Oral Health Survey

Dr yeguna.w Ayele
 What is an Oral Health Survey?

• A survey is a system for collecting information to describe, compare, monitor changes in oral
health status, knowledge, attitudes, and behavior.
 What’s OHS
• Basic oral health surveys provide a sound basis for assessing the current
oral health status of a population and its future needs for oral health care.
WHAT’S OHS
• Oral health is integral to general health and supports
individuals participating in society to achieve their potential.
• Yet oral diseases are the most widespread noncommunicable
diseases affecting almost half of the world’s population (45% or
3.5 billion people worldwide) over the life course from early life
to old age.
• WHO’s Global oral health status report (GOHSR) provides the first-ever
comprehensive picture of oral disease burden and highlights
challenges and opportunities to accelerate progress towards universal
coverage for oral health
• In order to undertake international comparisons, WHO encourages
Member States to report information on disease levels using
standardized methods.
 Oral Health Surveys helps

• Planning
• Writing a protocol
• Obtaining resources
• Collecting data
• Analyzing data
• Reporting the results
 OHS

• Surveys to determine the oral health status and treatment needs of

common unities and populations are an essential part of the duties of
chief dental officers and other administrators responsible for oral
health care services (WHO, 1997).
CONT…

• The World Health Organization (WHO) has a long tradition of

epidemiological survey methodology, which includes a
description of the diagnostic criteria that can be readily
understood and applied in public health programs worldwide.
 Use of Oral Health Surveys

• To determine the extent to which existing

oral health services are coping with the
current need for care.
 USE CONT….

• To determine the nature and extent of required

preventive, curative and restorative services.
Cont…

• To determine the resources needed to establish, maintain,

expand or reduce an oral health care programmer, including an
estimate of the number and type of personnel required.
PLANNING

• an systematic approach to defining the problem, setting the

priorities, developing specific goals & objectives , determining
alternative strategies, and a method of implementation’’
• E. C Banfeild defined “Plan is a decision about a course of
action”
USE OF PLANNING

• Match limited resources with many problems

• Eliminate wasteful expenditures or duplication of
expenditure
• Develop best course of action and to accomplish a
defined objective
TYPE OF HEALTH PLANNING
• Problem solving planning
• Program planning
• Coordination of efforts and activities planning
• Planning for allocation of resource
PLANNING STRATEGY FLOW

1.Identify the problem

2. Determining priorities
3. Development of program goals, objectives and activities
4. Resource identification
5. Identifying constraints
6. Identify alternative strategies
7. Develop implementation strategy
8. Implementation
9. Monitoring
10. Evaluation
1.IDENTIFY THE PROBLEM

• Identify the problem Conduct a need assessment: Needs

defined as “Deficiencies in health that call for preventive,
curative & eradication measures” WHO 1971
 Reason for Needs Assessment....CONT
• Defines the problem
• Identifies the extent & severity
• Provides a profile of the community to ascertain the causes of the
problem
• Helps in evaluating the effectiveness of the program
NA…INCLUDE
• THE INFORMATION SHOULD INCLUDED
• Number of individuals in the population
•Geographic distribution of the population
•Rate of growth
•Population density and degree of urbanization
•Ethnic backgrounds
•Diet and nutritional levels
•Standard of living
•Amount and type of public services and utilities
NA SHOULD …ALSO..INCLUDE

• General health profile

• Patterns and distribution of dental diseases Analysis of
data
• Once this is obtained from the needs assessment, the
information must be analyzed before the priorities are
determined
NEXT STEP 2.PRIORITY DETERMINATION…
• ‘Priority determination’ is a method of imposing people’s value
& judgment of what is important onto the raw data
• Is used to rank the problems according to the severity & helps
to utilize resources tactically
• If priorities are not determined then program may not serve
the people in need
When setting priorities…CONT

• for a community the planner must ask

• How serious is the problem?
• What percent of the population is affected by it
3.DEVELOPMENT OF Program Goals, Objectives
Activities

