International Delphi Study to Optimize the Oral Health Section in interRAI.

Introduction: The oral health (OH) of care-dependent older people is generally poor. Since caregivers are mainly responsible for older people's daily care, they can be considered important intermediaries to improve their OH by performing regular OH assessments. The interRAI instruments are introduced in 37 countries to assess care needs and facilitate care planning across different health care settings. The oral health section (OHS) within the interRAI instrument used in long-term care facilities was optimized for the Belgian context to identify residents who need assistance with daily oral care and/or need to be referred to a dentist. This Delphi study evaluated whether the OHS is also relevant and useful in other countries and modified the OHS accordingly until an international consensus was reached. Participants were experts in OH for older people. During 2 rounds of online questionnaires, experts rated the content, assessment process, triggering of Clinical Assessment Protocols, and accompanying guidelines and instruction videos of the optimized OHS. Based on the experts' comments and suggestions collected during the first round, the OHS was adjusted and presented to the experts in the second round for re-evaluation. The first and second questionnaires were completed by 48 and 42 oral health experts from 29 and 27 countries where the interRAI instruments are introduced, respectively. Five experts from 5 countries where interRAI is not introduced also participated in both rounds. After the second round, a consensus of over 86% was reached on all criteria. International consensus on the OHS was reached, considering national and cultural differences that may affect OH. The next step in this research is to evaluate the assessment process to identify potential barriers and facilitators to achieving reliable OH assessments internationally. Furthermore, the effect of the OHS at the level of the resident and of the caregivers will be evaluated.

Paediatric dentist's ability to detect and diagnose dental trauma using 2D versus 3D imaging.

BACKGROUND: Visualisation of the third dimension has been reported to increase effectiveness of correctly diagnosing traumatic dental injuries. AIM: To assess the ability of paediatric dentists to detect and diagnose Traumatic Dental Injuries (TDI) using two different imaging modalities, intraoral radiographs (2D) and CBCT scans (3D). In addition, observer's confidence regarding the obtained diagnosis, using either technique, was assessed. MATERIAL AND METHODS: Both 2D and 3D images of 20 dental trauma cases in children were presented in random order to a panel of thirteen paediatric dentists. Observers received instructions for the screening of the images for radiographic findings related to dental trauma, using structured scoring sheets for 2D and 3D images. Observed data were compared to those recorded by two experienced benchmark observers. A ten-point scale was used for assessing observer's confidence regarding their final diagnosis using 2D versus 3D images. RESULTS: Performance of individual observers showed wide variation. Statistical significance was reached for correctly detected and correctly diagnosed findings (p = 0.02), in favor of 3D. Most of the observers reported comparable confidence using 2D and 3D, two observers were more confident using 3D and one observer was more confident using 2D. CONCLUSIONS: Paediatric dentist's ability to detect and diagnose findings in patients with TDI was higher on 3D images. Most observers showed a similar confidence score of their diagnostic performance both on 2D and on 3D.

Non-invasive treatment approach for hypomineralised second primary molars using preformed metal crowns: results after 1-year follow-up.

PURPOSE: To evaluate the clinical and radiological outcome of Hypomineralised Second Primary Molars (HSPM) treated with Preformed Metal Crowns (PMC) using the Hall Technique (HT). METHODS: This prospective cohort study included healthy children presenting at the pediatric dental clinic of the University Hospitals Leuven (Belgium) with at least one primary molar affected by HSPM. The clinical and radiological situation at baseline and after a follow-up of 1 year was registered in detail using standardized criteria. After plaque removal and gentle drying, PMCs (3 M™ ESPE™ Stainless Steel Crowns) were fitted without administration of local anaesthesia nor tooth preparation. Strict outcome criteria, including gingival health condition, were applied. Informed consent was obtained for all individual participants. The study was approved by the institutional Ethics Committee. RESULTS: A total of 39 PMCs with a follow-up of 12 months, placed in 15 patients (7 boys and 8 girls), were included. The mean age of the patients at the time of fitting the PMC was 4.6 ± 1.1 years (range: 3-7). None of the PMCs was lost nor failed. Clinical outcome was considered fully successful in 64.1%, radiological outcome in 93.3% of the cases; all other cases were rated as acceptable. The main reason for not being categorized as fully successful was deterioration of the gingival condition. Overall, the treatment was well tolerated and accepted by the patients. CONCLUSION: PMCs fitted using the HT represent an acceptable and well-tolerated treatment option for the management of HSPM. Gingival condition should be incorporated in outcome assessment.

