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A Global Oral Health Survey of professional opinion using the International

Classification of Functioning, Disability and Health

Article in Journal of Dentistry · April 2015

DOI: 10.1016/j.jdent.2015.04.001 · Source: PubMed

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 journal of dentistry 43 (2015) 683–694

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/jden

A Global Oral Health Survey of professional opinion

using the International Classification of
Functioning, Disability and Health

Alison Dougall a, Gustavo F. Molina b, Caroline Eschevins c, Denise Faulks c,d,*

a
Dublin Dental University Hospital, Trinity College, Dublin, Ireland
b
Escuela de Odontologı́a, Universidad Católica de Córdoba, Argentina
c
Clermont Université, Université d’Auvergne, EA4847, Centre de Recherche on Odontologie Clinique, F-63100
Clermont-Ferrand, France
d
CHU Clermont-Ferrand, Service d’Odontologie, CH Estaing, F-63100 Clermont-Ferrand, France

article info abstract

Article history: Objectives: The concept of oral health is frequently reduced to the absence of disease,
Received 28 August 2014 despite existing conceptual models exploring the wider determinants of oral health and
Received in revised form quality of life. The International Classification of Functioning, Disability and Health (ICF)
11 March 2015 (WHO) is designed to qualify functional, social and environmental aspects of health. This
Accepted 1 April 2015 survey aimed to reach a consensual description of adult oral health, derived from the ICF
using international professional opinion.
Methods: The Global Oral Health Survey involved a two-round, online survey concerning
Keywords: factors related to oral health including functioning, participation and social environment.
Oral health Four hundred eighty-six oral health professionals from 74 countries registered online.
Professional opinion Professionals were pooled into 18 groups of six WHO world regions and three professional
Health personnel groups. In a randomised stratification process, eight professionals from each pool (n = 144)
International Classification of completed the survey. The first round consisted of eight open-ended questions. Open
Functioning, Disability and Health expression replies were analysed for meaningful concepts and linked using established rules
Public health to the ICF. In Round 2, items were rated for their relevance to oral health (88% response rate).
Holistic health Results: Eighty-nine ICF items and 30 other factors were considered relevant by at least 80%
of participants. International professionals reached consensus on a holistic description of
oral health, which could be qualified and quantified using the ICF.
Conclusions: These results represent the first step towards developing an ICF Core Set in Oral
Health, which would provide a practical tool for reporting outcome measures in clinical
practice, for research and epidemiology, and for the improvement of interdisciplinary
communication regarding oral health.
Clinical significance: Professional consensus reached in this survey is the foundation stone
for developing an ICF Core Set in Oral Health, allowing the holistic aspects of oral health to
be qualified and quantified. This tool is necessary to widen our approach to clinical decision
making, measurement of clinical outcomes, research and epidemiology.
# 2015 Elsevier Ltd. All rights reserved.

* Corresponding author at: EA 4847 CROC, UFR d’Odontologie, 2 Rue de Braga, F-63100 Clermont Ferrand, France. Tel.: +33 4 73 17 73 85;
fax: +33 4 73 17 73 88.
E-mail addresses: alison.dougall@dental.tcd.ie (A. Dougall), gfmolina@hotmail.com (G.F. Molina), caroline.eschevins@udamail.fr
(C. Eschevins), denise.faulks@udamail.fr (D. Faulks).
http://dx.doi.org/10.1016/j.jdent.2015.04.001
0300-5712/# 2015 Elsevier Ltd. All rights reserved.
684 journal of dentistry 43 (2015) 683–694