• Program goals are broad statements on the overall

purpose of a program to meet a defined problem.
• Program objective are more specific and describe in a
measurable way the desired end result of program
activities.
OBJECT SHOULD specify the following…CONT
• WHAT: Nature of the situation or Condition to be attained
• EXTENT: Scope & Magnitude of the situation or Condition to be
attained
• WHO: Particular group or Portion of the environment in which the
attainment is desired
• WHERE: Geographic areas of the program
• WHEN: Date by which the desired situation or condition is intended
to exist
Program activity how to bring about the desired
results….CONT

• Includes three component

• What is going to be done
• Who will be doing it
• When it will be done
4.Resource identification

• Resource identification Implies manpower, money,

material, skills, knowledge,& Technique needed or
available for implementation of the program
• Balance has to struck with what is required & what
is available
6.IDENTIFY THE CONSTRAINS

• Road blocks’ or ‘obstacles’

• Identification of Constraints early in the planning stage
• Can modify design of the program
• Create a more practical & realistic plan
CONSTRAINTS…CONT
Constraints may be as a result of
• Organizational policies
• Resource limitations
• Characteristics of the community such as
• lack of funding,
• labor shortages,
• restrictive governmental policies,
• inadequate transportation systems,
• negative attitudes.
One of the best way to identify constraints ..CONT

• To bring together a group of concerned citizens who might in

some capacity be involved in or affected by the project.
• A group that is familiar with local politics and community
structures can not only identify the constraints but also offer
alternative strategies and solutions for meeting the goals.
7.IDENTIFY ALTERNATIVE STRATEGIES…CONT

• Presence of existing constraints & available resources

• Planner Should consider Alternative Strategies
• Help achieve objectives
• Sufficient number of alternative plans should be at hand
IDENTIFY ALTERNATIVE STRATEGIES…cont
• Should help decide the most suitable plan either
individually or in combination
• Which should match the limited resources &
anticipated costs & effective in return to the main plan
8.DEVELOP IMPLEMENTATION STRATEGY

• An implementation strategy for each activity is complete when the

following questions are answered.
1. The effect of the objective to be achieved
2. WHAT- The activities required to achieve the objective
3. WHO- Individuals responsible for each activity
4. WHEN- Chronological sequence of activities
5. HOW- Materials, methods, techniques to be used
6. HOW MUCH- A cost estimate of materials and time
IMPLEMENTION STRATEGY…..

• To develop an implementation strategy, the planner must know

what specific activity he/she wants to do.
• The most effective method is to work backwards to identify the
events that must occur prior to initiating the activity
9.IMPLEMITING CONT..
• Implementing the process of putting the plan into operation is
referred to as implementation
• The implementation process involves individuals, organizations
and the community.
• Only through team work between the individual and the
environment can implementation be successful
Most health programs can be divided into four phases of implementation,
which are:

• The pilot phase: whose development proceeds on a trial and error basis
• The controlled phase: where a model of a particular program strategy is run
under regulated conditions to judge its effectiveness
• The actualization phase: where a model of the program strategy is
subjected to realistic operating conditions
• The operational phase: where the program is an ongoing part of the
structure
10.MONITOURING
• Monitoring refers to the maintenance of an ongoing watch
over the activities of an health service.
• Monitoring often denotes not only watching, but using the
observation as basis for continual modification of goals, plans or
activities.
MONITOURUNG…..CONT
• The data typically collected for monitoring include:
• Input data: Eg – financial/budgetary reports, personnel available and vacancies existing,
transportation records, equipment and supplies purchased
• 2. Process data: Eg – specific activities carried out in completing the program, the
sequence in which they are carried out and their timing
• 3. Out put data: Eg – services or goods provided (such as the proportion of target
population served)
11.EVALUATION

• Evaluation measures the degree to which objectives and targets

are fulfilled and the quality of the results obtained.
• It measures the productivity of available resources in achieving
clearly defined objectives.
• It makes possible the reallocation of priorities and of resources
on the basis of changing health needs
Criteria used in evaluation

1. Effectiveness
2. Efficiency
3. Appropriateness
4. Adequacy
EFFECTIVNESS
• Effectiveness- It has been defined as “ the ration between the
achievement of the program activity and the desired level
which, during the planning process, the planners had proposed
would result from the program”.
EFFECTNESS..CONT

• WHO 1974 Three variables are useful in evaluation

effectiveness:
1.Resources
2. Activities
3. Objectives
• Efficiency - as been defined as “the result that might be
achieved through expenditure of a specific amount of resources
and the result that might be achieved through a minimum of
expenditure.”
• WHO 1974 It is a measure of the resources spent (money, men,
material and time) in the process of providing a health care
program.
OTHER CRITERIA USED IN EVALUATION….

