Many different types of index systems have

Transcription

1 Turkish Dental Students and Dentists Ability to Assess Gingival Health Status with DAAGS Software Melike Camgoz, Ph.D.; Cem A. Gurgan, Ph.D.; Murat Akkaya, Ph.D. Abstract: The aim of this study was to compare the ability of final-year Turkish dental students and dentists to assess the level of gingival health status by using the Development of Ability to Assess Gingival Status (DAAGS) computer program. Forty-eight students in their final year of dental education and 240 dentists participated in DAAGS tests in which they judged twenty-four photos. The participants were organized into one group of students and five groups of dentists: those who graduated in the last five years, in the last six to ten years, in the last eleven to fifteen years, in the last sixteen to twenty years, and twenty and/or more years ago. A gold standard of each photo was shown to participants after they completed test 1; then, test 2 was conducted immediately. Participants were asked to evaluate the DAAGS by written survey. There were significant differences between the parameters of two tests for all groups. Significance levels differed for each group and both tests considering correct answers, reproducibility, irrelevant answers, and overall ability. The findings from this study indicated that the DAAGS software is easier for more recently graduated dentists to use. Dr. Camgoz works at the Presidency of Health Culture and Sports Office, Gazi University, Ankara, Turkey; Dr. Gurgan is Associate Professor, Department of Periodontology, Faculty of Dentistry, Ankara University, Turkey; and Dr. Akkaya is Professor, Department of Periodontology, Faculty of Dentistry, Ankara University, Turkey. Direct correspondence and requests for reprints to Dr. Melike Camgoz, Gazi Universitesi Rektorlugu Saglik Kultur Spor Dairesi Baskanligi, Dis Klinigi Teknikokullar/Besevler 06500, Ankara, Turkey; phone; fax; mlkozcan@yahoo.com. Keywords: Development of Ability to Assess Gingival Status (DAAGS), dental students, dentists, gingival health status, Turkey Submitted for publication 8/2/10; accepted 12/2/10 Many different types of index systems have been developed to define periodontal status during the last decades. 1-5 In the Oral Rating Index (ORI), scoring mainly depends on gingival condition, followed by calculus and plaque accumulation. Each patient s gingival status is undertaken without hand instruments and recorded on a five-grade ordinal scale from -2 (very poor) to +2 (excellent). 3,6 Using the ORI criteria, Dr. Makoto Kawamura developed the Development of Ability to Assess Gingival Status (DAAGS) computer software. This software consists of two courses group and private and three subcourses: 1) the beginners course for youth, 2) the advanced course for oral health instructors, and 3) the superlative course for researchers. 7 We previously tested the DAAGS among Turkish freshman (basic), preclinical, and clinical dental students. 7 Two hundred and thirteen students at these three levels of dental education voluntarily participated in tests in which they judged twenty-four photos. We observed significant differences between the groups for correct and irrelevant answers and overall ability (p<0.001). The basic group showed a significant (p<0.01) improvement between test 1 and test 2. This improvement was greater than that of preclinical students and almost equal to clinical students. The findings from that study indicated that the DAAGS software can serve as a useful instructive tool for education. The aim of the study described in this article was to compare the ability of final-year Turkish dental students and dentists at different years after graduation to assess the level of gingival health status by using the DAAGS program. Materials and Methods The study was carried out in 2003 and The final-year students and graduates of Ankara University Faculty of Dentistry in Turkey participated in the study. The students took the tests other than during the clinical working hours and classes. The dentists were visited at their offices by appointment. The study population consisted of 288 dentists between twenty-one and sixty-seven years of age (mean=34.47). Graduates of other dental schools and specialists were not included because of possible differences in the content of dental education. August 2011 Journal of Dental Education 1127

2 The students formed the first group, and the dentists were divided into five groups according to periods after graduation: dentists who graduated in the last five years (Group 2), those who graduated in the last six to ten years (Group 3), those who graduated in the last eleven to fifteen years (Group 4), those who graduated in the last sixteen to twenty years (Group 5), and those who graduated twenty and/or more years ago (Group 6). Fifty dentists were interviewed for groups 2, 3, 4, and 6; but Group 5 consisted of forty dentists because only forty were present in our city during the interview period. After we explained the ORI scoring, the gold standard (GS; a set of standard color photos from each level of the scale) was presented automatically at the beginning of each test (see Figure 1). Each photo illustrated a different ORI score (Figure 2). Then, the participants were asked to judge each of the twenty-four photos according to ORI criteria. Each randomized photos test contained four photos for excellent, five for good, five for questionable, five for poor, and five for very poor. The correct score according to the GS of each photo was shown after the participants completed test 1; then, test 2 was conducted immediately. The time for judgment was ten seconds for each photo in both tests. 7 The OnTime method in VBA was used to run a procedure periodically. 8 All projections were carried out using the same notebook, although in Group 1 the computer was attached to an LCD projector and white screen. The students took the tests in the same classroom at the same time and wrote their answers on individual sheets for each test. The other study participants also wrote their answers on sheets for each test. During the applications at dental offices, we made sure the medium was not too illumined and direct sunlight did not hit the screen; the lighting was adjusted where necessary. The computer was set in front of the individual to eliminate possible misjudgments resulting from looking through side angles. The participants were asked to set the screen on the mobile cover of the notebook in a way in which they could see most accurately. The DAAGS was applied afterwards. At the end of test 2, a ten-question survey was presented to the participants. They were asked to rate the DAAGS as a computer-aided test tool (CATT) using a scoring system consisting of agree, somewhat Figure 1. DAAGS StartUP screen using an LCD projector: scoring and criteria of the Oral Rating Index (ORI) 1128 Journal of Dental Education Volume 75, Number 8

3 agree, somewhat disagree, and disagree. The survey items were as follows: 1) This index provides us with valuable information to give instruction to youth; 2) This index classified individuals effectively in a group examination; 3) This index has simplicity; 4) This index has reproducibility (test-retest reliability); 5) This index is acceptable to youth; 6) This index motivates youth about their periodontal health care; 7) An advantage of this index is to be able to examine periodontal status without instruments; 8) An evaluation according to this index is inaccurate because instruments are not used; 9) It s necessary for us to practice many times in order to use this index; and 10) This computer program motivates us to understand periodontal health level. DAAGS test results were evaluated as follows on four measures 7 : correct answers were the number of correct answers out of twenty-four photos; for five pairs of identical oral pictures, reproducibility indicated the number of pairs in which the examinee s diagnosis was the same; irrelevant answers were the number of cases in which an examinee s absolute value of diagnosis differed from the correct score according to the GS by three or more points; finally, each examinee received an overall ability score for each test separately. The overall ability scores were calculated according to the following criteria: 1) if the correct answers were more than eight but less than twelve, the examinee received one point; if twelve or more, the examinee received two points; 2) if the reproducibility was two pairs out of five pairs, the examinee received one point; if the reproducibility was three pairs or more, the examinee received two points; and 3) if the number of irrelevant answers was zero or one, the examinee received one point. The maximum score for overall ability on the DAAGS beginners course was 5. If there were identical diagnoses for sixteen or more out of twenty-four photos (e.g., the same score was given to nineteen photos) or if answers to twelve or more out of twentyfour photos were left blank, the scores for that participant were not included in the data analysis. For statistical analyses, SPSS for Windows 10.0 (SPSS Inc., Chicago, IL, USA) was used. The mean values and standard deviations (SD) of each parameter were calculated for six groups. The differences between groups were analyzed by using the Mann-Whitney U test, and the relations between the parameters were analyzed by using Spearman s correlation analysis. The Wilcoxon Figure 2. Examples of cases shown for evaluation, from top to bottom in order: +2 to -2 August 2011 Journal of Dental Education 1129

4 signed rank test was used to analyze the differences between test 1 and test 2 for each group. Descriptive statistics, including standardized group means and their SD, are presented unless otherwise stated. Results The age range (mean age±sd) for Groups 1, 2, 3, 4, 5, and 6 were as follows, respectively: twentyone to twenty-six (22.79±1.20); twenty-three to thirty-two (26.96±1.87); twenty-seven to thirty-six (31.08±2.20); thirty-three to forty-one (36.20±2.03); thirty-eight to forty-seven (40.68±2.18); and fortytwo to sixty-seven (49.86±5.63). The results of the DAAGS tests for each group are shown in Table 1. The highest mean of overall ability and the mean of number of correct answers score belong to Group 3 for test 1 and Group 1 for test 2. The highest mean of reproducibility score was found to be for Group 1, and the highest mean of irrelevant answers score was found to be for Group 6 at both tests. For test 1, the difference between the third and fifth groups was significant (p<0.05), whereas the significance for the difference between the third and sixth groups was more (p<0.01) for correct answers. For reproducibility, the significance between the first and fourth, fifth, and sixth groups and between the third and sixth groups were moderate (p<0.01). However, the significance between the second and sixth and between the third and fourth groups was low (p<0.05). The differences between groups for irrelevant answers were at different rates. The difference between the sixth group and the first, fourth, and fifth groups was at a significant level (p<0.05); but, on the other hand, its difference from the second group was more significant (p<0.01) and the significance for the difference from the third group was high (p<0.001). The overall ability for test 1 revealed different levels of significance among groups. For test 2, the significance for the differences between the sixth group and the first and fourth groups were high (p<0.001); the significance for the differences between the first group and the fifth and between the second and sixth groups were moderate (p<0.01); and the differences between the first and third groups and between the fourth and sixth groups were also significant (p<0.05) regarding correct answers. The significance for the differences between the first and sixth groups, between the second and fourth groups, and between the first and fifth groups was high for reproducibility (p<0.001). However, the difference between the third and sixth groups was significant (p<0.01), and the differences among the fourth, fifth, and sixth groups were significant (p<0.05) for the same parameter. For irrelevant answers, the differences among the first, fourth, and sixth groups were significant (p<0.05). The comparison of overall ability for test 2 also revealed different levels of significance among groups. Table 1. Differences (mean±sd) between the six groups in tests 1 and 2 Test 1 Test 2 Correct Irrelevant Overall Correct Irrelevant Overall Group answers Reproducibility answers ability answers Reproducibility answers ability 1 Mean (n=48) SD Mean (n=50) SD Mean (n=50) SD Mean (n=50) SD Mean (n=40) SD Mean (n=50) SD Total Mean ** 2.94* 1.09* 12.88*** 2.42*** *** (N=288) SD *p<0.05; **p<0.01; ***p< Journal of Dental Education Volume 75, Number 8

5 The results of correlation analysis for the tests are shown in Table 2. The relationships between correct answers for the second and third groups, irrelevant answers for the fourth group, correct answers and irrelevant answers for the fifth group, and correct answers, irrelevant answers, and ability for the sixth group were significant (p<0.001). Discussion At the dental school where this study was conducted, periodontology is taught over three years. The first year (third class) of the course focuses on theoretical education, the second year (fourth class) is accompanied by clinical studies, and the third year (fifth class) consists of clinical training only. Continuing education after graduation is the dentist s responsibility. This study was conducted to compare the ability of final-year dental students and dentists at different years after graduation to assess the level of gingival health status by using the DAAGS computer software program. The DAAGS is a new way of evaluating gingival status and is not commonly used around the world. Since there are no published studies using the DAAGS in literature other than our previous study, which introduced the DAAGS, 7 it was not possible to compare our results with other reports. The results of the present study showed that, without any training with the DAAGS, there was an increase in the number of correct answers and reproducibility and a decrease in irrelevant answers in most of the groups (Groups 1, 4, 5, and 6). In addition, there was an increase in the overall ability for all groups although its calculation depends on the three parameters. The increases observed in the correct answers and reproducibility and the decrease in the irrelevant answers in test 2 were believed to be due to the fact that the participants learned and understood the style of the computer testing and learned how to visually diagnose the gingival status of the cases presented. Furthermore, displaying the correct scores according to the GS at the end of test 1 also must have contributed to their diagnostic ability. The participants might have learned to give correct answers by comparing the correct scores according to the GS with their diagnosis. This might be due to their personal memory of the scores according to the GS including recall and recognition. For Groups 2 and 3, although an increase in correct answers and reproducibility was observed as expected, due to the fact that participants learn about the application and become accustomed to what they should do in test 2, there was an increase instead of a decrease in irrelevant answers. This might be due to individuals inexperience and indecision about definition. Mean values of overall ability of Groups 1, 2, 3, 4, 5, and 6 were 1.0, 1.22, 1.48, 1.04, 0.88, and 0.86 for test 1 and 1.9, 1.76, 1.7, 1.7, 1.48, and 0.96 for test 2. In general, the overall ability in the study population could be classified between 1 (poor) and 2 (fair), ranging between 0 (very poor) and 3 (good) or 4 (excellent). The reason for these low ability scores could be the use of a new index system that was different from traditional ones that the participants have used and a system that did not require utilization of an instrument. Especially for dentists in Groups 4, Table 2. Comparison of evaluated parameters of ORI tests 1 and 2 with Spearman s correlation analysis within groups Group Correct answers Reproducibility Irrelevant answers Overall ability 1 r p value * * N.S. N.S. 2 r p value *** ** N.S. ** 3 r p value *** * ** ** 4 r p value * N.S. *** * 5 r p value *** N.S. *** * 6 r p value *** N.S. *** *** *p<0.05; **p<0.01; ***p<0.001; N.S.=non-significant August 2011 Journal of Dental Education 1131