Branch of the WHO Collaborating Centre for the Family of

1. Introduction International Classifications (DIMDI, Germany) in partnership
with the WHO Classification, Terminology and Standards
The concept of oral health is frequently reduced to the absence group (CTS).
of dental disease in both the public and professional
conscience,1 although there is now a steadily increasing 2.1. Participants
amount of literature on perceived oral health.2 A number of
evolving conceptual models have been proposed to describe Professional networking and snowball sampling were used to
oral health and its wider social and environmental determi- construct an international pool of 486 professionals from 74
nants, but the impact of these conceptual models on the countries. Professionals were required to fulfil entry criteria to
prevailing oral health paradigm appears minimal.1,3–5 Re- ensure professional experience in adult oral health and basic
search into oral health-related quality of life has shed light on data was gleaned using a secure Internet portal (SurveyMon-
the patient perspective, but lack of consensus amongst key.com1) (Table 1). Respondents were considered for inclu-
professionals on the wider aspects of oral health may be an sion if they were general dental practitioners, specialist dental
occupational hazard in the world of fee-per-item dental practitioners, or other professionals involved in oral health
services. However, lack of a common tool and language to (e.g. medical surgeons or physicians; dental nurses, hygienists
qualify and quantify non-disease aspects of oral health also or therapists; speech and language pathologists).
hinders expression of wider concepts. The International
Classification of Functioning, Disability and Health (ICF) 2.2. Sampling
(World Health Organisation (WHO))6 is a comprehensive
model for describing human experience in terms of body All registered professionals were stratified into one of 18 pools,
structure, body function, activities and participation. The according to the six WHO world regions16 and three
domains of health condition, environmental factors and professional groups (general dental practitioners; specialist
personal factors impact upon this experience within the dental practitioners; other medical and non-medical profes-
model. The basic premises of the ICF are that it is universal, i.e. sionals involved in oral health). From each pool, eight
that it is applicable to all people irrespective of health countries were randomly selected from which one profes-
condition or cultural context, and that it gives a positive sional was randomly chosen providing 144 sampled profes-
description of human functioning. The model is crystallised in sionals (8 countries  18 pools). The countries, and the
the ICF classification, which provides an exhaustive list of professionals within those countries, were randomly selected
items related to body structure, body function, activities and by the electronic software used to undertake the survey
participation, and environmental factors. The ICF classifica- (SurveyMonkey1). This sampling method could not be
tion is little used in oral health, as it is long and unwieldy, representative but was designed to recruit as wide a range
consisting of over 1400 items. In order to increase practical use of participants as possible, the aim of data collection being
of the ICF, the WHO has developed ICF Core Sets-reduced lists exhaustivity.
of ICF items specific to a particular domain and designed for
practical use in clinical and epidemiological contexts.7 ICF
Core Sets are defined following strict methodological protocols
and have been adopted in over 30 different health domains to Table 1 – Profile of professionals registered for the ICF
date.7–15 There are four requisite preliminary studies in the Global Oral Health Survey (prior to sampling).
development of an ICF Core Set – a qualitative study to elicit Professionals n = 486 % of
the patients’ point of view, a systematic literature review, an registered total
empirical study using a discipline-specific ICF Checklist and a WHO World Region Europe 153 31
survey exploring professional opinion.7 This manuscript gives Americas 137 28
results of the latter survey, exploring oral health from the Western Pacific 66 14
point of view of the professional. The results of the four South-East Asia 52 11
Eastern 41 8
preliminary studies are used to inform opinion during a
Mediterranean
consensus conference during which the ICF Core Sets are Africa 37 8
defined, subject to testing in the field. Age (years) 18–29 35 7
The aim of this survey is to reach a consensual description 30–39 166 34
of adult oral health, derived from the ICF using international 40–49 102 21
professional opinion. 50–59 141 29
60 and older 42 9
Preferred language English 341 70
2. Methodology French 88 18
Spanish 57 12
Professional category General dentist 123 25
A two-round, online Global Oral Health Survey was designed Specialist dentist 194 40
to collect the opinion of an international sample of profes- Other oral health 169 35
sionals concerning adult oral health and factors related to oral professional
Gender Male 181 37
health (function, participation and environment). The meth-
Female 305 63
odology was adapted from that developed by the ICF Research
 journal of dentistry 43 (2015) 683–694 685

2.3. Data collection 2.6. Calibration and training of the investigators

Professionals selected were invited to complete the online Four investigators were involved in the data collection and
questionnaire for data collection in English, Spanish or French, analysis. All investigators were familiar with the ICF and had
according to preference. undergone additional training and calibration for linking of
ICF codes to free-expression answers according to published
2.4. Round 1 linking rules.17,18 To assure quality, a list of ICF items
established by consensus during the piloting and calibration
Round 1 consisted of eight open-ended questions: training was systematically used as a guide throughout the
process. A random sample of 15% of all participants’ replies in
1. What physiological functions of the body are directly related each language were analysed and linked by two investigators
to oral health? fluent in that language. The degree of agreement between the
2. What physiological functions of the body indirectly influence two investigators regarding the identification of concepts and
oral health? linking to the ICF was calculated by Kappa statistic.
3. What cognitive or psychological functions impact on or are
influenced by oral health? 3. Results
4. What parts of the body are directly related to oral health?
5. What parts of the body indirectly influence oral health? 3.1. Round 1
6. What activities of daily life are affected by oral health?
7. What activities of daily life influence oral health? 3.1.1. Participants
8. What aspects of environment or living conditions influence The profile of the 144 sampled participants is shown in Table 2.
oral health either positively or negatively? Of the replies from the last 10 participants, only one new
meaningful concept was identified out of a total of 857 items
These questions were intended to elicit the broadest listed by these 10 participants. Saturation was therefore
possible range of answers to the first round and were assumed to have been reached with the sample of 144
structured on the domains of the ICF. Wording was tested participants and no further sampling was required.
by a convenience sample of eight oral health profes-
sionals independent of the study, changes were made 3.1.2. Frequency and prevalence of ICF items cited
and the questions were then piloted by a further six The 144 participants submitted 400 original meaningful
independent professionals until consensus was met on concepts. Of these meaningful concepts, 25 were cited by at
wording. least 50% of participants and 210 were cited by at least 5% of
Following the anonymous data collection process a list of participants (Table 3 and Appendix A). ICF codes were
meaningful concepts was extracted for each free-expression attributed to 179 of the 210 meaningful concepts cited by at
answer, with each investigator working in their native least 5% of respondents. Of these, 61 were in the body
language. The ICF classification provides an exhaustive list functions, 42 in the body structures, 46 in the activities
of over 1400 items related to body structures, body functions, and participation, and 30 in the environment domains
activities and participation, and environmental factors. (Appendix A). Meaningful concepts not given ICF codes were
Investigators used established linking rules to link free- identified as personal factors (n = 10), health conditions (n = 8)
expression meaningful concepts to ICF categories.17,18 Follow- unclassified (n = 11), and undefined (n = 2).
ing completion of the linking process, the frequency and
prevalence of citation of each ICF item was recorded (n and % 3.1.3. Calibration of investigators
of participants citing the item). The Kappa coefficients achieved between two investigators
independently coding a random sample of 15% of the replies in
2.5. Round 2 eachlanguagewere:0.88(English),0.96(French)and0.97(Spanish).