Review of the dental treatment backlog of people with disabilities in Europe.

AIM: The present research aims at reviewing the oral health conditions and treatment needs of people with disabilities in Europe. METHODS: A comprehensive literature search was conducted using Medline and Embase with a timeframe from January 2008 until December 2017. Subsequently, a citation tracking was undertaken. Articles in English, French and Dutch were included. RESULTS: Forty-two articles were included. A variety of oral health problems and treatment needs was reported. More untreated carious lesions, less restorations, a higher number of extractions and less prosthetic rehabilitations were seen in people with disabilities compared with other individuals without disabilities. The oral hygiene level and the periodontal conditions were poor. Moreover, a higher risk of dental trauma, orthodontic problems and tooth wear were reported. DISCUSSION: Different determinants contribute to the oral health condition and treatment needs of people with disabilities. These determinants can be inherent in persons with a disability (biological factors), their lifestyle, the environment or the organization of oral health care. A treatment backlog was a common finding in people with disabilities. However, results need to be interpreted with caution because of the variety of people with disabilities included in this literature review. Proposed solutions can be put at the level of daily oral care, through oral health promotion programs and the creation of a supportive environment, but also at the level of dental attendance, facilitating the access to oral health care services and focusing the training of dental students and dentists. CONCLUSION: This comprehensive review clearly shows a dental treatment backlog in people with disabilities. Solutions require efforts from the caregivers and dental professionals.

Social gradient in caries experience of Belgian adults 2010.

OBJECTIVE: This study aims to explore the caries experience of the Belgian population in relation to social indicators. BASIC RESEARCH DESIGN: Data collection (2009-2010) consisted of an oral health questionnaire and examination during a home visit. PARTICIPANTS: Representative sample of the Belgian population (⟩5 years old). Only the economically active population was included for final analyses. MAIN OUTCOME MEASURES: ANOVA and multivariable regression analyses were used to reveal associations between social indicators, oral hygiene, untreated decay, DMFT and edentulousness. RESULTS: 2742 participants completed the questionnaire, of whom 2563 were examined clinically. Most (53%) were female and mean age was 43.3 years (95% CI= 41.2-45.4). In the total population, 11.1 % were caries-free (DMFT = 0) and mean DMFT was 10.8 (95% CI = 10.0-11.5). In the analysed subsample, higher educated participants had lower DMFT scores than those with low or no educational qualifications (p = 0.003). Employment status was associated with the presence of untreated tooth decay, especially in the youngest age group (p = 0.015), and with edentulousness (p = 0.02), with a higher risk among unemployed women of being completely edentulous (OR = 5.32; 95% CI = 1.75-16.12). Untreated tooth decay was related to frequency of tooth brushing and plaque index (p ⟨ 0.002 and ⟨ 0.001 respectively). CONCLUSIONS: Caries experience in Belgium, expressed as mean DMFT and proportion of untreated tooth decay, is more associated with level of education and employment status than with family income, which is still the main criterion for larger government allowances for healthcare in Belgium.

Validation of the Oral Survey-B System for Electronic Data Capture in National Oral Health Surveys.

