tagedni n t e r n a t i o n a l d e n t a l j o u r n a l 7 3 ( 2 0 2 3 ) 5 6 6 − 5 7 3Scientific Research Report

TagedH1Standardised Practice-Based Oral Health Data
Collection: A Pilot Study in Different CountriesTagedEn
TagedPSean Taylor a, Sarah R. Baker b, Tom Broomhead b, Rachael England a*,
Steve Mason c, Michael Sereny d, Georgios Tsakos e, David M. Williams fTagedEn
aTagedP FDI World Dental Federation, Geneva-Cointrin, Switzerlandb
Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, UKcHaleon (formally known as GSK Consumer Healthcare), Weybridge, UKdPrivate Dental Practice, Hannover, GermanyeDepartment of Epidemiology and Public Health, University College London, London, UK
fBart’s and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK

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TAGEDPA R T I C L E

I N F OTAGEDPA B S T R A C T

Article history:

Background: The Oral Health Observatory (OHO), launched in 2014 by FDI World Dental Fed-

Received 17 July 2022

eration, aims to provide a coordinated approach to international oral health data collec-

Received in revised formtion. A feasibility project involving 12 countries tested the implementation of the

12 February 2023

methodology and data collection tools and assessed data quality from 6 countries.

Accepted 13 February 2023

Methods: National dental associations (NDAs) recruited dentists following a standardised

Available online 14 March 2023TagedEn

sampling method. Dentists and patients completed paired questionnaires (N = 7907) about

TagedEnTagedPKey words:

patients’ demographics, dental attendance, oral health−related behaviours, oral impacts,
and clinical measures using a mobile app. In addition, participating dentists (n = 93) com-

Impacts

pleted an evaluation survey, and NDAs completed a survey and participated in workshops

Practice-based research

to assess implementation feasibility.

Standardised

Results: Feasibility data are presented from the 12 participating countries. In addition, the 6

Implementation

countries most advanced with data collection as of July 2020 (China, Colombia, India, Italy,

Feasibility TagedEn

Japan, and Lebanon) were included in the assessment of data quality and qualitative evaluation of implementation feasibility. All NDAs in these 6 countries reported interest in collecting standardised, international data for policy and communication activities and tounderstand service use and needs. Eighty-two percent of dentists (n = 76) reported a patient
response rate of between 80% and 100%. More than 70% (n = 71) of dentists were either satisfied or very satisfied with the patient recruitment and data collection methods. There
were variations in patient oral health and behaviours across countries, such as self-reporting twice-daily brushing which ranged from 45% in India to 83% in Colombia.
Conclusions: OHO provides a feasible model for collecting international standardised data in dental practices. Reducing time implications, ensuring mobile app reliability, and allowing practitioners to access patient-reported outcomes to inform practice may enhance implementation.
Ó 2023 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation. This is
an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/)TagedEn

TagedH1IntroductionTagedEn
TagedPStandardised, international data on oral conditions andhealth care services are needed to effectively evaluate andplan oral health policies and services. Across countries,
they can enable comparisons of the impact of different
health policies and benchmarking of oral health and services for advocacy purposes.1 However, such data are currently lacking, in part due to the high costs of conducting* Corresponding
TagedEnauthor. FDI World Dental Federation, Chemin de
Joinville 26, 1216 Geneva, Switzerland.
E-mail address: rengland@fdiworlddental.org (R. England).
Sean Taylor: http://orcid.org/0000-0002-5031-3588
Sarah R. Baker: http://orcid.org/0000-0002-2861-451X
Steve Mason: http://orcid.org/0000-0002-3841-2313
Georgios Tsakos: http://orcid.org/0000-0002-5086-235X
https://doi.org/10.1016/j.identj.2023.02.002
0020-6539/Ó 2023 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

