Face and Content Validation of Caries Assessment Spectrum and Treatment Index among Few Subject Matter Experts in India

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1 International Journal of Dental Health Concerns (2015), 1, 1-6 Doi: /ins.ijdhc.4 ORIGINAL ARTICLE Face and Content Validation of Caries Assessment Spectrum and Treatment Index among Few Subject Matter Experts in India Sushil Phansopkar 1, Sahana Hegde-Shetiya 1, Arishka Devadiga 1, Deepti Agrawal 1, Amit Mahuli 2, Simpy Mittal-Mahuli 2 1 Department of Public Health Dentistry, Dr. D. Y. Patil Vidyapeeth s Dr. D. Y. Patil Dental College, Pimpri, Pune, Maharashtra, India. 2 Department of Public Health Dentistry, NIMS Dental College, Jaipur, Rajasthan, India. Correspondence: Dr. Sushil Phansopkar, Department of Public Health Dentistry, Dr. D. Y. Patil Vidyapeeth s Dr. D. Y. Patil Dental College, Pimpri, Pune , Maharashtra, India. Phone: , sushil3558r@yahoo.co.in How to Cite: Phansopkar S, Hegde-Shetiya S, Devadiga A, Agrawal D, Mahuli A, Mittal-Mahuli S. Face and content validation of caries assessment spectrum and treatment index among few subject matter experts in India. Int J Dent Health Concern 2015;1:1-6. Received: Accepted: ABSTRACT Introduction: The proposed new index by Dr. Frencken: Caries Assessment Spectrum and Treatment (CAST) Index. It addresses the assessment of clinical stages of carious lesion progression in enamel, dentine, pulp and cavity restored under 9 codes. Content validity as a part of psychometric testing was conducted by Frencken in Brazil, which included 15 countries and India was not included. Hence, the aim of this study was to assess the face and content validity of CAST Index in India. Materials and Methods: Face and content validity of CAST Index was conducted amongst dentists with post-graduate degree qualification (Conservative and Endodontics, Pediatric Dentistry, Public Health Dentistry and Oral Medicine and Radiology) in India. The proforma for content and face validation containing the description of the index along with the original article was given in person to 20 Subject Matter Experts (SME s) through convenience sampling. Results: The SME s concluded that face validity of CAST Index seemed to be a reasonable way of recording dental caries, and it was feasible and appropriate with certain modifications to use in the Indian population. The content validity ratio of all the codes of CAST Index showed that the ACCEPTABLE codes were 0, 2, 3, 5, 6, 7 and 8. Conclusion: The CAST Index could be used for epidemiological surveys in India but with a few modifications of the original index. Furthermore, its application can be justified due to a varied population with different socio-economic and cultural backgrounds in India and it also covers the entire spectrum of dental caries. Key words: Caries assessment spectrum and treatment, caries epidemiology, caries index, decayed, missing, filled teeth, International Caries Detection and Assessment System, pulpal involvement, ulceration, fistula and abscess. INTRODUCTION Dental indices are a powerful tool to quantify the disease; to establish the prevalence of any oral disease in a population, appropriate index must be used and its psychometric properties must be tested for that population. Dental caries is one of the prevalent diseases in India, According to National Oral Health Survey Decayed, Missing, Filled Teeth (DMFT) values ranged from 1.2 to 2.6, which was low, when compared with the world. Prevalence of dental caries within India was found to be high i.e., % of the population according to the national survey conducted by Dental Council of India DCI (2003). [1] Indices used in Recording Dental Caries The most commonly used indices for recording of dental caries is DMFT/Surface (DMFT/S) index by Klein, Palmer and Knuston (1938); [2] World Health Organization (WHO) modification of DMFT index 1987 and [3] The def Index by Gruebbel (1944) for measuring dental caries in primary dentition; [4] Significant Caries Index by Bratthall (2000) is a reliable tool for focusing on children with high caries experience. [5] The Root Caries Index by Katz in 1979 for detection of root caries; [6] Filled/Sound Teeth Index by Sheiham et al. in 1987 proposed a different approach for the assessment of dental caries. The basis for the calculation of this index was the number of teeth with preserved function. [7] Newer Indices Newer indices are constantly being developed to record dental caries more accurately, precisely and more efficiently. These newly introduced indices included, the International Caries Detection and Assessment System (ICDAS-I, ICDAS-II) by 1