• Adequacy - measure of adequacy is the extent to which the

population in need was covered by the services or the extent to
which the services covered the various aspects of the
underlying problem.
Type of evaluation
• There are different types of evaluation depending on the object
being evaluated and the purpose of the evaluation.
• The most important basic types of evaluation are, Formative
evaluation Summative evaluation
TYPE OF EVALUTION..CONT..
• Formative refers to the internal evaluation of a program. It is an
examination of the activities of a program, as they are taking
place.
• It is usually carried out to aid in the development of a program in
its early phase.
• It is used primarily by the program developers as to whether they
are workable or whether changes should be made to improve
program activities
SUMMATIVE EVALUATION…CONT
• It judges the merit or worth of a program after it has been in
operation. It is an attempt to determine whether a fully
operational program is meeting the goals for which it was
developed.
• Summative evaluation is aimed at program decision makers,
who will decide as to a programs continuation or termination
and also at decision makers from other programs who might be
considering adoption of the program.
CONCLUSION
• Can play a vital role in helping to avoid mistakes or
recognize hidden opportunities. Planning helps in
forecasting the future, making the future visible to
some extent.
• It bridges between where we are and where we want
to go
Planning helps in forecasting the future….
Key features of a good survey
• Specific objectives and straightforward
research questions.
• Clear definition of the population.
• Appropriate size of the sample.
• Sound sampling procedures.
• Reliable and valid survey instruments.
• Trained and calibrated examiners and
interviewers.
• Appropriate examination area and good cross-
infection control.
 Key features…cont
• Ensure emergency care and
referral.
• Appropriate data analysis.
• Accurate reporting of survey
results.
• Reasonable resources.
• Pilot study.
• Detailed survey protocol.
 Outline for a Survey Protocol

• Title
• Background Data and information required Objectives
• Population to be studied
• Sample size
• Sample selection criteria
• Survey procedures
Outline for a Survey Protocol cont…
• Survey procedures
• Data collection and instruments
• Data analysis
• Plans Reporting
• Plans Research team Facilities, equipment, supplies
• Budget
• Time schedule
Basic Methods. 4th ed, 1997. Geneva, WHO
• The WHO manual Oral Health Surveys provides: a Basic
Methods has encouraged countries to conduct standardized
oral health surveys that are comparable internationally.
• The WHO Global Oral Health Data Bank collates the data
gathered through country surveys on the burden of oral disease
and WHO recommended statistical analysis on key indicator age
groups of children and adult
The manual provides

• Basic Methods. 4th ed, 1997. Geneva, WHO A description of

diagnostic criteria that can be readily understood and applied in
all countries
• Information on means of obtaining practical assistance for
planning and implementing surveys, summarizing data and
analyzing results.
 Aims of the manual

• To provide a systematic approach to the collection and reporting of data

on oral diseases and conditions.
• To ensure that data collected in a wide range of environments are
comparable.
• To encourage oral health administrators in all countries to make standard
measurements of oral diseases and conditions as a basis for planning oral
health care services.
• The manual provides:
• Guidelines on a practical and economic sample design suitable for
assessing oral diseases and treatment needs for planning and monitoring
oral health services.
Oral Health Surveys: Basic Methods. 4th ed, 1997.
Geneva, WHO
• The manual was not designed to collect information about
etiological factors affecting disease distribution or severity,
or to test the clinical effectiveness of different preventive or
care procedures.
• The manual provides a guide to implementing brief
intervention programmers in primary care settings,
highlighting facilitators and barriers to implementation.
• Oral Health Surveys: Basic Methods. 4th ed, 1997. Geneva,
WHO.
• Guide for estimating the level of disease:
• Low Level of disease Prevalence < 80%
• Moderate Level of disease Prevalence < 95% and> 80%
• High Level of disease Prevalence > 95%
In this new edition of the manual, the basic methods have been
brought up to date to include recent developments in oral
care and epidemiological techniques
Structure of this manual
• Section 1- outlines the principles of clinical oral health surveys
as recommended by WHO. These include guidance for
conducting the survey, the diagnostic criteria, reliability of data
and selection of participants
• The forms give the essential elements of the survey report and
examples of tables that should be prepared from statistical
analysis of the data that have been collected are also provided
as separate annexes
Section 2 cont..
• Section -2 explains the approach of WHO to development of
integrated oral health information systems.
• The risk factor model, which provides the conceptual
framework for inclusion of self-reported oral health and risk
factors within STEPS, is further detailed in this section.
• Additional measurements such as diabetes testing, and height
and weight for calculation of the body mass index (BMI) may be
included.
Section -3 cont..