tagedns t a n d a r d i s e d p r a c t i c e - b a s e d d a t a c o l l e c t i o nnational oral health surveys and the complexity of coordinating standard approaches internationally.2−4TagedEn
TagedPTo facilitate the collection of internationally standardisedoral health data, FDI World Dental Federation (FDI) and theInternational Consortium for Health Outcomes Measurement(ICHOM) developed a set of oral health outcome measures,
the FDI-ICHOM Adult Oral Health Standard Set (AOHSS), thatcovers a comprehensive spectrum of patient-centred oral
health outcomes.5TagedEn
TagedPIn parallel, FDI established the Oral Health Observatory(OHO) project to provide a mechanism for data collection.
OHO seeks to collect robust data that can be used tounderstand patterns of oral health and dental services ata national level and provide international comparisons.
Data on oral health care will importantly provide insightsfrom both service providers and service users and also
combine these with data about dental practices and service delivery. This will allow the comparison of patientreported oral health measures with clinical data to consider the impact of oral conditions, assess treatment
needs and expectations, and assess how dental service
characteristics may influence patients’ oral health andbehaviours. It could also complement epidemiologic databy providing an inexpensive data collection method topartly fill data gaps when national oral health surveys are
not feasible.TagedEn
TagedPThe aim of this study was to pilot a standardised international oral health data collection instrument in routine clinical dental practice and evaluate its feasibility.TagedEn
TagedPTwelve countries were involved in this initial phase of the
OHO project: Armenia, China, Colombia, Germany, India,
Italy, Japan, Kenya, Lebanon, Poland, South Africa, and Tanzania. Oral health data are reported from the 6 countries
most advanced with data collection as of July 2020, when the
project stopped due to the COVID-19 pandemic: China,
Colombia, India, Italy, Japan, and Lebanon.TagedEn

TagedH1MethodsTagedEn
TagedH2Study designTagedEn
TagedPThis was a cross-sectional, analytical observational study. A
mobile app containing 2 separate questionnaires, one completed by the patient and the other by the dentist about thepatient’s clinical oral health status, was used to generate data
in dental practice. A third online questionnaire collected
information from dentists about the dental practices in whichdata were collected. All variables are listed in Supplementary
Table 1.TagedEn
TagedPTo evaluate implementation feasibility, 6 national dental associations (NDAs) and 191 dentists who had completed or nearly completed data collection by April 2020
were sent an anonymous survey. Responses were received
from 5 NDAs and 93 dentists by November 2020. Additionally, 2 workshops were organised in November 2020 withthe 6 NDAs. Feasibility data relating to dentist recruitment
and the time required to collect data are presented fromall 12 participating countries.TagedEn

567

TagedH2Questionnaire developmentTagedEn
TagedPThe 3 questionnaires about patient oral health and dental
practice characteristics were developed through expert consensus.1 Clinical and patient-reported oral health measures
were selected from commonly used measurement instruments.5 Over 3 review rounds, the expert group selected themeasures considered most important for assessing oral
health and its determinants in dental patients. Questionnaires were translated into the appropriate languages by professional translators and verified by NDA staff fluent inEnglish.TagedEn

TagedH2Country selectionTagedEn
TagedPTo test the application of the tools and methodology indiverse settings, the study was open to FDI member NDAs
with the capacity to implement the study protocol. Countries
without an active FDI member NDA or where the NDA was
not willing or able to participate were ineligible.TagedEn

TagedH2Dentist sampling and recruitmentTagedEn
TagedPA stratified cluster sampling method was used to select sites.
For each NDA that showed an interest in participating in the
study, registered dentists were clustered according to the primary administrative division (e.g., state, province) in which
they were located. The number of dentists to be recruited ineach cluster was set according to the proportion of thenational population living there. Then, dentists were randomly selected per cluster from the list of all dentists in thatcluster. A minimum sample of 24 dentists per country wasset, in line with common sample sizes used in feasibility
studies that do not seek to estimate effect size.6 Participating
dentists were sent the guidance document in Appendix A
before beginning the study.TagedEn