2 ICDAS Foundation [8,9] and the Pulpal involvement, Ulceration, Fistula and Abscess (PUFA) index published by Monse et al. [10] The ICDAS indices does not record the pulpal involvement occurring as a consequence of severe dental caries whereas on the other hand PUFA did not record the enamel, dentinal or root caries lesions as it was concerned with only the extreme ends of the caries disease spectrum. [11] Authors of caries assessment spectrum and treatment (CAST) Index have tried to combine the advantages of three indices namely ICDAS II, PUFA and M- and F-components of DMF Index by WHO. It has been designed to record the caries in enamel, dentine, pulp, along with sealants and restorations and teeth lost due to caries. The CAST Index explains the complete spectrum of dental caries, going from one extreme to the other. Frencken stated that the quantity and the quality of information that can be gathered from a whole population through the adoption of this new index clarified the extent of dental caries and facilitated easy communication between the dental community and policy makers. [11] Thus having all these data accumulated in one index, the spectrum of dental caries status was justified, and various strategic treatment protocols to deal with it were developed. The CAST Index has already been validated (face and content validity) in 15 different countries like Canada, Mexico, Brazil, Chile, South Africa, Tanzania, Nigeria, Iraq, Turkey, Finland, Germany, United Kingdom, China, Thailand and Australia but, it s validation in India has not been done. [11,12] Before any index can be recommended for widespread use, it has to be validated in the country of use. CAST Index has not been validated in India. It was an invited research with prior permission from the author to validate this index in India. In the present study, the SME s selected were dentists with a postgraduate degree qualification in India. MATERIALS AND METHODS A questionnaire study was conducted from November 2012 to February 2013, in which, dentist s from dental institutions with post-graduate degree qualification (M.D.S) i.e., (5 - Conservative Dentist and Endodontist, 5 - Pediatric Dentist, 5 - Public Health Dentist and 5 - Oral Medicine and Radiologist) in India were included for validation of the CAST Index. The proforma for validation and original CAST Index manuscript titled The CAST Index: Rational and development from the International Dental Journal 2011 was personally handed over to all the 20 SME s. The first part consisted of face validity, the second part consisted of content validity and the third part consisted of additional questions (suitability, appropriateness, acceptability, implementation, sequence of codes of CAST Index and its use for epidemiological surveys, clinical research and use in deciduous dentition) based on the CAST Index. Convenience sampling technique was adopted. A type of non-probability sampling technique in which there was no sample design and sample size calculation. The Scientific Committee approval was obtained from the institutional review board of Dr. D. Y. Patil Dental College and Hospital, Pimpri. The following steps were followed for validation of questionnaire; Formulation of CAST Index: Face validation Content validation Face validity: Face validity is not really validity but refers to the appearance of the questionnaire (Table 1): Does it look professional or carelessly and poorly constructed? Professionallooking questionnaires are more likely to elicit serious responses. It is an important consideration for both the pre-test and the final product. Hence, the face validity of the codes of CAST Index was done with 20 SME s. [13,14] a. Content validation: In order to assess the content validity of the CAST Index the SMEs were asked to determine if each of the codes (0-9) were essential or non-essential and also justify the reason for it by writing their comments for each code. Content validity ratio (CVR) was calculated for the content validity of the CAST Index. [13] Table 1: CAST Index codes Characteristic Code Description Sound 0 No visible evidence of a distinct carious lesion is present Sealant 1 Pits and/or fissures are at least partially covered with a sealant material Restoration 2 A cavity is restored with an (in) direct restorative material Enamel 3 Distinct visual change in enamel only. A clear caries related discoloration is visible, with or without localized enamel breakdown Dentine 4 Internal caries related discoloration in dentine. The discolored dentine is visible through enamel which may or may not exhibit a visible localized breakdown of enamel 5 Distinct cavitation into dentine. The pulp chamber is intact Pulp 6 Involvement of the pulp chamber. Distinct cavitation reaching the pulp chamber or only root fragments are present Abscess/Fistula 7 A pus containing swelling or a pus releasing sinus tract related to a tooth with pulpal involvement Lost 8 The tooth has been removed because of dental caries Other 9 Does not correspond to any of the other descriptions The codes and descriptions of the hierarchical CAST epidemiological index for primary and permanent teeth, used per surface. CAST: Caries Assessment Spectrum and Treatment 2