The aims of the present study were to incorporate and to validate the electronic capture of participant-related outcomes into the Oral Survey-B System, which was originally developed for the electronic capture of clinical data. The validation process compared the performances of electronic and handwritten data captures. The hypothesis of noninferiority would be established if participants performed electronic data capture of the questionnaire survey with an effectiveness of at least 95% of that of handwritten data capture. In this multicenter, randomized, one-period crossover study design, participants (n = 261) were allocated to start with either electronic or handwritten data capture. The incorporation of the electronic self-completed questionnaire into the Oral Survey-B System was successful. The validation of the electronic questionnaire was performed by participants aged from 18 to 75 years. The interrater reliability of participants performing electronic and handwritten data capture of nonclinical assessments per questionnaire and per entry showed a kappa value of 0.72 (95% CI: 0.53-0.94). The noninferiority of electronic data capture in relation to that of the handwritten data capture and transfer was shown (p < 0.0001; 95% CI: 1.47-2.99). In conclusion, the electronic capture of participant-related outcomes with the Oral Survey-B System, originally designed for capture of clinical data, was validated. The electronic data capture was accurate and limited the number of errors. The participants were able to perform electronic data capture effectively, supporting its implementation in further National Oral Health Surveys. With the consideration of participant preference and time savings, this could lead to the implementation of electronic data capture worldwide in National Oral Health Surveys.

Treatment needs and impact of oral health screening of athletes with intellectual disability in Belgium.

BACKGROUND: Special Olympics Special Smiles (SOSS) is an initiative created for oral health data collection and education in oral hygiene for athletes with an intellectual disability. The aims of this study were to evaluate treatment needs of participants of Special Olympics in Belgium 2013 in comparison with those from 2008 and to assess the impact of screening and referral within the SOSS in a group of athletes who participated in two consecutive events, 2012 and 2013. METHODS: Data were collected following a standardized protocol developed by the U.S. Centres for Disease Control and Prevention, Division of Oral Health. Oral hygiene habits, treatment urgency and reports of oral pain, gingival signs, sealants, untreated caries, missing and filled teeth were recorded. Data analysis of data from 2013 consisted in descriptive statistics followed by the analysis of the data by univariable and multivariable logistic regression. This data was compared with data from 2008 published by Leroy et al., 2012 using Chi square tests. Data from athletes who participated in both Special Olympics events (2012 and 2013) were compared using Exact McNemar's test and Chi-square test for homogeneity of proportions. The level of significance for all tests was set at a p-value < 0.05. RESULTS: A total of 627 athletes with intellectual disability participated to the SOSS program in 2013, while 132 athletes met the inclusion criteria of being a participant at both SO Belgium 2012 and 2013. The prevalence of gingival signs was 44.3 % in 2013, slightly higher than in 2008 (42.4 %). The burden of untreated decay affected 27.1 % of the population showing a net increase in comparison to 2008 (20.9 %). McNemar's test and Chi-square test revealed that there were no statistically significant differences in the proportions of all compared parameters between 2012 and 2013. CONCLUSION: Special Olympics results from 2013 indicate a considerable unmet treatment need among Belgian Special Olympics Athletes, persistent from 2008 to 2013. Moreover, SO intervention had no impact in the oral health of athletes who participated in 2012 and 2013 events. Continuous efforts for preventive and restorative oral health care are needed for this population.

Long-term outcome of oral health in patients with early childhood caries treated under general anaesthesia.

AIM: Reports on the long-term outcome of oral health in children with early childhood caries (ECC) treated under general anaesthesia (GA) are lacking. The aim of this study was to assess oral health in adolescents with history of ECC treated under GA at young age. METHODS: A total of 98 children treated under GA because of ECC at the University Hospitals of Leuven (Belgium) (1995-1996) were included in a follow-up study. Information was collected at baseline (GA) and 1 and 12 years after treatment. The children were examined clinically [oral hygiene, caries experience (CE)] and oral health behaviour was recorded using a questionnaire. RESULTS: At second recall, 46 (48 %) adolescents could be contacted; 21 of these attended the dental clinic. Their mean age was 17.5 years (SD 1.4) with mean time span since GA of 13.1 years (SD 0.8); 91 % presented with CE. Mean D3MFT was 8.2 (SD 5.6) (median 7; range 0-18); 71 % showed untreated decay. A considerable gap between knowledge of content and actual use of fluoride in toothpaste was evident. CONCLUSIONS: Individuals with a history of ECC remained at high risk for caries in their permanent dentition. There is a need for well-designed long-term studies to explore associated factors.

