The global aging population necessitates increased accessibility to oral healthcare, particularly for older and dependent individuals who often face barriers to accessing dental services. Simple oral health screenings by non-dental healthcare personnel could significantly improve oral health outcomes for this population. Dental personnel include dentists, dental assistants (DAs), dental hygienists (DHs), and in Thailand, community health volunteers (CHVs) who act as primary healthcare providers. The Revised Oral Assessment Guide (ROAG) by Andersson et al. is a comprehensive tool for non-dental professionals, but requires adaptation for different cultural contexts and populations. This study aimed to translate the ROAG into Thai and modify it to increase its validity and reliability for use by non-dentists in Thailand, including DAs, DHs, CHVs, and nurses, enhancing oral health screening accessibility for a wider range of individuals. The existing ROAG needed modifications to incorporate self-care instructions and improve its ability to identify dental treatment needs, particularly in the teeth and denture categories. The study aimed to address these limitations in the Thai context.

Several tools exist for non-dentists to assess oral health. A systematic review highlighted the ROAG as one of the most comprehensive tools available. The ROAG originated from the Oral Assessment Guide (OAG), developed to evaluate oral health in bone marrow transplant patients. Andersson et al. translated and modified the OAG into the ROAG, which has since been translated into several languages and adapted for various populations, including intensive care patients and individuals undergoing chemotherapy. These adaptations involved removing or adding categories to suit the specific needs of each population. However, the existing ROAG lacked detailed self-care instructions and needed improvements in its ability to identify dental treatment needs, particularly for teeth and dentures. Therefore, the current study addressed these limitations.

This cross-sectional study, conducted from January 2022 to November 2022, involved adult and older individuals (≥40 years) and non-dentists (DAs, DHs, CHVs, and nurses). The study comprised five phases: Phase I: Translation of the ROAG into Thai using WHO guidelines (forward and backward translation, expert panel consensus). Phase II: Pilot study of the Thai ROAG (pre-test ROAG) to assess content and face validity using a four-point Likert scale (dentists) and dichotomous scale (dentists and non-dentists). Inter-examiner reliability between two dentists was evaluated using weighted Kappa (κ). Non-dentists underwent training and needed to achieve an 80% κ before assessing patients. Phase III: Modification of the ROAG based on Phase II feedback from nine experts (five dentists, one each from DAs, DHs, CHVs, and nurses). The modified ROAG for non-dentists (ndROAG) was created, separating teeth and dentures into two categories (resulting in nine categories). Self-care instructions were added. Phase IV: Assessment of the ndROAG's measurement properties. Face and content validity were evaluated, similar to Phase II. Criterion validity was tested by 46 non-dentists assessing 82 patients, with a calibrated dentist as the reference standard. Inter- and intra-examiner reliability were evaluated using weighted Kappa (κ) and Intraclass Correlation Coefficient (ICC). Phase V: Translation of the ndROAG back into English using forward-backward translation and expert consensus. Data analysis used SPSS version 29.0, with criterion validity assessed using weighted Kappa (κ) for three-level responses and ICC for the continuous summation score. Internal consistency was determined using Cronbach's alpha. Sensitivity and specificity were calculated after dichotomizing the three-level response into healthy and changed.

The study involved 82 adult and older patients (mostly female, mean age 63.1-66.1 years) and 46 non-dentists (mean age 63.1 years, 2-25 years of experience). Inter-examiner reliability between two dentists for both the pre-test ROAG and ndROAG was high (90-99% κw). Criterion validity of the ndROAG showed moderate to excellent agreement (κw), with significantly higher values than the pre-test ROAG. ICC values indicated poor agreement for the pre-test ROAG and excellent agreement for the ndROAG. Cronbach's alpha for the ndROAG was 12% higher than the pre-test ROAG. Sensitivity of the ndROAG ranged from 57.1% (saliva) to 100%, and specificity from 90.9% to 100%. Intra-examiner reliability (κw) ranged from 0.75 to 0.99, with the lowest value in the saliva category. The mean assessment time for CHVs was 11 minutes.

The ndROAG demonstrated improved validity and reliability compared to the original ROAG when used by non-dentists. Modifications, including the addition of self-care instructions and a clearer structure, improved the tool's usefulness. Comparisons with previous modifications of the ROAG highlight the unique contribution of this study; while others simplified or excluded categories, the current study expanded the categories to better assess teeth and denture problems. The inclusion of patient and caregiver responses addressed the limitations of solely relying on direct observation. Specific improvements, such as separating the teeth and denture categories and adding detailed criteria for each, enhanced the tool's ability to identify problems and guide appropriate interventions. While the saliva category demonstrated lower reliability, possibly due to the subjective nature of tactile assessment, the overall improvement in validity and reliability validates the ndROAG's effectiveness.

The study successfully translated and revised the ROAG into the ndROAG, significantly improving its validity and reliability for use by non-dentists. The ndROAG provides a valuable tool for assessing oral health in adults and older individuals, facilitating early detection of oral changes, providing self-care instructions, and guiding appropriate referrals. Future research should focus on evaluating the ndROAG's responsiveness to changes over time, its application in diverse settings, and its translation into other languages. Training programs for non-dental professionals are crucial to ensure the widespread and effective implementation of the ndROAG.

The cross-sectional design limits the evaluation of the ndROAG's ability to detect changes over time. The reliance on a dentist as the reference standard, while necessary due to a lack of a standardized oral health assessment, does not fully reflect real-world application where a multidisciplinary approach is often required. The generalizability of the findings may be limited to the specific context of the study, and further research is needed to confirm the ndROAG's validity and reliability across various populations and settings. Additional research is needed in different cultural settings and with individuals with cognitive impairment.