TagedH2Patient sampling and recruitmentTagedEn
TagedPA modified systematic sampling method was used to sample
participants amongst all patients attending the dental clinic during the study period. One patient was surveyed each working
day according to the order in which they arrived in the practice;on the first day of the study the first patient was surveyed, on
the second day of the study the second patient was surveyed,and so on. If the selected patient declined, the following patient
was invited to participate. This methodology provides a simple
sampling technique, without the need for additional tools, tominimise the risk of error or dentist dropouts.TagedEn
TagedPParticipating patients received the information sheet inAppendix B. Fifty patients per dentist were surveyed. To be
eligible, patients had to be able to give informed consent andbe a resident in the study country. For children younger than12, parents gave proxy consent. Consent was obtained
through the mobile app.TagedEn
1
TagedEn Questionnaires were developed by 4 experts with specialisation and experience in dental public health, global oral health,and general dental practice.

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taylor et al.

TagedEnTable 1 – Dentist recruitment per country.
Country

Data collection status
by July 2020

No. of dentists
in sample

Recruitment
periodProportion of dentists incountry included in study
populationa

Armenia
China
Colombia
Germany
India
Italy
Japan
Kenya
Lebanon
PolandSouth Africa
Tanzania

Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Ongoing
Completed
Not started
Ongoing
Not started
Ongoing
Not started

27
70
26
27
75
27
29
25
26
29
26
26

36 weeks
40 weeks
21 weeks
N/A
4 weeks
6 weeks
34 weeks
N/A
8 weeks
N/A
N/A
37 weeks

49%
27%
8%
69%
28%
50%
51%
21%
67%
N/A
51%
37%

Countries in bold are those with data included in the present study.
aProportion is calculated using the number of dentists registered with the participating national dental association and the number of dentists in the country
according to the World Health Organization Global Health Observatory (https://www.who.int/data/gho).

TagedH2Data collectionTagedEn
TagedPData were encrypted when stored on the app and transferred
to FDI’s secure servers. Patients completed the patient questionnaire using a tablet computer whilst waiting to begin
their appointment. The dentist completed the dentist questionnaire during the appointment or later using the patient
record. Dental practice data were collected one time only via
an online survey.TagedEn

TagedH2Implementation and monitoringTagedEn

declining to participate included conflict with planned
national oral health surveys, national political and/or economic instability, and inability to commit the required
resources to the project.TagedEn
TagedPThree of the twelve recruited countries had not started
data collection when the project was put on hold in July 2020,
mainly due to the length of the ethical approval process.TagedEn

TagedH2Dentist recruitmentTagedEn

TagedPA preliminary descriptive analysis of 6 countries was carriedout, which included detailing each survey variable and segmenting the data according to country and key demographics(e.g., age, sex).TagedEn

TagedPTable 1 shows the number of dentists recruited, the recruitment period, and the proportion of dentists within eachcountry that are a member of the NDA and therefore includedin the study population.TagedEn
TagedPThe median length of time taken to complete dentist
recruitment was 27.5 weeks. Three out of five NDAs that completed the relevant questionnaire reported that dentist recruitment was amongst the main challenges they faced and thatthe time implications for dentists was the main barrier. Four offive NDAs reported that the time commitment of the study
was the main reason for dentist dropouts. In countries that
had started data collection, the dentist dropout rate was 19%.TagedEn

TagedH1ResultsTagedEn

TagedH2Patient recruitmentTagedEn

TagedPBy July 2020, OHO was being implemented in 12 countries. At
this point, data collection had stopped in all countries due tothe COVID-19 pandemic. The below results report the oral
health data and evaluation survey and workshop responses
from the 6 countries most advanced with data collection.
Data about country and dentist recruitment recorded during
project implementation are also reported.TagedEn

TagedPEighty-two percent of dentists (n = 76) reported an acceptance
rate of between 80% and 100% of patients invited to participate in the study. Seventy-seven percent (n = 71) of dentists
were either satisfied or very satisfied with the patient selection method. The most common reasons for patient nonparticipation reported by dentists were lack of time (63%, n = 59)
and not being interested in the topic (27%, n = 25). Dentists’evaluation of the patient recruitment procedures is detailedin Supplementary Table 2.TagedEn

TagedPNDAs obtained appropriate ethical approval according tonational regulations. Several NDAs organised training workshops or individual calls with participating dentists.TagedEn