Evaluating the implementation fidelity of a multicomponent intervention for oral health promotion in preschool children.

This study evaluates the process of implementation of a longitudinal intervention program to promote oral health in preschool children in Flanders, Belgium. As the program was implemented in an existing preventive health care organization, the study also evaluates this setting as the context for implementation. Qualitative and quantitative methods were used to evaluate implementation fidelity, based on Carroll's theoretical framework of implementation fidelity (Carroll et al., Implementation Science 2:40, 2007). Questionnaire data from participants and health workers were analyzed, and document analyses were performed to compare registrations of the actions with the planning manual. Results were mixed. Whereas more than 88 % of all parents attended all home visits, only 57 % received at least 9 of the 11 planned consultations. Fifty-two percent of the families received all supporting materials, and on average, 73 % of all attending families received all information at a contact as described in the manual. Moderating factors such as the adequate use of facilitators and high participant responsiveness had a positive impact on implementation fidelity, whereas the quality of delivery differed to a great extent between the nurses who were involved during the entire intervention period and those who gave only a few sessions. Implementing an intervention in an existing well-baby program has many advantages, although lack of time presents a challenge to implementation fidelity. The results of this process evaluation allow a better understanding of the contribution of implementation fidelity to the effectiveness of health promotion programs.

Correction for misclassification of caries experience in the absence of internal validation data.

OBJECTIVES: To quantify the effects of risk factors and/or determinants on disease occurrence, it is important that the risk factors as well as the variable that measures the disease outcome are recorded with the least error as possible. When investigating the factors that influence a binary outcome, a logistic regression model is often fitted under the assumption that the data are collected without error. However, most categorical outcomes (e.g., caries experience) are accompanied by misclassification and this needs to be accounted for. The aim of this research was to adjust for binary outcome misclassification using an external validation study when investigating factors influencing caries experience in schoolchildren. MATERIALS AND METHODS: Data from the Signal Tandmobiel(®) study were used. A total of 500 children from the main and 148 from the validation study were included in the analysis. Regression models (with several covariates) for sensitivity and specificity were used to adjust for misclassification in the main data. RESULTS: The use of sensitivity and specificity modeled as functions of several covariates resulted in a better correction compared to using point estimates of sensitivity and specificity. Age, geographical location of the school to which the child belongs, dentition type, tooth type, and surface type were significantly associated with the prevalence of caries experience. CONCLUSIONS: Sensitivity and specificity calculated based on an external validation study may resemble those obtained from an internal study if conditioned on a rich set of covariates. CLINICAL RELEVANCE: Main data can be corrected for misclassification using information obtained from an external validation study when a rich set of covariates is recorded during calibration.

Measuring determinants of oral health behaviour in parents of preschool children.

OBJECTIVE: The aim of this study was to develop a valid and reliable measure for oral health behaviour and its determinants in five-year-old Flemish children, based on the Theory of Planned Behaviour (TPB) and to test its predictive validity. METHODS: 1157 parents of five-year-olds completed a questionnaire measuring three behaviours related to oral health among children (dietary habits, oral hygiene, dental attendance) and their determinants (attitude, subjective norms, perceived behavioural control, intention). The sample was randomly split in two halves and principal component analyses were performed on one half sample to identify the factor structure. Confirmatory factor analyses were performed on the remaining half sample to obtain a cross-validation. Predictive validity was tested using multiple regression analyses. RESULTS: For each behaviour four component structures reflecting the TPB-dimensions, accounting for 44% to 55% of the variance were retrieved and confirmed in the cross-validation. Internal consistency (Cronbach's alpha) of the scales ranged from 0.52 to 0.80. A sizeable percentage of variance of intentions and behaviours was explained by the model. CONCLUSIONS: The TPB components were significant predictors of intentions and behaviours. These findings argue for the reliability and validity of the questionnaire for exploring determinants underlying parental oral health behaviour.