In Round 2 a list of items cited by at least 5% of participants in 3.2. Second round

Round 1 was presented. Participants were asked to strongly
agree, agree, disagree, strongly disagree or be unsure, in reply 3.2.1. Participants
to the following question: One hundred twenty-six of the 144 initial participants took
‘‘This item is relevant to oral health or to oral function’’. part in the second consensus round of the ICF Global Oral
This second round was designed to eliminate the more Health Survey, giving an 88% response rate.
peripheral items given in the open-response first round and to
gain consensus on those items considered relevant by the 3.2.2. Frequency and prevalence of ICF items cited
majority of respondents. Of the 210 meaningful concepts presented for consensus in the
Data was analysed using descriptive statistics including the second round (Appendix A), 119 were agreed or strongly
mean, mode and level of consensus, with items retained if a agreed upon by at least 80% of participants. Of these, 25 were
minimum threshold of 80% consensus was reached. This cut from the body functions domain, 17 from the body structure
off was arbitrary and chosen to ensure a manageable number domain, 19 from the environment domain, 28 from the
of items for reporting whilst still maintaining a high level of activities and participation domain (89 ICF codes in total)
agreement. and 30 were factors not currently listed in the ICF (Table 4).
686 journal of dentistry 43 (2015) 683–694

Table 2 – The profile of the respondents.

18 Pools General dentist Specialist dentist Other profession Language used Total
Americas 8 respondents 8 respondents 8 respondents English: 30% n = 24
13 countries/35 countries in region (37%) 8 countries 8 countries 6 countries Spanish: 71%
French: 0%
Western Pacific 8 respondents 8 respondents 8 respondents English: 92% n = 24
10 countries/27 countries in region (37%) 8 countries 8 countries 4 countries Spanish: 4%
French: 4%
SE Asia 8 respondents 8 respondents 8 respondents English: 100% n = 24
5 countries/11 countries in region (45%) 4 countries 4 countries 4 countries Spanish: 0%
French: 0%
E Mediterranean 8 respondents 8 respondents 8 respondents English: 79% n = 24
11 countries/22 countries in region (50%) 6 countries 7 countries 7 countries Spanish: 4%
French: 17%
Africa 8 respondents 8 respondents 8 respondents English: 33% n = 24
15 countries/46 countries in region (33%) 8 countries 8 countries 7 countries Spanish: 0%
French: 67%
Europe 8 respondents 8 respondents 8 respondents English: 54% n = 24
13 countries/53 countries in region (25%) 8 countries 8 countries 8 countries Spanish: 17%
French: 30%
Total n = 48 n = 48 n = 48 English: 65% n = 144
Spanish: 16%
French: 19%

data from a range of participants of different cultural and

4. Discussion professional backgrounds and the Global Oral Health Survey
confirmed the complexity of the concept of oral health.
A consensual description of adult oral health could be derived The items retained by the professionals were extremely
from international professional opinion using the ICF. The ICF varied. Although the items in the body structures domain
proved to be an effective tool for the collection of exhaustive seemed intuitive (mouth, teeth, gums, etc. . .) a wider picture

Table 3 – Items cited by at least 50% of participants in the first round.

ICF codes Meaningful concepts No. of % participants
participants citing citing the item
the item (n = 144) (n = 144)
Body function domain
b510 Ingestion 112 78
b5102 Chewing 83 58
b5105 Swallowing 83 58
b5103 Manipulation of food in mouth 80 56
b515 Digestive function 77 53
b280 Pain sensation 72 50
b310 Voice function 72 50
Body structure domain
s7104 Muscles of head and neck region 82 57
s3200 Teeth 77 53
Activities and participation domain
d550 Eating 122 85
d5701 Managing diet and fitness 113 78
d870 Economic self-sufficiency 100 69
d330 Speaking 97 67
d7 Interpersonal interactions and relationships 89 62
d620 Acquisition of goods and services, e.g. shopping 88 61
d520 Caring for body parts 79 55
d850 Remunerative employment 77 53
d440 Fine hand use 72 50
d445 Hand and arm use 72 50
Environmental factors domain
e580 Health services systems and policies 125 87
e570 Social security (financial aid) 121 84
e165 Assets including financial assets 103 72
e1100 Food 100 69
e565 Economic services systems and policies 88 61
e340 Support care providers 83 58
 journal of dentistry 43 (2015) 683–694 687

Table 4 – List of items considered relevant to oral health by at least 80% of the participants.
ICF codes Meaningful concepts Total agree or % Consensus
strongly agree (n = 126)
Body function domain
b5102 Chewing 125 99
b5101 Biting/incising 123 98
b5103 Manipulation of food in mouth 124 98
b5104 Salivation 123 98
b5105 Swallowing 122 97
b122 Global psychosocial functions (socialisation) 118 94
b280 Pain sensation 118 94
b510 Ingestion 118 94
b1 Mental functions 117 93
b515 Digestive function 117 93
b117 Intellectual functions 113 90
b320 Articulation function 111 88
b5106 Regurgitation, vomiting 111 88
b126 Temperament and personality functions 109 86
b130 Energy and drive functions, e.g. motivation, appetite 109 86
b152 Emotional functions 107 85
b435 Immunological functions 107 85
b110 Consciousness functions 106 84
b147 Psychomotor functions 106 84
b156 Perceptual functions, e.g. gustatory perception, visual perception 106 84
b250 Taste 104 83
b530 Weight maintenance function 104 83
b140 Attention functions 103 82
b540 General metabolic function 103 82
b180 Experience of self and time including body image 100 80
Body structure domain
s320 Mouth 126 100
s3200 Teeth 126 100
s3201 Gums 126 100
s3203 Tongue 126 100
s3204 Lip 126 100
s3202 Palate 124 98
s510 Salivary glands 120 95
s7104 Muscles of head and neck region 115 91
s710 Structure of head and neck region 114 90
s7103 Joints of head and neck region 113 90
s7101 Bones of face 109 87
s1106 Cranial nerves 106 85
s330 Pharynx 107 85
s7105 Ligaments and fasciae of head and neck region 107 85
s520 Oesophagus 103 82
s110 Brain 101 80
s530 Stomach 101 80
Activities and participation domain
d5201 Caring for teeth 125 99
d5702 Maintaining one’s health, e.g. going to dentist 125 99
d550 Eating 122 97
d560 Drinking 122 97
d330 Speaking 118 94
d570 Looking after one’s health 118 94
d3 Communication 117 93
d5701 Managing diet and fitness 116 92
d120 Other purposeful sensing (touching, smelling, tasting) 113 90
d335 Producing nonverbal messages, e.g. smiling, facial expression 112 89
d350 Conversation (talking) 112 89
d820 School education 112 89
d9205 Socialising 112 89
d5 Self-care 111 88
d230 Carrying out daily routine 109 87
d7 Interpersonal interactions and relationships 109 87
d770 Intimate relationships including sexual relationships 108 86
d520 Caring for body parts 107 85
688 journal of dentistry 43 (2015) 683–694