• Section-3 describes analysis of data and reporting of the

results;
• In addition, this section provides information on the
assistance available from WHO.
Special characteristics of oral diseases

• The particular epidemiology of oral diseases has permitted

development of an approach to sample design and survey
planning for the most common oral diseases.
• The special considerations concerning the two major oral
diseases – dental caries and periodontal disease – are as follows.
• The diseases are strongly age-related.
• The diseases exist in all populations, varying only in prevalence
and severity.
Special characteristics cont..

• One of the diseases, dental caries, is irreversible (at the

cavitation level used in the methods described here), and thus
information on current status provides data not only on the
amount of disease present but also on previous disease
experience.
Special cont…

• There is extensive documentation on variation in profiles of oral

disease among population groups with different socioeconomic levels,
behavioral characteristics and environmental conditions.
• Standardized measurement in each subject requires several
observations to be made; in the case of caries for each tooth and for
the assessment of periodontal status for each tooth present in the
mouth, with the exception of loss of attachment, Index ages and age
group
Sample selection
• Prior to sample selection, public health administrators and
survey planners need to decide whether the survey will be
carried out at local, regional or national level, the variables that
will be examined in the survey and the age groups to be
included.
• It is important to take these factors into consideration
especially later in the process, i.e. when making inferences
from the results of the survey to the population of the region or
the country
 TECHNIQUES FOR ESTIMATING THE SAMPLE SIZE OF A
POPULATION
• The two major methods are probability and non probability
sampling.
• Depending on resources available and technical conditions,
probability sampling can be executed in a number of ways including
simple random sampling, systematic sampling, stratified cluster
random sampling, probability proportional to size, as well as other
variations.
• Investigators are encouraged to consult these texts and obtain
advice from statisticians as a preliminary step in survey design.
 Probability selection methods cont…
• Probability selection methods With a probability sample, each individual in the study
population has a known, non-zero chance of being included in the sample.
• With this design, selection biases may be avoided provided that the response rate is
high.
• A critical factor for any form of probability selection is the existence of a sampling frame
from which the sample elements can be selected.
• Random sampling techniques require either numbering each individual in the entire
group, mixing the numbers and – much like a lottery
• Simple random sampling is not widely used.
• That can be used for selecting survey samples representative
of the target population
• Among these, the techniques most commonly used is cluster
sampling and probability proportional to size sampling.
Systematic sampling

• Systematic sampling involves selecting at random the

first person from a list and then taking every xth
number or element (person) until the desired total of
individuals has been selected.
• This number depends on the desired number of
persons to be examined and the total number available
as per a list pertaining to a particular age group.
 Example….
• If, for example, there were 1800 older people in an institution and the
desired sample size was 200, the resulting sampling fraction would be 9.
• A random number is then chosen from between 0 and 9 to select the first
person and then every ninth person listed is selected until the total needed
for examination is obtained.
• Thus in systematic sampling, every person in the population listed has the
same odds of being selected for the examination
Stratified sampling
• When this kind of sampling conducting surveys in a population, it is important to record
the type of location where the participants live.
• Generally, three types of community descriptors are used: urban, peri -urban and rural.
• Other information that may be available about the population to be studied can also be
used to classify the population into groups and subgroups.
• This is the fundamental nature of stratification. Thus, the population can be classified into
subgroups or strata, following which separate samples from each stratum are selected.
Pathfinder surveys
• Pathfinder surveys Where there is no opportunity to conduct
probability sample size estimates, a non-probability sampling
method is applied.
• The particular factors associated with the most common oral
diseases and the extensive experience gained in oral
epidemiology over the past 35 years have allowed a practical,
economic survey sampling method to be defined, the so-called
pathfinder method.
Path finder…cont

