ID involved a systematic review of published literatures on existing oral/dental data collecting tools that utilised non-dental individuals who assessed mostly older people. Alongside the construction, the content validity was established with the use of Content Validity Ratio (CVR) approach and through consultation with a panel of experts, as well as input from non-dental assessors. The new tool and its training programme were then tested in a pilot phase with a population without ID, before finalising it for the clinical phase of this research. 3. Irish adults with ID, who are living in Dublin, were invited to participate in the clinical research phase of this study. Ethical approval was granted by the Faculty of Health Science Research Ethics Committee (FHSREC) Trinity College Dublin, the School of Dental Science Level 1 Research Ethics Committee as well as each of the Research Ethics Committees of the two ID service providers that had agreed to participate. Three (3) non-dental individuals and one (1) dentist were trained to use the ODNF index. 4. There were 49 participants examined, by the non-dental assessors as well as a gold standard dental assessor and a non-gold dental assessor. In order to test for the concurrent validity, dental assessors were asked to carry out the ODNF assessment,followed by conventional dental assessment (Dentition status and CPITN). Secondly, test-retest reliability of the ODNF was assessed by each examiner repeating the examination on all participants after an interval of 30 minutes. Thirdly, Inter-rater reliability was tested by comparing the results of the ODNF examination results of the non-dental assessors with those of the gold standard dental assessor. Finally, the feasibility of the ODNF tool was investigated by (1) recording the time taken for each examination by each assessor, (2) by considering the expense of both the training and utilisation of the non-dental assessors to use the ODNF tool as well as (3) by considering the acceptability of the ODNF tool to both the participants with ID and the non-dental assessors. 5. Data management and analysis were then carried out using the statistics programmes R v.3.2.2 and Statistical Package for Social Science (SPSS) 20.0 (SPSS Co., Chicago, USA). Agreement tests (Percent agreement, Cohen's Kappa and Gwet's AC1 coefficients) and Spearman's correlation tests were used to determine the concurrent validity, inter-rater reliability and test-retest reliability of each ODNF category. Preliminary cost analysis was carried out to compare the cost of the ODNF assessment against conventional dental examination. Descriptive statistics were used to present the results from the questionnaire, clinical assessments, feedback from both participants and non-dental assessors as well as time sheets. RESULTS: 1. The construction of the ODNF tool was completed by reviewing relevant items from existing oral/dental assessment tools that have been used and validated previously for use by non-dental assessors. Content validity of the tool was established during the construction with input from a panel experts, use of a content validity ratio (CVR) approach and feedback from non-dental assessors. 2. A training programme was developed specific for this ODNF tool. 3. A high level of agreement with sufficient sensitivity and specificity of ODNF categories 'Tooth count', 'Gums' and 'Visible caries' contributed to concurrent validity of ODNF tool. Further, concurrent validation is needed for the remaining categories. 4. The ODNF tool has a good level of inter-rater reliability except for 'Soft tissues', 'Oral Cleanliness' and 'Gum condition'. Results demonstrated high levels of test-retest reliability for all assessors except for the categories of 'Soft tissues', 'Oral Cleanliness'. Further research on these categories are warranted. 5. The average time taken to administer the ODNF tool was 7 minutes. The tool was found to be acceptable to participants with ID as well as to the non-dental users. Based on a preliminary cost analysis, the ODNF assessment costs 6 times less than does the conventional dental assessment. CONCLUSION: This thesis presents evidence that it is feasible to train non-dental individuals to use the ODNF index to collect oral health data from this population with Intellectual Disabilities (ID). The findings of this study suggest that non-dental individuals can be trained for the assessment of Tooth count, Denture wear, Soft tissues (Lips, Mucosa, Tongue, Roof of mouth and Floor of mouth), Occluding pairs, Gum condition, Oral cleanliness, Visible caries and Dental pain. The newly constructed ODNF tool was found to have high level of validity, sensitivity and specificity especially for ODNF categories 'Tooth count', 'Gum condition' and 'Visible caries'. The inter-rater and test-retest reliability of the tool was found to be good except for the items of 'Soft tissues', 'Oral Cleanliness' and 'Gum condition'. The feasibility assessment in this study has shown that the ODNF index is quick and acceptable to use; and may be less expensive compared to the use of conventional dental indices and all that these entail. However, further work can be done to strengthen the validity and reliability of this ODNF tool. Research data on this population are vital to inform clinicians and policy makers in the promotion of the oral health of individuals with ID.