TagedH2Data analysisTagedEn

TagedH2Country recruitmentTagedEn
TagedPCountry recruitment began in May 2017. Twenty-two countries responded to the call to run the study nationally andwere invited to participate, and 10 accepted. A further 2 countries contacted FDI to request to join the project. Reasons forTagedH2Data collection, mobile app, and questionnairesTagedEn
TagedPFourteen percent of dentists reported that data collection
took longer than 50 working days, most commonly due to569

tagedns t a n d a r d i s e d p r a c t i c e - b a s e d d a t a c o l l e c t i o n

TagedEnTable 2 – Data collection status of dentists and number of patients surveyed per country.
Country

Proportion of dentists
having started datacollection

Proportion of dentists
having finished datacollection

Median No. of patientssurveyed per dentist

Length of data collection
periodArmenia (n = 27)
China (n = 70)
Colombia (n = 26)
Germany (n = 27)
India (n = 75)
Italy (n = 27)
Japan (n = 29)
Lebanon (n = 26)
South Africa (n = 26)

48%
90%
96%
22%
75%
89%
100%
100%
35%

0%
43%
77%
0%
27%
44%
93%
84%
4%

0.5
40.5
50
0
28
39.5
50
50
0

6 weeks
70 weeks
48 weeks
6 weeks
123 weeks
105 weeks
52 weeks
38 weeks
29 weeks

problems with the app and data synchronisation. Most dentists were satisfied (48%, n = 45) or very satisfied (25%, n = 23)
with the use of the mobile app for data collection. During theworkshops, NDAs reported some problems related to the app;however, they also noted the advantages of the method used,notably the lower cost compared to other national-level datacollection projects. Problems included missing data and trouble submitting responses in rural areas in some countries due
to slower internet connections.TagedEn
TagedPTable 2 shows the data collection status per country andthe median number of patients surveyed by each active dentist. In no country did all dentists complete the data collection, and only in Japan and Lebanon did all recruited dentists
start data collection. As shown by the length of data collection periods, dentist recruitment and data collection took longer than planned in all settings.TagedEn

TagedH2Use of resultsTagedEn
TagedPAll NDAs stated that they intend to use the results to advocate for improved oral health policies and for communication
campaigns, mentioning the importance of international
standardised data for benchmarking. They suggested that thedata could be used to understand patterns of dental service
use and reasons for not attending and to advocate better care
integration. Some NDAs mentioned that in the absence ofrecent national oral health survey data, OHO results could
provide insights into oral disease prevalence and determinants at a national level.TagedEn
TagedPAmongst dentists, only 17% said they had adapted theirclinical practice due to participation in the OHO project. However, 89% stated that they would want to be able to accesstheir patient’s individual responses, to inform patient communication and education (49% of dentists, n = 46), or to
inform treatment decisions (40% of dentists, n = 37). Dentists’feedback about the data collection process and intended useof results is detailed in Supplementary Table 2.TagedEn

age was between 36 and 39 years. India had the greatest sexrelated difference in dental attendance, with 39% of patients
being female.TagedEn
TagedPFigure 1 shows the variation across countries in patientsself-reported brushing frequency and sugar consumption.
Between 78% and 83% of patients reported brushing twice ormore per day in all countries except Lebanon and India.
Patients in China and India predominantly brush their teeth
before breakfast, whilst those in Colombia, Italy, and Japanare more likely to do so after breakfast. In India, patients
reported the highest sugary food consumption frequency,with 32% of patients answering twice a day or more, compared with 11% in China. In all countries, most patients had
visited a dentist in the last year, ranging between 51% in India
and 80% in Japan. Patients in China and India were the most
likely to have never visited a dentist.TagedEn
TagedPAmongst patients who had not visited a dentist in the past
year, the most common reported reasons were their dental
problems not being serious enough, being too busy, being
afraid of or not liking dentists, or having nothing wrong with
their teeth.TagedEn
TagedPFigure 2 shows the self-rated oral health of patients.
Patients in all countries were most likely to rate their oral
health as “good” or “very good,” except in Japan where morepatients rated their oral health as “poor” or “very poor.” Oral
impacts were common in all countries and followed similar
patterns. Between 24% and 47% of patients had experienced
pain, and between 20% and 36% had experienced difficultyeating or chewing during the last 12 months due to problems
with their mouth or teeth.TagedEn
TagedPFigure 3 shows the results of 2 dentist-reported variables.
Periodontal status varied across countries, with 23% of
patients in Japan being categorised as having a healthy periodontal status vs 56% in Colombia. The mean number of
untreated caries in patients ranged from 1.8 in Japan to 3.7 in
Lebanon.TagedEn