Table 4 (Continued )
ICF codes Meaningful concepts Total agree or % Consensus
strongly agree (n = 126)
d710 Basic interpersonal interactions including physical contact in 106 84
relationships
d160 Focusing attention (concentrating) 105 83
d240 Handling stress, responsibility, crisis etc. 104 83
d510 Washing oneself 104 83
d9 Community, social and civic life 104 83
d163 Purposeful thinking 103 82
d870 Economic self-sufficiency 103 81
d760 Family relationships 101 80
d810 Informal education 101 80
d815 Preschool education 100 80
Environmental factors domain
e1100 Food 126 100
e1101 Drugs (medication) 123 98
e355 Support of health professionals 122 97
e410 Attitudes of immediate family 120 95
e460 Societal attitudes 120 95
e465 Social norms 120 95
e585 Education 120 95
e580 Health services, systems and policies 119 94
e110 Products for personal consumption 116 92
e340 Support of care providers 116 92
e455 Attitudes of health related professionals 116 92
e440 Attitudes of care providers 116 92
e115 Products for daily living including oral hygiene aids and assistive 111 88
products
e310 Support of immediate family 110 87
e575 Social support services, systems and policies 109 87
e570 Social security services, systems and policies 107 85
e415 Attitudes of extended family 102 81
e360 Support of other professionals 101 80
e450 Attitudes of health professionals 100 80
Items not currently listed in the ICF
nd General health and well being 125 99
hc Nutritional imbalance (quality and quantity of food and drink intake) 124 98
nc Oral habits (bruxism, clenching, nail biting etc.) 124 98
nc Smoking 124 98
nc Occlusion and oral morphology 123 98
pf Attitude to health 123 98
nc Halitosis 122 97
nc Mucosa 122 97
pf Oral health history 122 97
nc Social environment/living conditions 122 97
pf Economic status 122 97
pf Social status 121 96
pf Educational level 121 96
hc Orofacial disease and dysfunction 121 96
nd Side effects of medication and treatment 120 95
nc Stress 118 94
nc Physical appearance 118 94
pf Self esteem 117 93
pf Family background 117 93
pf Culture and ethnicity 117 93
hc Intellectual disability and autism spectrum disorders 115 91
pf Self confidence 115 91
nc Kissing 114 90
hc Physical disability 114 90
hc Systemic disease and dysfunction 113 90
hc Mental illness 113 90
nc Alcohol consumption 112 89
hc Pregnancy and menopause 111 88
nc Recreational drugs 110 87
hc Anxiety and phobia 109 87
nd, not definable in the ICF; hc, health condition; nc, not covered in the ICF; pf, personal factor.
 journal of dentistry 43 (2015) 683–694 689