• The pathfinder survey method is a stratified cluster sampling

technique that aims to include the most important population
subgroups likely to have different disease levels.
• In this way, reliable and clinically relevant information for
surveillance can be obtained at minimal expense.
The method…
• The method is suitable for obtaining the following information:
• Overall prevalence of the major oral diseases and conditions affecting the
population;
• Variations in disease levels and severity in subgroups of the population. This
enables identification of groups with special intervention needs; and
• Age profiles of oral diseases in the population to enable assessment of need for
intervention in different age groups,
• to provide information about severity and progression of disease, and to assess
whether the levels of a disease are increasing or decreasing
PILOT SURVEY

• A pilot survey is one that includes only the most important subgroups in
the population and only one or two index age.
• Such a survey provides the minimum amount of data needed to
commence planning.
• Additional data should then be collected to provide a reliable baseline for
the implementation and monitoring of oral health programmed.
Organizing the survey
• It is important to prepare a written protocol for the survey, and
this should contain the following information:
1. Purpose and main objectives of the survey
2. Description of the type of information to be collected and of the
methods to be used
3. Description of design and sampling methods to be used
4. Personnel and physical arrangements
5. Training and calibration of examiners
6. Statistical methods to be used in analyzing the data
• 7. Dissemination of findings
Obtaining approval from the authorities

• Permission to examine population groups must be obtained from

the relevant local, regional or national authority.
• If schoolchildren are to be examined, for example, the school
authorities should be approached, the purpose of the survey
explained and their approval obtained.
• In some instances, written permission from parents will need to be
obtained before children can be examined.
• Local dental society officers and dental practitioners can often
help in gaining the cooperation of the community for the survey,
and of any of their patients who may be included in the sample
Budget

• A budget for the survey should be prepared, listing the resources

required, including personnel to carry out the survey.
• Basic oral health surveys can often be conducted as part of the
duties of chief dental officers or dental public health workers, and
they may be undertaken with only minor additions to existing
budgets
Scheduling
• The preparation of a schedule for data collection is an important aspect
of survey planning. If this is not done, examining personnel may waste
time waiting for subjects to arrive, or be otherwise unnecessarily delayed.
• The schedules should allow for some flexibility, so that unexpected
delays do not cause major upsets in the survey timetable.
• Since fatigue contributes significantly to inaccuracy and inconsistency, the
schedule should not be too demanding.
Emergency intervention and referral

• Emergency intervention and referral If a life-threatening condition or a

condition that requires immediate attention is detected during the
examination, it is the responsibility of the examiner
• Examiners conducting the survey should not be encouraged to provide
emergency care during the course of the oral examinations
REPORTING THE SURVEY
• Courtesy reporting It is appropriate, and often essential, to report the
survey findings to local authorities. The report may be a simple summary
of the number of subjects examined and the general observations of the
examiner.
• This can usually be delivered personally, immediately after completion of
the survey.
• Courtesy reporting should also be conducted for parents of participating
children or for adults participating in the survey.
 Courtesy reporting…CONT
• Children and adults participating in the survey will benefit from knowing
whether they require any dental attention
• provision of routine, prompt or urgent oral intervention for an oral disease,
pain or infection, or oral manifestation of a systemic disease that would
require comprehensive evaluation by a dentist or physician.
• A full technical report will require more time to prepare, but should be sent
as soon as it is complete
 Reliability and validity of data

• Training and calibrating examiners Although examiners may differ in

their assessment of the oral health status of individuals, there should
be close agreement between assessments in population groups .
• When an epidemiological survey is undertaken by a team, it is
essential that the participating examiners are trained to make
consistent clinical judgements.
 RELABLITY AND VALIDITY

There are two main reasons for variability in clinical scoring:

• inconsistency in scoring different levels of an oral disease; and
• physical and psychological factors related to the examiner, such as fatigue,
fluctuations in interest in the study, and differences in visual acuity and
tactile sense
 REABILITY….