TagedH1DiscussionTagedEn
TagedH2Preliminary results of data collectionTagedEn
TagedPSupplementary Table 3 describes patient demographics, oral
health-related behaviours, and oral health outcomes fromthe 6 countries most advanced with data collection.TagedEn
TagedPPatients’ mean age was older in Italy (45 years) and Japan(53 years) than in the other countries, where mean patient

TagedPThe successful dentist recruitment and dentists’ high levelsof satisfaction with the methodology demonstrate the feasibility of collecting data through dental practices. The highpatient participation rates indicate that the methodology is
acceptable to patients. This is aligned with previous studies
that have suggested the feasibility of collecting both patient-TagedEn570

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taylor et al.

Fig. 1 – Toothbrushing frequency and sugar consumption.TagedEn

reported health data and clinical oral health data in healthcare settings7,8 and the feasibility of using mobile apps forpractice-based data collection.9 The results of this study suggest that such methods can be used across diverse countries
and to collect data relevant for both clinical and policy objectives. The time taken to begin study implementation varied
notably across countries, mostly due to the ethical approval
process and resources available to dedicate to dentist recruitment. Similarly, data collection took longer than intended in
all cases, due in part to the need to replace dentist dropouts.

TagedEn

TagedFiur

Overall, countries should expect project implementation totake more than 1 year.TagedEn
TagedPSeveral lessons can be drawn to inform future data collection efforts. Further financial support to countries andadapted implementation periods to avoid clashes with othernational surveys may help increase country participation.
Efforts to demonstrate the value of the research and assist
people in using the mobile app should be made to avoid
potential sources of sampling bias. Testing of data collection
apps in all project settings and with large quantities of data

Fig. 2 – Self-rated oral health.TagedEn

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tagedns t a n d a r d i s e d p r a c t i c e - b a s e d d a t a c o l l e c t i o n