was drawn in the body functions domain, where not only the A small number of other items, such as occlusion and oral
expected functions of chewing, biting, etc. . . were listed, but morphology, or mucosa, could not be coded using the ICF and
also the mental and psychomotor functions necessary to the authors suggest that these results should be taken into
maintain oral health. Similarly, the wide social impact of oral account during the on-going process of revision of the ICF.
health is demonstrated in the activities and participation Health conditions, including oral disease such as caries, are
domain. Intuitive replies, such as eating, drinking, and the not included in the ICF, as they are covered in its sister
ability to self-care are listed. In addition, a range of social classification the International Classification of Disease
interaction is mentioned including communication and (ICD).23
intimate relationships. Participation is clearly important, Content analysis of the open ended questions in the first
including education, economic self-sufficiency and socialising round of the survey demonstrated that, although partici-
for example. The influence of the environment is also clearly pants could not cover the whole scope of oral health in
stated. Environmental factors include the immediate social individual answers, collectively they produced a compre-
impact of the support and attitudes of family, carers, hensive range of data for inclusion in Round 2. The initial
professionals, etc. . . and the impact of general societal sample size was empirical and was similar to that used in
attitudes. In addition, social infrastructure was confirmed as previous studies in different medical domains.24–30 Satura-
relevant to oral health in terms of social support and social tion of concepts was checked in real-time during data
security services, systems and policies. These findings are analysis, however, and was confirmed after 144 respondents.
significant – to have over 80% of professionals declare that The survey thus achieved the objective of exhaustivity.
items such as ‘‘education’’, ‘‘societal attitudes’’, ‘‘intimate Feedback from certain participants suggested that they had
relationships’’, or ‘‘ability to handle stress’’ are relevant to oral difficulty replying to such vast questions in the open-
health confirms that professionals are able to identify the expression replies in Round 1, a problem elicited in previous
wider influences on oral health described in the literature. studies of this type.31 The literature suggests that a response
These results can be discussed in the light of the ‘‘Refined rate of 70% is the minimum to ensure the rigour of the
Model of Oral Health’’ suggested by Brondani et al.4 This model process32 and the high second round response rate reported
was developed using focus groups of older adults and thus here (88%) demonstrates the interest generated by the
represents a lay perception of the concept of oral health from survey, despite the arduous nature of the first round. This
an ICF perspective. Its domains include: (i) personal and socio- second round was designed to reach consensus on those
cultural environment; (ii) activities and participation; (iii) items relevant to oral health but also to improve face validity
coping, adaptation and expectations, and (iv) economic by removing the more peripheral items. The breadth of the
priorities and health values and beliefs. When the domains ICF description given by the professionals in this survey
of the Refined Model are compared to the consensual list remains problematic (119 items retained). These data are not
produced by professionals here (Table 4), the domain of in themselves to be taken as a conceptual model of oral
‘‘coping, adaptation and expectations’’ is poorly represented health, however, but may be used to inform the process of
whilst body functions and body structures appear in the ICF Core Set development.
professional consensus but not in the lay perception. Earlier This study was the first of its kind to achieve a balanced
approaches to the patient perspective include tools such as the sample in terms of international representation and profes-
Oral Health Impact Profile.19 This questionnaire was devel- sional group. The difficulty of recruiting participants beyond
oped around seven conceptual dimensions of impact: func- Western Europe and North America has been noted by other
tional limitation, physical pain, psychological discomfort, authors.24–27,29 The decision to recruit participants and collect
physical disability, psychological disability, social disability data in three languages seems to have been crucial in
and ‘‘handicap’’ (the term ‘‘handicap’’ in this context was achieving a balanced sample. It would, of course, have been
derived from that of the previous WHO ICIDH classification – preferable to be able to recruit participants in all the main
‘‘concerned with disadvantages experienced by the individual global languages, for example English, Spanish, German,
as a result of impairment and disability’’). Of the 49 items in French, Russian, Portuguese and Chinese as suggested by
the OHIP, all are covered at some level in the list of items recent analysis.33 This strategy was unfeasible in terms of
retained by the professionals in this study, with the exception calibration of investigators. However, the desired number of
of those questions relating directly to denture wear. The participants per pool in the present study would not have
domain of physical pain is present but much less detailed in been reached for America or for Africa, without the use of
the ICF description. Items in the ICF based list are less specific Spanish and French, respectively (see Table 2). The use of
than those in the OHIP but they cover a much wider range of three languages was thus simultaneously a strong point and a
human experience. Previous authors have also reported that potential flaw in the methodology. Intensive, on-going
health-related quality of life scales can be mapped to and are feedback and peer review was used throughout the data
covered by the ICF.20,21 Other items that cannot be qualified or analysis processes in order to ensure the quality of data
quantified in an ICF description of oral health include many of treatment. The high Kappa scores for agreement between
the social determinants of health,22 such as social status investigators would seem to confirm the success of this
over and above economic self-sufficiency. These findings procedure and give reassurance as to the quality of data
emphasise the need for wide consultation of oral health collection and analysis. The importance of continual com-
professionals, public health experts and lay persons when munication between investigators cannot be sufficiently
developing conceptual models of oral health. emphasised.
690 journal of dentistry 43 (2015) 683–694

4.1. Perspectives a tool could also serve as an effective instrument to give

insight within public health and social policy arenas and help
This study has demonstrated that the ICF can be used to to sway the prevailing oral health paradigm towards a more
describe the wider aspects of oral health although the views of holistic standpoint.
other stakeholders are required to complete the picture. The
results of this survey need now to be integrated with data from
other ICF oral health studies in order to develop a holistic ICF Acknowledgements
Core Set for Oral Health. One of the four requisite preliminary
studies in the development of an ICF Core Set is a survey The authors would like to extend their warmest thanks to all
exploring professional opinion, as undertaken here. The other those anonymous professionals who registered to participate,
preliminary studies are a qualitative study to elicit the and in particular to all those who completed the survey; to the
patients’ point of view, a systematic literature review, and ICF Research Branch of the WHO Collaborating Centre for the
an empirical study using a discipline-specific ICF Checklist Family of International Classifications in Germany (DIMDI); to
(such as that used by Faulks et al. in 2013).34 Thus developed, Benoı̂t Varenne (WHO, Regional Office for Africa); Peter
an ICF Core Set in Oral Health would provide a practical tool for Cooney (Chief Dental Officer, Canada); Clive Friedman
defining and reporting outcome measures both in clinical (Canadian Dental Association); Gabriela Scagnet (National
practice and in research, for epidemiology, and for the University of Buenos Aires); Noreen O’Sullivan (St James’
improvement of interdisciplinary communication regarding Hospital, Dublin); Bruno Pereira (statistician, CHU Clermont-
oral health, thus facilitating the common risk approach. Such Ferrand); and Gary Fleming (Trinity College, Dublin).