• The objectives of standardization and calibration therefore are to ensure

uniform interpretation, understanding and application by all examiners.
• An interval of at least a few days is desirable between training and
calibration to allow the examiners time to assimilate their knowledge of the
indices and to practice the procedures.
• It is necessary to assess the consistency of each individual examiner (intra-
examiner reproducibility) and also the variations between examiners
 4.Implementing the survey

• General preparation
• Contacts with persons in authority
• Persons in authority in the institutions or organizations where people
will be examined must be contacted in advance.
• In schools, for example, the principal or head teacher should be
consulted about school term dates and when the children would be
available for examination, and whether there is a suitable area or
room that could be used for the assessments.
 General prepration…..cont
• Instruments and supplies The quantity and weight of instruments and supplies used in the survey
should be kept to a minimum; however
• instruments for oral examination: plane mouth mirrors; metallic periodontal probes (Community
Periodontal Index (CPI) probe) that conform to WHO and several pairs of tweezers;
• containers (one for used instruments and one for disinfecting or sterilizing instruments) and
concentrated disinfecting solution in sufficient quantity;
• rubber gloves; gauze
• wash basin for either water and soap or disinfectant solution;
GENERAL PREPARATION…CONT

• Generally, a minimum of 30 mouth mirrors and 30 periodontal probes per examiner

should be provided, as this will permit some instruments to be sterilized while the others are
being used.
• Used instruments should be placed in disinfectant solution, then washed and drained well
before sterilization
Infection control
• Infection control the survey coordinator and all personnel participating
in the survey must be made aware of the possibility of cross-infection

• Current national recommendations and standards should be

responsibly followed for both infection control and waste disposal.
INFECTION CONTROL…..

• Examiners are responsible for maintaining adequate infection control in survey

procedures.
• During their training, it should be emphasized that all areas of the oral cavity can be fully
examined with appropriate use of mouth mirrors and the periodontal probe, and without
the need for digital manipulation of the oral tissues.
• Use of disposable masks and gloves and wearing of protective glasses are also
recommended.
• The survey team must have disinfecting solutions available in sufficient quantity.
EXAMINATION SITE….

• Examination -area for conducting examinations should be planned and arranged for
maximum efficiency and ease of operation.
• The exact arrangement will be determined by the physical condition of the site, but
certain controllable features should be kept in mind. Examinations may be conducted in a
dental office or in the field.
Assessment of oral health statue

• Suitable standardized forms for recording clinical oral

health assessments as described in this manual are
provided
• Standard codes must be used for all sections of the
form(s).
• If this requirement is not observed, WHO will be unable
to make recommendations for processing the data and
summarizing the results.
Preparation of survey reports

• The report of the survey must contain the following

information:
• Statement of the purposes of the survey: This
statement should include a succinct and clear
description of the aims of the survey and the expected
ways in which the results will be used.
REPORT CONT…
2. Materials and methods: include the following:
• Area and population: This section will include a general description of the geographical
region and the sample of people examined.
• The nature of the information collected and the methods used: A description is required
of the type of information collected and of the methods used to collect the data,
• Sampling method: An explanation should be given of the method of sampling that was
used, the size of the total sample and sub-samples, response rate, and the extent to which
the sample is considered representative of the target population.
• The report ,should include the number and description of persons who were selected for
the sample but were not examined, and any sampling problems encountered, should
also be reported.
REPORTING CONT…
• Personnel and physical arrangements: It is advisable to give a brief account of the
physical arrangements at the examination sites, the equipment used, and the
organization, training and experience of the personnel employed in collecting,
processing and tabulating the data.
• Statistical analysis and computational procedure: The statistical methods used in
compiling the final summary tables from the raw data should be described briefly or
appropriate references provided.
• Cost analysis: Information on survey expenses and the length of time spent on data
collection is of considerable interest.
 REPORTING SUMMARY
• Reliability and reproducibility of the results: It is important to include data on inter-
examiner and intra-examiner variability as revealed by pre-survey calibration
examinations and duplicate examinations conducted during the course of the survey.
• This information gives the planner for the area and the reader of the report an
indication of the degree of examiner error that may apply to any of the results.
• Oral health survey reports should include a description of the calibration activities,
including how and when the calibration process was carried out, how many examiners
and recorders were trained, the variables included in the calibration, and the individual
and overall (all examiners) per cent agreements and corrected kappa statistics for intra-
and inter-examiner reliability.