3 The formula for CVR CVR = (n e N/2)/(N/2) Where, CVR = Content validity ratio n e = Number of dentist s with post-graduate degree qualification indicating essential N = Total number of dentist s with post-graduate degree qualification The data were collected and analyzed for CVR in Microsoft Excel Worksheet (.xlsx) 2010 version. The various CVR values for all codes are mentioned in Table 2. [13,14] RESULTS Face Validity The SME s concluded that, the CAST Index seemed like a reasonable way to gain information regarding dental caries and it would be appropriate to use in the Indian population but it is too extensive, time consuming and complex, in comparison with regularly and commonly used DMFT/S index (1938) by Klein, Palmer and Knutson. Content Validity Table 2 shows the CVR ratio of all the codes of the CAST Index. The NOT-ACCEPTABLE codes were 1, 4 and 9 while the ACCEPTABLE codes were 0, 2, 3, 5, 6, 7 and 8. Comments by the Indian SME s on the CAST codes were; for Sound (0): Identification of initial carious lesions in enamel (incipient or white spot lesions) could be affected by subjective bias/interpretation. Sealants and restoration (1 and 2): In case of restorations needing replacement i.e., restorations with caries where should secondary caries be coded? Dentin (4): As the author has not included the type of dental examination to be performed or the instruments to be used (visual alone or visual + tactile), many SMEs felt that adjunctive use of radiographs would help in a clearer diagnosis. Subjective interpretation would be an issue for dentin and pulp (5 and 6). Lost (8) was subjected to Table 2: CVR values Codes CVR Interpretation (min: 0.42) ACCEPTABLE NOT ACCEPTABLE ACCEPTABLE ACCEPTABLE NOT ACCEPTABLE 5 1 ACCEPTABLE 6 1 ACCEPTABLE ACCEPTABLE ACCEPTABLE NOT ACCEPTABLE CVR: Content validity ratio recall bias and hence care has to be taken to elicit a proper history. This is especially true in countries like India where extraction is a rule (rural areas and urban slums) rather than an exception for treatment of any type of dental problems. DISCUSSION The collection of cumulative caries indices available for epidemiological researchers do not cover the total spectrum of carious lesion progression. For example, the ICDAS II system does not cover those carious lesions that involves the pulp and beyond the pulp i.e., the peri-apical region. The PUFA index covers the carious lesions involving the pulp and peri-apical tissues but not the initial caries attack to enamel and dentine. In contrast, the CAST Index integrates the various stages of carious lesion progression and abscesses/fistulae as well as preventive and restorative care in a single-digit coding system. This study was carried out to assess the face and content validity of the CAST Index in India. The comments reported, give an idea of how the CAST Index is being interpreted by SME s in India. The codes deemed essential for the Indian population were the 0, 2, 3, 5, 6, 7 and 8 and the codes not essential were 1, 4 and 9. Codes Code 0 (Sound) was acceptable because it gave a baseline data of the condition being examined, namely dental caries. A few SME s pointed out that identification of initial carious lesions in enamel (incipient or white spot lesions) could be affected by subjective bias/interpretation. A variation existed in regards to sensitivity and specificity of conventional caries detection methods, were given by Bader et al. [15] and Pretty and Maupome. [16] Conventional method of detecting caries is based on subjective interpretation by visual examination and tactile sensation, confirmed by radiographs, which may give a differential diagnosis related to early caries detection. It is recognized that the current methods cannot detect carious lesions until it has relatively reached a tertiary stage, involving one-third or more of thickness of enamel. [16,17] It is therefore concluded that conventional methods for dental caries detection do not comply with the criteria for an ideal caries detection method especially in case of initial lesions. Therefore many SMEs felt that there was a need to place such lesions into a separate category preferably termed questionable lesions category. Code 1 (Sealant) was non-acceptable as this code was of less relevance for the Indian population as the dental practice trend seen here is more of curative therapy rather than preventive therapy both from the dentist as well as from the patient s point of view. This was also seen in a study conducted by Galarneau and Brodeur [18] in which 10 distinct regions of the teeth containing a pit or crack were analyzed by 20 dentists, and for which they had 3