Appendix A

Items cited by at least 5% of participants in Round 1 and presented for rating in Round 2.
ICF codes Meaningful concepts (n = 210) No. of participants % participants
citing item (n = 144) (n = 144)
Body functions
b1 Mental functions 13 9%
b110 Consciousness functions 31 22%
b114 Orientation functions 26 18%
b117 Intellectual functions 33 23%
b122 Global psychosocial functions (socialisation) 29 20%
b126 Temperament and personality functions 67 47%
b130 Energy and drive functions, e.g. motivation, appetite 16 11%
b134 Sleep functions 45 31%
b140 Attention functions 48 33%
b144 Memory functions 13 9%
b147 Psychomotor functions 70 49%
b152 Emotional functions 25 17%
b156 Perceptual functions, e.g. gustatory perception, visual perception 26 18%
b164 Higher level cognitive functions, e.g. organisation, time management, 65 45%
insight
b167 Mental functions of language including mental expression of language 65 45%
b180 Experience of self and time including body image 31 22%
b210 Seeing 12 8%
b230 Hearing and balance functions 9 6%
b250 Taste 20 14%
b255 Smell 9 6%
b265 Touch 7 5%
b280 Pain sensation 72 50%
b310 Voice function 72 50%
b320 Articulation function 69 48%
b330 Fluency and rhythm of speech function 66 46%
b340 Alternative vocalisation function (singing etc.) 18 13%
b410 Heart functions 29 20%
b415 Blood vessel function 15 10%
b420 Blood pressure function 13 9%
b430 Haematological functions 20 14%
b435 Immunological functions 37 26%
b440 Respiratory function 45 31%
b445 Respiratory muscle function 42 29%
b450 Additional respiratory function, (coughing, sneezing, yawning) 48 33%
b510 Ingestion 112 78%
 journal of dentistry 43 (2015) 683–694 691

Appendix A (Continued )
ICF codes Meaningful concepts (n = 210) No. of participants % participants
citing item (n = 144) (n = 144)
b5101 Biting/incising 19 13%
b5102 Chewing 83 58%
b5103 Manipulation food in mouth 80 56%
b5104 Salivation 63 44%
b5105 Swallowing 83 58%
b5106 Regurgitation, vomiting 21 15%
b515 Digestive function 77 53%
b520 Assimilation function 39 27%
b525 Defecation function 10 7%
b530 Weight maintenance function 37 26%
b540 General metabolic function 29 20%
b545 Water, mineral and electrolyte balance 18 13%
b550 Thermoregulatory function 12 8%
b555 Endocrine gland function 24 17%
b610 Urinary excretory function 14 10%
b640 Sexual functions 19 13%
b710 Mobility joint function 19 13%
b715 Stability joint function 25 17%
b730 Muscle power 63 44%
b735 Muscle tone 70 49%
b740 Muscle endurance function 62 43%
b750 Motor reflex function 11 8%
b755 Involuntary movement reaction 30 21%
b760 Control voluntary movement including coordination 45 31%
b765 Involuntary movement 25 17%
b770 Gait pattern 13 9%
Body structures
s1 Structure of nervous system 20 14%
s110 Brain 37 26%
s1106 Cranial nerves 26 18%
s210 Eye socket 24 17%
s220 Eyeball 27 19%
s230 Structures around eye 25 17%
s240 External ear 19 13%
s250 Middle ear 14 10%
s260 Inner ear 15 10%
s310 Nose 31 22%
s320 Mouth 58 40%
s3200 Teeth 77 53%
s3201 Gums 46 32%
s3202 Palate 14 10%
s3203 Tongue 63 44%
s3204 Lip 45 31%
s330 Pharynx 33 23%
s340 Larynx 8 6%
s410 Structure of the cardiovascular system 44 31%
s420 Structure of the immune system 19 13%
s430 Structure of the respiratory system 31 22%
s510 Salivary glands 68 47%
s520 Oesophagus 46 32%
s530 Stomach 62 43%
s540 Intestine 43 30%
s550 Pancreas 36 25%
s560 Liver 40 28%
s580 Structure of the endocrine glands 12 8%
s610 Structure of the urinary system including the kidney 27 19%
s710 Structure of head and neck region 26 18%
s7100 Bones of cranium 7 5%
s7101 Bones of face 52 36%
s7102 Bones of neck region 19 13%
s7103 Joints of head and neck region 57 40%
s7104 Muscles of head and neck region 82 57%
s7105 Ligaments and fasciae of head and neck region 27 19%
s720 Structure of the shoulder region 8 6%
s730 Upper extremity (arm) 43 30%
692 journal of dentistry 43 (2015) 683–694

Appendix A (Continued )
ICF codes Meaningful concepts (n = 210) No. of participants % participants
citing item (n = 144) (n = 144)
s7302 Hand 47 33%
s750 Lower extremity (hip, leg and foot) 16 11%
s760 Structure of the trunk including the vertebral column 21 15%
s810 Structure of skin 24 17%
Activities and participation
d120 Other purposeful sensing (touching, smelling, tasting) 9 6%
d160 Focusing attention (concentrating) 43 30%
d163 Purposeful thinking 8 6%
d230 Carrying out daily routine 21 15%
d240 Handling stress, responsibility, crisis etc. 44 31%
d3 Communication 36 25%
d310 Receiving spoken messages 7 5%
d330 Speaking 97 67%
d335 Producing nonverbal messages, e.g. smiling, facial expression 63 44%
d350 Conversation (talking) 52 36%
d4 Mobility 18 13%
d415 Maintaining a body position 25 17%
d440 Fine hand use 72 50%
d445 Hand and arm use 72 50%
d450 Walking 13 9%
d5 Self-care 8 6%
d510 Washing oneself 33 23%
d520 Caring for body parts 79 55%
d5201 Caring for teeth 55 38%
d530 Toileting 31 22%
d550 Eating 122 85%
d560 Drinking 56 39%
d570 Looking after one’s health 29 20%
d5701 Managing diet and fitness 113 78%
d5702 Maintaining one’s health, e.g. going to dentist 54 38%
d620 Acquisition of goods and services, e.g. shopping 88 61%
d660 Assisting others (looking after children etc.) 15 10%
d7 Interpersonal interactions and relationships 89 62%
d710 Basic interpersonal interactions including physical contact in 31 22%
relationships
d720 Complex interpersonal interactions 11 8%
d760 Family relationships 8 6%
d770 Intimate relationships including sexual relationships 35 24%
d810 Informal education 46 32%
d815 Preschool education 42 29%
d820 School education 52 36%
d825 Vocational training 46 32%
d830 Higher education 51 35%
d840 Apprenticeship 48 33%
d845 Acquiring, keeping and terminating a job 63 44%
d850 Remunerative employment 77 53%
d855 Non-remunerative employment 54 38%
d870 Economic self-sufficiency 100 69%
d9 Community, social and civic life 43 30%
d920 Recreation and leisure 19 13%
d9201 Sports 49 34%
d9205 Socialising 40 28%
Environmental factors
e110 Products for personal consumption 41 28%
e1100 Food 100 69%
e1101 Drugs 62 43%
e115 Products for daily living including oral hygiene aids and assistive 37 26%
products
e150 Design and architecture of buildings for public use 8 6%
e165 Assets, including financial assets 103 72%
e2151 Population density 7 5%
e310 Support of immediate family 25 17%
e315 Support of extended family 17 12%
e325 Support of acquaintances and community members 9 6%
e340 Support of care providers 83 58%
 journal of dentistry 43 (2015) 683–694 693