Oral health and oral health-related behaviour in preschool children: evidence for a social gradient.

This study aims to investigate the social gradient in the reported oral health-related behaviour and oral health status of preschool children. Participants were 1,057 children born between October 2003 and July 2004 in Flanders, Belgium. Oral health examinations were performed by trained dentists when the children were 3 and 5 years old (respectively, in 2007 and 2009); data on dietary habits, oral hygiene habits and dental attendance of the children were obtained through structured questionnaires completed by the parents. Maternal educational level, measured in four categories, was used as a proxy of socio-economic status. Logistic and ordinal regressions showed a social gradient for the oral health-related behaviours: a lower educational level of the mother was related to a higher consumption of sugared drinks between meals and to a lower brushing frequency and dental attendance of the child. Children from low-educated mothers also had seven times more chance to present with caries experience than children from mothers with a bachelor degree. Contrary to the expectations, there was a deviation from the gradient in 3-year-olds from the highest educational group showing an increased risk for caries experience (OR = 3.84, 95 % CI = 1.08-13.65). Conclusion. Already in very young children, a graded relationship is observed between socio-economic position, oral health and related behaviours. The results suggest that different approaches are required to promote oral health during early childhood depending on the mother's educational background. As children from the highest social group also have an increased caries risk, specific techniques may be needed.

Caries experience and related factors in 4-6 year-olds attending dental clinics in Kinshasa, DR of Congo.

OBJECTIVES: The aim of this study was to examine the prevalence and severity of caries experience (CE) in 4-6 year-olds attending dental clinics in Kinshasa, DR Congo, and to explore possible associations with reported behavioural and socio-demographic factors. METHODS: A convenience sample of children attending five dental clinics was recruited. Carers, usually parents, completed a questionnaire consisting of socio-demographic information, oral health and tobacco consumption profile of parents, socio-economic family situation and oral health habits of the child. Children were clinically examined using WHO criteria by trained dentist-examiners. To investigate factors associated with CE, multivariate logistic regression was applied with the significance level set at 0.05. RESULTS: Some 158 children with mean age 5.3 (sd 0.7) years were recruited; 80% presented with clinical signs of CE. Between-meal snacking and drinking was reported by 78% and 65%; 35% had sugar-containing drinks. Most (81%) brushed once a day and 82% brushed in the morning. Prevalence of CE was associated with gender, frequency of meals, consumption of drinks during meals and consumption of sugar-containing drinks; severity with type of infant feeding and sugar-content of the last meal at night. CONCLUSION: The present study shows that both prevalence and severity of caries experience were associated with reported dietary habits, confirming the importance of preventive interventions dealing with these habits in young children living in a developing country.

Assessment of caries experience in epidemiological surveys: a review.

OBJECTIVES: To review aspects of methods for assessing caries experience (CE) in epidemiological surveys. METHOD: A search of English language literature published between January 2000 and December 2008 was undertaken using 'epidemiology', 'dental caries' and 'assessment' as search terms. Information on criteria for CE assessment, materials and settings, diagnostic threshold, training of examiners and validation of the screening results was extracted from the reports. RESULTS: Eighty-nine reports met the inclusion criteria. In 9 of the reports (10%) no reference was made to existing standardisation criteria for assessment of CE. Light condition applied (60 reports, 67%) and the use of a probe (60 reports, 67%) were frequently reported. Most reports mentioned that training and calibration of examiners took place, but the outcome of reliability checks were often not presented (48 reports, 54%). Only 28 of the reports (32%) specified that cleaning took place before the examination. Journals with Impact Factor (IF) provided specific information on methods more frequently than journals without. The WHO Basic Methods for Oral Health Surveys were most often applied (52 surveys, 58%). However, deviations from the original description were found especially for measurement and reporting of reliability measurement (24, 46% and 29, 56% respectively), type of probe used (27, 52%) and light condition (16, 31%). All of these hamper the (external) validity of the obtained results. CONCLUSIONS: There is a clear need for improvement of the reporting and application of methods for assessing CE in epidemiological surveys. A check-list of aspects of methods to be included in reports of surveys assessing CE is proposed by the authors.