4 to choose a specific treatment. In all, the intervention decisions were rather spread across the diversity of choices, encouraging, especially amalgam (29%), then the dental sealants (25%) and, thirdly, conservative composite resin restoration (19.5%). Most SME s also raised the question as to where should restorations needing replacement i.e., restorations with caries be coded? According to the recent article on CAST Index which was published after the commencement of this study, it stated that if a tooth with secondary caries around sealant is present then the more severe code should be considered i.e., caries (Code 3) over sealant (Code 1). [19] Code 2 (Restoration) was acceptable because it gave a treatment status of the tooth and helped in calculating the F component of DMFT index. Many SME s found that, if a tooth which was filled also had caries on another surface it would lead to a problem in CAST scoring. This issue was sorted in the CAST Index article, [19] which stated that if a tooth with secondary caries with restoration was present then the more severe code was considered i.e., caries (code 3) over restoration (code 2). [19] The only controversy was regarding the designation of in (direct) restorations as it confused many SME s. The index needs to be more specific in describing the in (direct) restorative materials like Inlays, on-lays, crowns and temporary crowns. The recent manuscript on CAST Index [19] did not specify the details about the in (direct) restorations. Code 3 (Enamel) was acceptable as this code could be used to assess the D component as in the case of the DMFT index as it gave caries status of the tooth involving the enamel. However, the only drawback pointed out by the SME s was that the visible discoloration without enamel breakdown could be prone to subjective interpretation, especially in cases of extrinsic stains, enamel hypoplasia, mild fluorosis, and developmental disorders. Code 4 (Dentine) was non-acceptable and many SME s wanted this code to be clubbed with code 5. The SME s stated that inter-observer differences are likely to occur due to difficulty in differentiating code 3 (caries in enamel) from code 4 (early dentinal caries) and difficulty in diagnosing dentinal caries without visible enamel breakdown/cavitation just on basis of discoloration without the use of radiographs, especially in the proximal regions. Studies [15,20-22] have shown that sensitivity values for visual examination of teeth in detecting proximal carious lesions was around while the specificity values were usually higher than Around approximately 70% of cavitated caries lesions would be missed during visual inspection alone. The authors concluded that the use of a bitewing radiography as an appendage to the clinical examination could predict more accurate detection of proximal and occlusal caries lesion in dentin and provide better estimation of lesion depth than the visual inspection alone. Moreover, the surveillance of carious lesions could be more promising and authentic than the traditional clinical examination parse. As the author has not included the type of dental examination to be performed or the instruments to be used (visual alone or visual + tactile), many SME s felt that adjunctive use of radiographs would help in a clearer diagnosis of Code 4, reducing subjective interpretation leading to a more sensitive index. In the absence of such adjuncts, the clubbing of codes 4 and 5 seemed more appropriate. Code 5 (Dentine) was acceptable but again here the subjective interpretation would vary between code 4 and 5. Rather combining the two codes (4 and 5) would make it easy for assessing and scoring both the CAST as well as the DMFT score. Combining both codes 4 and 5 would not affect the dentinal caries score of an individual in specific or the CAST score in general. Code 6 (Pulp) was acceptable and gave a clear picture of the tooth status and the treatment needs of the condition could be diagnosed based on this code. This code also assessed the D of the DMFT index as it gave caries status of the tooth involving the pulp. Even though the CAST Index recorded only the disease status and didn t mention the treatment need, most of the SME s looked at an index not only in terms of just recording the disease status but also focused on the possible treatment options for a particular code as in case of dentition status and treatment needs. Code 7 (Abscess/fistula) was acceptable and gave a clear picture of the tooth status and the treatment needs of the condition could be diagnosed based on this code. This code does not