Appendix A (Continued )
ICF codes Meaningful concepts (n = 210) No. of participants % participants
citing item (n = 144) (n = 144)
e355 Support of health professionals 37 26%
e360 Support of other professionals 7 5%
e410 Attitudes of immediate family 61 42%
e415 Attitudes of extended family 57 40%
e440 Attitudes of care providers 8 6%
e450 Attitudes of health professionals 12 8%
e455 Attitudes of health related professionals 8 6%
e460 Societal attitudes 44 31%
e465 Social norms 34 24%
e510 Services, systems and policies for the production of consumer goods 41 28%
e530 Utilities services, systems and policies 39 27%
e540 Transportation services, systems and policies 9 6%
e560 Media services, systems and policies 23 16%
e565 Economic services, systems and policies 88 61%
e570 Social security services, systems and policies 121 84%
e575 Social support services, systems and policies 47 33%
e580 Health services systems and policies 125 87%
e585 Education 56 39%
e590 Employment 52 36%
Other
hc Anxiety and phobia 16 11%
hc Intellectual disability and autism spectrum disorders 14 10%
hc Mental illness 23 16%
hc Nutritional imbalance (quality and quantity of food and drink intake) 36 25%
hc Orofacial disease and dysfunction 24 17%
hc Physical disability 13 9%
hc Pregnancy and menopause 7 5%
hc Systemic disease and dysfunction 41 28%
nc Alcohol consumption 20 14%
nc Halitosis 12 8%
nc Kissing 19 13%
nc Mucosa 25 17%
nc Occlusion and oral morphology 12 8%
nc Oral habits (bruxism, clenching, nail biting etc.) 40 28%
nc Physical appearance 27 19%
nc Recreational drugs 11 8%
nc Smoking 55 38%
nc Social environment/living conditions 24 17%
nc Stress 28 19%
nd General health and well being 62 43%
nd Side effects of medication and treatment 18 13%
pf Attitude to health 12 8%
pf Culture and ethnicity 13 9%
pf Economic status 36 25%
pf Educational level 27 19%
pf Family background 12 8%
pf Oral health history 16 11%
pf Self confidence 32 22%
pf Self esteem 44 31%
pf Social status 31 22%
pf Temperament 40 28%
hc, health condition; nc, not covered in the ICF; nd, not definable in the ICF; pf, personal factor.

references of life: a systematic review. Journal of Oral Science

2006;48:1–7.
3. MacEntee MI. An existential model of oral health from
1. Brondani MA, MacEntee MI. Thirty years of portraying oral evolving views on health, function and disability. Community
health through models: what have we accomplished in oral Dental Health 2006;23:5–14.
health-related quality of life research. Quality of Life Research 4. Brondani MA, Bryant SR, MacEntee MI. Elders assessment of an
2014;23:1087–96. evolving model of oral health. Gerodontology 2007;24:189–95.
2. Naito M, Yuasa H, Nomura Y, Nakayama T, Hamajima N, 5. Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA,
Hanada N. Oral health status and health-related quality Soobader MJ, Bramlett MD, et al. Influences on children’s
694 journal of dentistry 43 (2015) 683–694