The oral health status of special olympics athletes in Belgium.

OBJECTIVES: To describe and evaluate the oral condition and oral treatment needs of the participants of the Special Olympics Special Smiles program organised in Belgium in 2008. DESIGN: A cross-sectional study where the data were collected through interviews and clinical examinations. PARTICIPANTS: 687 Belgian Special Smiles athletes participated, mean age 33 years. RESULTS: More than 70% had at least one missing tooth. Distinct signs of gingivitis and visible caries experience were observed in 44% and 22% of dentate athletes respectively. Dutch-speaking athletes were less likely to present with untreated caries (OR: 0.46; 95% CI: 0.31-0.68) or with gingivitis (OR: 0.51; 95% CI: 0.37-0.71) compared to their French-speaking colleagues. Signs of past injury were identified in 12% of athletes. Of those athletes with an edentulous mandible, only 53% presented with a removable denture; 73% of athletes missing some maxillary anterior teeth and 30% of those missing all anterior teeth had no prosthetic replacement in the maxilla. Nearly two fifths of athletes were referred for treatment: in 12% of athletes dental treatment was considered urgent. CONCLUSION: The results suggest that there is a tremendous unmet need for dental treatment in the Belgian Special Smiles population, with French-speaking athletes in greatest need. Improvements in data collection should be encouraged for example. more detailed screening methods (e.g. caries screening including enamel lesions, full periodontal examination) and questionnaires (e.g. inclusion of questions related to dietary habits, dental attendance). In this way barriers to optimal oral health (care) in this population could be further explored, attempts made to reduce them and so reduce health inequalities.

Effects of time and socio-economic status on the determinants of oral health-related behaviours of parents of preschool children.

The oral health-related beliefs of parents have an important impact on the oral health status of their children; however, they are not stable over time. This study aimed to assess the changes, over time, in the determinants of parental oral health-related behaviour based on the Theory of Planned Behaviour and to investigate socio-economic inequalities. The cohort consisted of the parents - mainly the mothers - of 1,057 children born in 2003 and 2004 in Flanders (Belgium). According to the Theory of Planned Behaviour, validated questionnaires, completed at children's birth and at age 3 and 5 yr, assessed parental attitudes, social norms, perceived behavioural control, and intention towards three behaviours: dietary habits, oral hygiene habits, and dental attendance. Linear mixed-model analyses were applied. Positive parental attitudes towards oral health-related behaviours increased between birth and 3 yr of age, whereas the scores for subjective norms and intentions decreased. Scores remained stable for children between three and 5 yr of age. Highly educated mothers had significantly higher scores for attitudes, perceived behavioural control, and intentions than less-educated mothers. Health promotion campaigns should take these natural changes and inequalities of dental beliefs into account when developing and evaluating interventions.

Validity of an information and communication technology system for data capture in epidemiological studies.