571

Fig. 3 – Periodontal status and teeth with untreated caries.TagedEn

may help identify problems before implementation. Theselessons are similar to those that have been discussed in otherprojects outside of dentistry. For a example, a study assessing
the feasibility of collecting physical activity measures thougha smartphone app noted the importance of data feedback
and personalisation to improve acceptability of the tool.10
Other studies using mobile app−based surveys in low-income
settings have discussed challenges related to internet connection and device charging that can be barriers to data collection and transfer.11,12TagedEn
TagedPThe results also demonstrate the potential implicationsand value of such data collection initiatives. Variations in risk
factors such as sugar consumption and dental attendance
highlight the need for tailored oral health promotion programmes and policies per country. For example, in India, thecountry where patients most frequently reported consuming
sugar twice a more times per day, a recent initiative launchedby the Indian Dental Association and FDI identified several
population-level priority actions to reduce sugar consumption.13 Based on these initial results, it may also be importantto prioritise behavioural interventions to improve toothbrushing frequency in India and Lebanon given lower rates of
twice-daily brushing, a suggestion in line with other published studies.14,15 In Italy, health authorities may choose tofocus on promoting tobacco cessation services,16 particularly
in dental practice. Demographic segmentation or data collection in specific population groups could help further target
these activities. This information would be valuable in
informing population-level interventions in lower-resource
settings, where the financial costs required to conductnationally representative population surveys is prohibitive.17TagedEn
TagedPInformation about patients’ self-rated health and oral
impacts show the potential to evaluate care needs andexpectations or identify service gaps.18−20 For example, therelatively high number of patients reporting pain experiencesin Lebanon may suggest a need for improved access to or
demand for preventive dental care. Patient demographic data
may also be used to identify access issues in specific population groups. In a larger study, segmentation of data by geographic region or dental practice type could inform thedevelopment of more targeted access programmes.21 Furthermore, combining subjective and clinical oral health outcomesas well as behavioural measures (all of which are collected aspart of the OHO data collection tool) can be helpful in identifying treatment needs for population groups and targeting
services accordingly.TagedEn
TagedPUnderstanding patients’ expectations and oral impacts
can also be used in making treatment decisions and evaluating care outcomes.5,20 This is reflected in the high proportionof participating dentists who would like to access individual
patient responses to inform patient communication andtreatment decisions. To draw further insights into careaccess, affordability, and quality, additional questions related
to the treatments and services provided, equipment used,and care costs could be integrated into the questionnaire
about dental practice characteristics.22,23 Further analysis
and consideration of national and regional/local context arealso needed to understand what may be driving these variations and how they can be addressed.24TagedEn
TagedPThere are limitations to the described methodology,
related to the representativeness of data collected in the dental practice using a mobile app. Care should be taken not tooverinterpret the preliminary results. This does not take theplace of a national epidemiologic survey, but in many countries these are neither affordable nor feasible. The study does
provide important information about the oral health status
and attitudes of patients attending for dental treatment,
which is relevant for developing oral health policy and services. It should also be noted that the project was implemented
by FDI member associations, which may result in a more positive evaluation of the project implementation and feasibility.
To counter this, the evaluation surveys were run anonymously and NDAs were reminded of the importance of frankand open feedback prior to the evaluation workshops.TagedEn

TagedH1ConclusionsTagedEn
TagedPThis study demonstrated the feasibility of collecting international standardised data in dental practices using a

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taylor et al.

mobile app and the interest amongst dental practitioners
and national associations in using patient-reported outcomes to inform clinical practice. OHO may provide anaffordable and robust way to conduct standardised oral
health surveys.TagedEn

TagedH1Conflict of interestTagedEn
TagedPSteve Mason is employed by Haleon (formally known as GSK
Consumer Healthcare). He reports no other conflicts of interest regarding the work under consideration for publication or
relevant financial activities outside the submitted work. Sean
Taylor, Sarah R. Baker, Tom Broomhead, Rachael England,
Michael Sereny, Georgios Tsakos, and David M. Williams
report no conflicts of interest regarding the work under consideration for publication, no relevant financial activities outside the submitted work, and no patents or copyrights.TagedEn

TagedH1AcknowledgementsTagedEn
TagedPThe Oral Health Observatory project was conceived by the FDIOHO Task Team and managed by the FDI Education and Public Health department with funding from Haleon.TagedEn
TagedPThe authors sincerely thank all National Dental Associations, dentists, and patients who participated in the Oral
Health Observatory project.TagedEn
TagedPSpecial thanks go to the national project leads: Professor
Yi Liu and Ms Alice Jiang (Chinese Stomatological Association); Dr Mauricio Garcia, Dr Johanna Hernandez, and Ms
Nancy Hernandez (Colombian Dental Federation); Dr Aarti
Prabhu, Dr Kunal Oswal, and Ms Ashwini Avasare (Indian
Dental Association); Dr Angela Rovera and Mr Luca Vettore(National Association of Italian Dentists); Professor Hiroshi
Ogawa (Japan Dental Association); and Dr Dany Daou and Dr
Mohamad Mashmoushi (Lebanese Dental Association).TagedEn
TagedPThanks also go to Dr Mariana Pinheiro de Araujo for her
help in preparing the manuscript.TagedEn

TagedH1FundingTagedEn
TagedPThis work was supported by Haleon (formally known as GSK
Consumer Healthcare).TagedEn

TagedH1Supplementary materialsTagedEn
TagedPSupplementary material associated with this article can befound in the online version at doi:10.1016/j.identj.2023.02.002.TagedEn

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