Cross-cultural translation and modification of the revised oral assessment guide for oral health assessment by non-dentists

The study addresses the need for accessible oral health assessment among adults and older individuals, particularly given global population aging, increased systemic disease burden, and barriers to dental care access. Non-dentist health personnel (dental assistants, dental hygienists, community health volunteers, and nurses) can improve early detection and management of oral problems through simple screening tools. The revised oral assessment guide (ROAG) is a widely used tool for non-dental personnel but required cross-cultural translation to Thai and modifications to enhance validity, reliability, inclusion of self-care guidance, and clearer identification of treatment needs (especially teeth and denture issues). The research objective was to translate ROAG into Thai and develop a modified version for non-dentists (ndROAG), then evaluate its measurement properties against a dentist reference standard.

The original Oral Assessment Guide (OAG) was developed for patients undergoing bone marrow transplantation and later adapted (translated into Swedish) for chemotherapy patients. The ROAG was introduced in 2002 for older patients assessed by nurses. It has since been translated into Portuguese, German, and Swedish and used by nurses, community health volunteers, physicians, and caregivers to assess older people. Prior adaptations tailored ROAG for specific contexts, including intensive care and chemotherapy, by adding/removing categories (e.g., focusing on mucosal changes from antineoplastic therapy or on thirst/dry mouth in ICU). Despite these uses, gaps remained: lack of self-care instructions and limited ability to identify treatment needs for teeth and dentures, motivating the present modification.

Design: Cross-sectional study (January–November 2022) approved by the Human Research Ethics Committee, Faculty of Dentistry, Chulalongkorn University (HREC-DCU 2020-103). Participants: Adults and older individuals (≥40 years) and non-dentists (dental assistants [DAs], dental hygienists [DHs], community health volunteers [CHVs], nurses). Exclusions: those declining assessment or unwilling non-dentists. Informed consent obtained; caregivers consented for bedridden or dexterity-limited patients. Settings: (1) Prosthodontic clinic, Faculty of Dentistry, Chulalongkorn University (DAs and dental patients); (2) Dental clinic, Maharat Hospital, Phra Nakhon Si Ayutthaya (DHs and dental patients); (3) Hospitalized patients at Maharat Hospital (nurses); (4) Community-dwelling dependent adults/older people in Maharat District (CHVs). Development Phases: Phase I (Translation): Original ROAG (8 categories: voice, lips, mucous membrane, tongue, gums, teeth/denture, saliva, swallowing; scores 0–2 per category; total 0–16) was translated into Thai using WHO forward–backward methodology with expert panel consensus, producing a pre-test Thai ROAG. Phase II (Pilot/pre-test ROAG-T): Content validity by 10 dentists (4-point Likert suitability and suggestions). Face validity by 5 dentists and 20 non-dentists (5 DAs, 5 DHs, 5 CHVs, 5 nurses) using clear/unclear ratings; items >20% unclear flagged. Training: 3-hour program with photographs and audio clips; non-dentists required κ ≥ 0.80 vs dentist before patient assessments. Inter-examiner agreement between two dentists evaluated in 40 patients (45–89 years). Criterion validity: 20 non-dentists assessed patients vs calibrated dentist (reference). Feedback on unclear descriptions and discrepancies was discussed post-exam. Phase III (Modification to ndROAG): Nine experts (five dentists and one representative each of DA, DH, CHV, nurse) revised assessment methods, category descriptions, self-care instructions, and referral rules. Teeth and denture separated, expanding to 9 categories (voice, lips, mucous membrane, tongue, gums, teeth, denture, saliva, swallow). Three-level responses retained; scores 0–2 per category; total 0–18. Any severe alteration triggers dentist referral. Self-care instructions established by consensus (physicians, nurses, prosthodontists, general dentists). Phase IV (Assessment of ndROAG): Face/content validity repeated with 10 dentists and 20 non-dentists. Criterion validity: 46 non-dentists (9 DAs, 5 DHs, 22 CHVs, 10 nurses) assessed 82 adult/older patients (randomly selected from records) with 1–2 patients per non-dentist, against a calibrated dentist (reference). Inter-examiner reliability between two dentists evaluated in 15 additional individuals. Training: 3-hour sessions per cadre, requiring κ ≥ 0.80 before assessments. One week later, the same 46 non-dentists reassessed the same 46 participants at the same time point for intra-examiner reliability. Phase V (Back-translation): ndROAG forward-back translated to English with expert consensus; developed a pre-test English ndROAG. Measurement and Analysis: Data analyzed in SPSS v29. Dentist served as reference standard. Criterion validity: weighted Kappa (κ) for categorical items; ICC for total score. Interpretations: κ ≤0.2 poor, 0.21–0.40 weak, 0.41–0.60 moderate, 0.61–0.80 good, 0.81–1.00 excellent; ICC <0.50 poor, 0.50–0.75 moderate, 0.75–0.90 good, >0.90 excellent. Internal consistency: Cronbach’s alpha. Sensitivity/specificity: three-level responses dichotomized (healthy vs changed) for each category. Key modifications to procedures included using fingers/gauze instead of a mouth mirror for saliva, adding patient/caregiver reports for voice, swallow, teeth, denture, and detailed criteria for teeth and denture problems and gum inflammation; explicit self-care and uniform referral rule for severe alterations.

Participants: Phase II patients: 80.0% female; mean age 63.1 ± 10.5 years (46–85). Phase IV patients: 84.1% female; mean age 66.1 ± 13.7 years (40–91). Non-dentists (n=46): mean age 63.1 ± 10.5 years (24–70), 2–25 years’ experience. Reliability (dentists): Inter-examiner reliability for pre-test ROAG-T and ndROAG across categories was high (weighted κ ≈ 0.90–0.99). Validity improvements with ndROAG vs pre-test ROAG-T: - Category-level weighted κ (non-dentists vs dentist): Pre-test ROAG-T ranged poor–moderate (e.g., saliva κ=0.10; gums κ=0.302; lips κ=0.388), whereas ndROAG ranged moderate–excellent (voice 1.00; swallow 1.00; gums 0.89; dentures 0.89; mucosa 0.88; tongue 0.86; teeth 0.84; lips 0.82; saliva 0.71). - Total score ICC: pre-test ROAG-T 0.69 (poor–moderate) vs ndROAG 0.91 (excellent; 95% CI 0.86–0.94). - Cronbach’s alpha: ndROAG 0.671 vs pre-test ROAG-T 0.599 (≈12% higher). Diagnostic performance (ndROAG; healthy vs changed): - Sensitivity (%) by category: voice 100.0; lips 97.4; mucous membrane 75.0; tongue 85.7; gums 84.8; teeth 97.8 (n=67); dentures 87.5 (n=46); saliva 57.1; swallow 100.0. - Specificity (%) by category: 100.0 for all except teeth 90.9. Intra-examiner reliability (non-dentists): κw 0.75–0.99 (lowest in saliva). Feasibility: Mean CHV assessment time ~11 minutes (range 5–15). Overall, ndROAG showed higher validity, reliability, and acceptable sensitivity/specificity, with saliva being the most challenging category.

Translating ROAG into Thai and systematically modifying it into ndROAG addressed identified gaps by enhancing clarity of assessment methods and criteria, adding self-care instructions, and standardizing referral decisions. Separating teeth and denture categories improved the ability to localize problems and determine treatment needs (e.g., addressing plaque/debris, broken teeth, mobility, retained roots, denture chipping and dislodgement), which are common issues in adults and older adults. The tool also incorporated practical adjustments for community settings (e.g., replacing mouth mirror with finger/gauze for saliva assessment; leveraging patient/caregiver reports for voice, swallowing, teeth, and denture issues). Compared with previous ROAG adaptations that narrowed focus for specific clinical contexts (chemotherapy, intensive care), ndROAG broadened scope to general adult and older populations while improving measurement properties. The ndROAG achieved moderate–excellent agreement with a dentist reference across categories, excellent ICC for total score, and improved internal consistency. The saliva category remained the most challenging due to the subjectivity of tactile-based friction assessment, explaining relatively lower κ and sensitivity. Inclusion of clear self-care instructions for mild alterations and a simple rule that any severe alteration warrants dental referral provides actionable guidance for non-dentists and streamlines care pathways. The results support using category-level scores for screening and the continuous total score for monitoring change over time. Overall, ndROAG can strengthen primary healthcare capacity by enabling timely detection, self-care, and appropriate referral, fostering interdisciplinary collaboration and potentially improving oral health outcomes.

The original ROAG was translated into Thai and revised into a non-dentist version (ndROAG) with improved validity and reliability. ndROAG enables non-dentists to assess oral health in adult and older individuals for early detection of oral changes, provide standardized self-care instructions, and guide patient referral.

- Cross-sectional design: responsiveness (ability to detect changes over time) was not evaluated. - Dentist-centric reference and referral in the study may not reflect multidisciplinary pathways required in practice; referral options may vary by setting. - Generalizability: further studies are needed to confirm validity across other non-dentist cadres, patients with functional limitations, and residential care settings. - Translation: additional validation of the English version and other language translations is needed. - Training and implementation: broader training for DHs and CHVs is necessary to support scale-up in primary oral healthcare.