The Belgian National Institute of Health Insurance is implementing an oral health data registration and surveillance system. This study aimed to develop and validate a system of electronic data capture for oral health surveys at a national level - Oral Survey-B - and to identify the advantages and disadvantages of the electronic system in comparison with the traditional handwritten data capture. Six series of full-mouth recordings simulating the clinical examination of 6 patients were set up in a Powerpoint presentation. The validation was undertaken by 52 general practitioners. A randomized one-period crossover design was used with two formats of data capture, i.e. electronic followed by handwritten or handwritten followed by electronic system. Further, 6 benchmarked handwritten forms were transferred to the electronic format. For the electronic data capture, 86.5% of the practitioners had a correct completion rate of ≥95%. The corresponding value for the handwritten data capture and transfer was 78.8% (p = 0.25, McNemar test). The overall accuracy of forms without any error was 73.4% for the electronic and 62.5% for the handwritten data capture (p < 0.001, signed-rank test). Significantly lower percentages of errors and less time were observed for the electronic data capture (p < 0.001, signed-rank test). Practitioners considered the electronic data capture as being much more difficult to carry out (p < 0.001). As information technology has turned into an ever more necessary working tool in epidemiology, there should be an important potential for uptake of further improvements in electronic data capture in the future.

Oral hygiene and gingival health in Flemish pre-school children.

OBJECTIVES: The study aimed to describe oral hygiene habits, oral hygiene status and gingival health in Flemish pre-school children and to explore factors associated with these clinical oral health variables. METHODS: Cross-sectional data from 1,071 3-year-old and 1,119 5-year-old children from four geographical areas in Flanders (Belgium) were analysed Buccal plaque accumulation and gingival health were assessed on six index teeth. Data on oral hygiene and dietary habits, oral health behaviour and socio-demographic variables were obtained through questionnaires. RESULTS: 34% of 3-year-olds and 25% of 5-year-olds started brushing before the age of one, 17% of 3-year-olds and 23% of 5-year-olds brushed twice a day. Roughly, 30% of 3-year-olds and 37% of 5-year-olds presented with visible plaque accumulation. In both age groups, only 3 to 4% of children presented with signs of gingival inflammation. Multiple logistic regression models revealed that in both age groups children whose mothers had a college or university degree, had a smaller chance of presenting with visible plaque than children whose mothers had a lower educational level. With gingival health as dependent variable, multiple logistic regression analysis confirmed the major association between bacterial plaque accumulation and the presence of gingivitis. In the oldest age group, children's former exposure to passive smoking was also significantly associated with gingivitis. CONCLUSION: Parents should be motivated to start brushing at an early age and brush thoroughly in order to maintain good oral health in their offspring. Special attention should go to children raised by mothers with a lower educational level.

Correcting for misclassification for a monotone disease process with an application in dental research.

Motivated by a longitudinal oral health study, we evaluate the performance of binary Markov models in which the response variable is subject to an unconstrained misclassification process and follows a monotone or progressive behavior. Theoretical and empirical arguments show that the simple version of the model can be used to estimate the prevalence, incidences, and misclassification parameters without the need of external information and that the incidence estimators associated with the model outperformed approaches previously proposed in the literature. We propose an extension of the simple version of the binary Markov model to describe the relationship between the covariates and the prevalence and incidence allowing for different classifiers. We implemented a Bayesian version of the extended model and show that, under the settings of our motivating example, the parameters can be estimated without any external information. Finally, the analyses of the motivating problem are presented.

Factors that influence data quality in caries experience detection: a multilevel modeling approach.

Caries experience detection is prone to misclassification. For this reason, calibration exercises which aim at assessing and improving the scoring behavior of dental raters are organized. During a calibration exercise, a sample of children is examined by the benchmark scorer and the dental examiners. This produces a 2 × 2 contingency table with the true and possibly misclassified responses. The entries in this misclassification table allow to estimate the sensitivity and the specificity of the raters. However, in many dental studies, the uncertainty with which sensitivity and specificity are estimated is not expressed. Further, caries experience data have a hierarchical structure since the data are recorded for the surfaces nested in the teeth within the mouth. Therefore, it is important to report the uncertainty using confidence intervals and to take the clustering into account. Here we apply a Bayesian logistic multilevel model for estimating the sensitivity and specificity. The main goal of this research is to find the factors that influence the true scoring of caries experience accounting for the hierarchical structure in the data. In our analysis, we show that the dentition type and tooth or surface type affect the quality of caries experience detection.