have much impact on the treatment plan so could be clubbed with code 6. This code could also be included in the D of the DMFT index as it gave caries status of the tooth involving the dentine and pulp. Code 8 (Lost) was acceptable as it gave the M status of the DMFT index and also interpreted the attitude of the individual toward dental care needs and utilization. A tooth could be lost for any number of reasons ranging from dental caries, periodontal disease, trauma, orthodontic reasons etc. In order to record this code it is essential that the individual provides accurate history for reasons for tooth loss and differentiate those teeth lost due to caries from those lost due to other causes. This code is therefore subjected to recall bias and hence care has to be taken to elicit a proper history. This is especially true in countries like India where extraction is a rule (rural and urban slums) rather than an exception for treatment of any type of dental problems. The WHO in 1997 modified the DMFT Index to include all teeth lost, irrespective of the disease process in M component in individuals above the age of 30 years and older. [3] The SME s were therefore interested to know if such a modification could be applied to the CAST Index which could be more appropriate in the Indian context. Code 9 (Other) was non-acceptable because it did not specify what other dental disease conditions to consider under it 4

5 apart from dental caries, like the physiological and pathological anomalies related to tooth and oral tissue apparatus. There were two similar studies conducted by Dr. Frencken which included 15 and 27 countries that included all codes and was done using On-line Rand modified e-delphi consensus method [11,12,19] Furthermore, the recent article on CAST published in 2013 [19] stated various changes in the index. i.e., in cases where two codes are assigned consider the severity of the condition that comes first and code accordingly. Hence, certain doubts raised by the SME s were cleared and discussed. Recommendations The CAST Index recommended by Indian SMEs is framed in Tables 3 and 4. CONCLUSION The face and content validation of the CAST Index enabled the SME s from India to effectively contribute to its development. Based on their comments and suggestions, the CAST codes were placed in a stratified order according to the SME s for the Indian population and codes and descriptions were improved accordingly and a recommended version of CAST Index for the Indian population was mentioned in the recommendation section. It has been stated by the author that construct validity and reliability of the CAST Index are in progress. Table 3: Comparison of the CAST Index Characteristics Codes Original CAST index Sound 0 Sealant 1 Restoration 2 }Treatment clubbed Enamel 3 Dentine 4 5 }Clubbed Pulp 6 Abscess/fistula 7 }Clubbed Lost 8 }Split Other 9 }Deleted CAST index recommended by Indian SME s Sound 0 Questionable lesion 1 Enamel 2 Dentine 3 Pulp 4 Restored 5 Lost (missing) 6a 6b CAST: Caries Assessment Spectrum and Treatment, SME s: Subject Matter Experts The CAST Index could be a promising tool to be used for epidemiological surveys in India, as it covers the whole spectrum of caries progression from incipient to advanced carious lesions, followed by the treatment status of the tooth. The SME s would have preferred if treatment needs were also mentioned following the codes, and hence it would help the dentist plan a well-defined treatment protocol for the same in the field survey or in a clinical setting. Also, the author has not stated the use of instrumentation and type of dental examination to be used while recording the CAST Index in an epidemiological survey or clinical trials, which can in future determine the specificity and sensitivity of the CAST Index. The most recent trend is the use of the probe to evaluate enamel surface texture (smooth or rough for enamel lesions; hard or soft dentine for dentinal lesions. Another recommendation is evaluation of the presence of discontinuities in enamel or microcavitation by using the WHO probe, which is ball-ended with a sphere presenting 0.5 mm in the extremity, allowing this kind of evaluation for better sensitivity and specificity. [23] It is expected that CAST Index can become a suitable instrument for use in epidemiological surveys in India once it is being applied practically. Whether the CAST Index is also Table 4: CAST Index recommended by Indian SMEs Characteristics Codes Description Sound 0 No visible evidence of a distinct carious lesion. The surface of enamel appears smooth and unpitted or discolored Questionable lesion 1 Discoloration of enamel (white or brown in color) without cavitation or enamel breakdown/loss of translucency of enamel Enamel 2 Distinct visual change