6 5, and 6, who were also older, it might have been harder to understand and apply the new index system. Although the DAAGS can be considered an instructive tool for education of the novice students, 7 it may be more difficult for those at more advanced ages to perceive and apply an innovation. The mean ability scores of the first four groups were close to each other. This is probably because of similar periodontal education in Turkey for the last fifteen years. Periodontology education including more visual instructional plans and visual communication devices might have affected the outcomes. The DAAGS program is software operated over a computer monitor. The students who saw periodontal diseases over slides and/or computer projections, which have been used commonly in classrooms over the last years, might have succeeded better than those accustomed to this media. Although the ORI in the DAAGS software is not a strict quantitative index for the determination of oral health status and screening by ORI does not make a specific diagnosis of a periodontal condition, it appears helpful for identifying suspected gingival inflammation and level of oral hygiene need. 3,7 As such, it appears to be a useful public health tool to classify a person s effective oral health behavior. All examinees were asked to fill out the ORI/DAAGS estimation survey to obtain their opinions about this innovation. Although 39.6 percent of Group 1, 34 percent of Group 2, 38 percent of Group 3, 32 percent of Group 4, 42.5 percent of Group 5, and 22 percent of Group 6 agreed that the ORI was easy to use (item 3), which reflects the opinion of 34.4 percent of the total study population, their mean overall ability scores indicated otherwise. Most of the participants agreed (30.6 percent, 46.2 percent, respectively) or somewhat agreed (33 percent, 34.7 percent, respectively) that this system was acceptable to young people (item 5) and had an advantage of not having to use hand instruments (item 7). More than 50 percent of the participants agreed or somewhat agreed that it was necessary to practice many times before using the index (item 9). Seventy-five percent had a positive opinion about the DAAGS and indicated that it motivated them to assess a patient s periodontal health status (item 10). Although the participants had positive opinions about the ORI system and regarded it easy to use, their scores indicated otherwise. Conclusions The hypothesis of this study was based on the concept that the more you face a disease, the easier it is to diagnose it. Therefore, we believed that with the increase in years after graduation, overall ability scores would also increase. However, the outcomes were on the contrary. Students and more recent graduates, although with less experience, received higher scores. This indicates that evaluation is much more accurate when the individual has fresh knowledge. As the years pass, dentists knowledge may weaken, and they may need to refresh their oral health knowledge to improve themselves. REFERENCES 1. Greene JC, Vermillion JR. The oral hygiene index: a method for classifying oral hygiene status. J Am Dent Assoc 1960;61: Jackson D. The measurement of gingivitis. Br Dent J 1965;118: Kawamura M, Fukuda S, Inoue C, Sasahara H, Iwamoto Y. The validity and reproducibility of an oral rating index as a measurement of gingival health care and oral hygiene level in adults. J Clin Periodontol 2000;27: Löe H. The gingival index, the plaque index, and the retention index systems. J Periodontol 1967;38: Markkanen H, Paunio K, Paunio I, Rajala M. Reproducibility of a clinical screening method for assessing gingival inflammation, pockets, and plaque retentions. Community Dent Oral Epidemiol 1985;13: Kawamura M, Aoyama H, Sasahara H, Tsuchida K, Nagao M, Iwamoto Y. Behavioral dental science. Part VIII. The dentist s rating and adolescents perceptions of oral health. (In Japanese, abstract in English). J Japanese Soc Periodontol 1998;30: Camgoz M, Gurgan CA, Kajiwara K, Kawamura M. Dental students ability to assess gingival health status with DAAGS software. J Dent Educ 2008;72(1): The OnTime method: scheduling events with OnTime and Windows timers. At: aspx. Accessed: July 21, Journal of Dental Education Volume 75, Number 8