oral health: a conceptual model. Pediatrics 2007;120: generic health-related quality of life: an application of the
e510–20. International Classification of Functioning, Disability and
6. World Health Organisation. International Classification of Health for children and youth and item response theory.
Functioning, Disability and Health (ICF). Geneva, PLOS ONE 2014;9:e107771.
Switzerland: WHO; 2001. Available at: http://www.who.int/ 22. World Health Organisation. In: Wilkinson ca, Marmot ca,
classifications/icf/en/ [accessed 08.08.14]. editors. Social determinants of health: the solid facts. 2nd ed.
7. Bickenbach J, Cieza A, Rauch A, Stucki G. ICF Core Sets. Denmark: WHO; 2003. Available at: http://www.euro.who.
Manual for clinical practice. Göttingen, Germany: Hogrefe int/__data/assets/pdf_file/0005/98438/e81384.pdf [accessed
Publishing; 2012. 06.01.15].
8. Cieza A, Ewert T, Ustün TB, Chatterji S, Kostanjsek N, Stucki 23. World Health Organisation. International statistical
G. Development of ICF Core Sets for patients with chronic Classification of Diseases and related health problems tenth
conditions. Journal of Rehabilitation Medicine 2004;44S:9–11. revision (ICD-10). Geneva, Switzerland: WHO; 1992.
9. Stucki A, Daansen P, Fuessl M, Cieza A, Huber E, Atkinson R, 24. Weigl M, Cieza A, Kostanjsek M, Kirschneck M, Stucki G. The
et al. ICF Core Sets for obesity. Journal of Rehabilitation ICF comprehensively covers the spectrum of health
Medicine 2004;44S:107–13. problems encountered by health professionals in patients
10. Grill E, Ewert T, Chatterji S, Kostanjsek N, Stucki G. ICF Core with musculoskeletal conditions. Rheumatology
Sets development for the acute hospital and early post- 2006;45:1247–54.
acute rehabilitation facilities. Disability and Rehabilitation 25. Scheuringer M, Kirchberger I, Boldt C, Eriks-Hoogland I,
2005;27:361–6. Rauch A, Velstra IM, et al. Identification of problems in
11. Tschiesner U, Cieza A, Rogers SN, Piccirillo J, Funk G, Stucki individuals with spinal cord injury from the health
G, et al. Developing core sets for patients with head and neck professional perspective using the ICF: a worldwide expert
cancer based on the International Classification of survey. Spinal Cord 2010;48:529–36.
Functioning, Disability and Health (ICF). European Archives of 26. Tschiesner U, Becker S, Cieza A. Health professional
Otorhinolaryngology 2007;264:1215–22. perspective in head and neck cancer. Archives of
12. Bernabeu M, Laxe S, Lopez R, Stucki G, Ward A, Barnes M, Otolaryngology Head Neck Surgery 2010;136:576–83.
et al. Developing core sets for persons with traumatic brain 27. Escorpizo R, Finger ME, Glässel A, Cieza A. An international
injury based on the international classification of expert survey on functioning in vocational rehabilitation
functioning, disability, and health. Neurorehabilitation and using the International Classification of Functioning,
Neural Repair 2009;23:464–7. Disability and Health. Journal of Occupational Rehabilitation
13. Danermark B, Cieza A, Gangé JP, Gimigliano F, Granberg S, 2011;21:147–55.
Hickson L, et al. International classification of functioning, 28. Gradinger F, Boldt C, Högl B, Cieza A. Part 2. Identification of
disability, and health core sets for hearing loss: a discussion problems in functioning of persons with sleep disorders
paper and invitation. International Journal of Audiology from the health professional perspective using the
2010;49:256–62. International Classification of Functioning, Disability and
14. Coenen M, Cieza A, Freeman J, Khan F, Miller D, Weise A, Health (ICF) as a reference: a worldwide expert survey. Sleep
et al. The development of ICF Core Sets for multiple Medicine 2011;12:97–101.
sclerosis: results of the International Consensus 29. Berno S, Coenen M, Leib A, Cieza A, Kesselring J. Validation
Conference. Journal of Neurology 2011;258:1477–88. of the comprehensive International Classification of
15. Gradinger F, Cieza A, Stucki A, Michel F, Bentley A, Functioning, Disability and Health Core Set for multiple
Oksenberg A, et al. Part 1. International Classification of sclerosis from the perspective of physicians. Journal of
Functioning, Disability and Health (ICF) Core Sets for Neurology 2012;259:1713–26.
persons with sleep disorders: results of the consensus 30. Leib A, Cieza A, Tschiesner U. Perspective of physicians
process integrating evidence from preparatory studies. Sleep within a multi-disciplinary team: content validation of the
Medicine 2011;12:92–6. comprehensive ICF Core Set for head and neck cancer. Head
16. World Health Organisation. WHO Regional Offices. Available & Neck 2012;34:956–66.
at: http://www.who.int/about/regions/en/index.html 31. Weigl M, Cieza A, Andersen C, Kollerits B, Amann E, Stucki
[accessed 08.08.14]. G. Identification of relevant ICF categories in patients with
17. Cieza A, Brockow T, Ewert T, Amman E, Kollerits B, Chatterji chronic health conditions: a Delphi exercise. Journal of
S, et al. Linking health-status measurements to the Rehabilitation Medicine 2004;44:12–21.
International Classification of Functioning, Disability and 32. Hasson F, Keeney S, McKenna H. Research guidelines for the
Health. Journal of Rehabilitation Medicine 2002;34:205–10. Delphi survey technique. Journal of Advanced Nursing
18. Cieza A, Geyh S, Chatterji S, Kostanjsek N, Üstün B, Stucki G. 2000;32:1008–15.
ICF linking rules: an update based on lessons learned. 33. Ronen S, Gonçalves B, Hu KZ, Vespignani A, Pinker S,
Journal of Rehabilitation Medicine 2005;37:212–8. Hidalgo CA. Links that speak: the global language network
19. Slade GD, Spencer AJ. Development and evaluation of the oral and its association with global fame. Proceedings of the
health impact profile. Community Dental Health 1994;11:3–11. National Academy of Sciences of the United States of America
20. Cieza A, Stucki G. Content comparison of health-related 2014. http://dx.doi.org/10.1073/pnas.1410931111.
quality of life (HRQOL) instruments based on the 34. Faulks D, Norderyd J, Molina G, MacGiolla Phadraig C,
International Classification of Functioning, Disability and Scagnet G, Eschevins C, et al. Using the International
Health (ICF). Quality of Life Research 2005;14:1225–37. Classification of Functioning, Disability and Health (ICF) to
21. Gandhi PK, Thompson LA, Tuli SY, Revicki DA, Shenkman E, describe children referred to special care or paediatric
Huang IC. Developing item banks for measuring paediatric dental services. PLOS ONE 2013;8:e61993.

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