in enamel. A clear carious related discoloration (white or brown in color) is visible, including localized enamel breakdown without clinical visual signs of dentine involvement Dentine 3 Enamel appears grayish black due undermining as a result of dentin involvement or presence of distinct cavitation into dentine. No (suspected) pulpal involvement is present Pulp 4 Involvement of pulp chamber. Distinct cavitation reaching the pulp chamber or only root fragments are present (root pieces) or pulpal involvement with pus, abscess, fistula, sinus tract etc. Restored 5 A cavity restored with a direct/indirect or permanent/temporary restorative material without a dentine carious lesion and no fistula/abscess present Lost (missing) 6a 6b The tooth has been extracted because of dental caries. Due to any other reason in persons above the age of 30 years CAST: Caries Assessment Spectrum and Treatment, SME s: Subject Matter Experts 5

6 applicable clinically in private practice and at undergraduate level is still a hypothetical research question. The CAST Index would be suitable for the Indian population but with a few modifications of the original index. The CAST Index could be used for epidemiological surveys in India, as a varied population with different demographic and socioeconomic backgrounds exist. The author Frencken could generate a separate CAST Index for the Indian population based on the criteria s mentioned earlier. ACKNOWLEDGMENT I would like to acknowledge the academic support of the Subject Matter Experts for their support and assistance for the validation of CAST Index. REFERENCES 1. Bali RK, Mathur VB, Talwar PP, Chanana HB. Oral health status. In: National Oral Health Survey and Fluoride Mapping. India, New Delhi: Dental Council of India; p. 114, Klein HT, Palmer CE, Knutson JW. Studies on dental caries I dental status and dental needs of alimentary school children. Public Health Rep 1938;53: World Health Organization Geneva. Oral Health Survey Basic Methods. 4 th ed. Delhi: AITBS. Publishers and Distributors; p Bagińska J, Rodakowska E. Current dental caries indices: Review of literature. J Stomatol 2012;65: Bratthall D. Introducing the significant caries index together with a proposal for a new global oral health goal for 12-yearolds. Int Dent J 2000;50: Katz RV. Development of an index for the prevalence of root caries. J Dent Res 1984;63: Sheiham A, Maizels J, Maizels A. New composite indicators of dental health. Community Dent Health 1987;4: Jablonski-Momeni A, Stachniss V, Ricketts DN, Heinzel- Gutenbrunner M, Pieper K. Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro. Caries Res 2008;42: Diniz MB, Rodrigues JA, Hug I, Cordeiro Rde C, Lussi A. Reproducibility and accuracy of the ICDAS-II for occlusal caries detection. Community Dent Oral Epidemiol 2009;37: Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Palenstein Helderman W. PUFA An index of clinical consequences of untreated dental caries. Community Dent Oral Epidemiol 2010;38: Frencken JE, de Amorim RG, Faber J, Leal SC. The caries assessment spectrum and treatment (CAST) index: Rational and development. Int Dent J 2011;61: Souza de AL, Sanden van der WJ, Leal CS, Frenken EJ. The caries assessment spectrum and treatment index (CAST): Face and content validation. Int Dent J 2011;62: Lawshe CH. A quantitative approach to content validity. Pers Psychol 1975;28: Greco LD, Walop W. Questionnaire development: 1. Formulation. Can Med Assoc J 1987;136: Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying carious lesions. J Public Health Dent 2002;62: Pretty IA, Maupome G. A closer look at diagnosis in clinical dental practice: Part 5. Emerging technologies for caries detection and diagnosis. J Can Dent Assoc 2004;70:540a-i. 17. Stookey GK, González-Cabezas C. Emerging methods of caries diagnosis. J Dent Educ 2001;65: Galarneau C, Brodeur JM. Inter-dentist variability in the provision of fissure sealants. J Can Dent Assoc 1998;64: Frencken JE, de Souza AL, van der Sanden WJ, Bronkhorst EM, Leal SC. The caries assessment and treatment (CAST) instrument. Community Dent Oral Epidemiol 2013;41:e Braga MM, Morais CC, Nakama RC, Leamari VM, Siqueira WL, Mendes FM. In vitro performance of methods of approximal caries detection in primary molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e Novaes TF, Matos R, Braga MM, Imparato JC, Raggio DP, Mendes FM. Performance of a pen-type laser fluorescence device and conventional methods in detecting approximal caries lesions in primary teeth In vivo study. Caries Res 2009;43: Yang J, Dutra V. Utility of radiology, laser fluorescence, and transillumination. Dent Clin North Am 2005;49: Braga MM, Mendes FM, Ekstrand KR. Detection activity assessment and diagnosis of dental caries lesions. Dent Clin North Am 2010;54: