https://orcid.org/0000-0002-9853-1138
Figures
Abstract
Premature, non-physiological tooth wear in childhood has numerous repercussions for oral health. This is a growing problem with multifactorial causes and associated with the current lifestyle. The introduction of new concepts and indices is crucial for enhancing the understanding and management of dental conditions. In this context, we present the Childhood Early Oral Aging Syndrome (CEOAS) and the associated index, which aim to assess early enamel wear in the primary dentition. Rather than focusing solely on isolated etiologies, the index proposes a comprehensive evaluation of signs and symptoms, considering various factors that contribute to the premature and non-physiological loss of dental structure, including wear of both intact and hypomineralized enamel. Indices that evaluate the main factors of early oral aging in childhood and their interactions are fundamental for understanding the condition and developing effective control and treatment strategies, particularly given that there is currently no global index encompassing this information. The aim of the present study was the development and determination of content validity of the Childhood Early Oral Aging Syndrome (CEOAS) index for the primary dentition as a diagnostic and epidemiological survey tool.
Trial registration: ClinicalTrials.gov ID: NCT06378385.
Citation: Honório Mandetta AR, Gimenez T, Sobral APT, Spinola SG, Gonçalves MLL, Soares PV, et al. (2024) Development and content validation of the Childhood Early Oral Aging Syndrome (CEOAS) index for the deciduous dentition: Research protocol. PLoS ONE 19(10): e0310543. https://doi.org/10.1371/journal.pone.0310543
Editor: Fernando Oliveira Costa, Federal University of Minas Gerais: Universidade Federal de Minas Gerais, BRAZIL
Received: July 2, 2024; Accepted: September 3, 2024; Published: October 25, 2024
Copyright: © 2024 Honório Mandetta et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Regarding data availability, we would like to clarify that this manuscript describes a research protocol focused on the validation of the proposed scale. As the scale has not yet been implemented, no data has been generated at this stage.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The increase in premature, non-physiological tooth wear in childhood has numerous repercussions for oral health. This constitutes a growing phenomenon associated with multifactorial causes and the current lifestyle. With more in-depth knowledge on dental caries and its control, new demands emerge that need to be recognized by healthcare providers to ensure prevention as well as the control of the disease and etiological factors [1].
Non-carious diseases lead to progressive, irreversible dental structure loss, with initial causes unrelated to bacterial involvement [2]. Tooth wear, influenced by age, encompasses erosion, attrition, and abrasion, resulting in varying degrees of structure loss. Pathological tooth wear, marked by unacceptable levels of wear, can cause sensitivity and impact aesthetics and function [3]. The rising prevalence of non-carious oral issues underscores the need for improved practices, health education, research, training, and a transdisciplinary approach [1]. Conditions like erosive wear and enamel defects, including molar-incisor hypomineralization (MIH), hypomineralized second primary molar (HSPM), and dental fluorosis, are a growing concern globally [4].
Recent systematic reviews on erosive wear in children and adolescents faced challenges due to differing indices used for assessment [4]. The Basic Erosive Wear Examination (BEWE), established in 2008, is widely used but focuses solely on erosive etiology, neglecting other contributing factors like attrition and abrasion [5]. Enamel defects, such as hypomineralization, make teeth more prone to wear and accelerate early aging [4].
Enamel defects of higher prevalence have a significant impact on the oral health of affected children [1]. Understanding the current prevalence of early enamel wear in the primary dentition, caused by various etiologies such as abrasion, attrition, and acid erosion, or the combination of these factors, is crucial. Additionally, it is essential to investigate the synergistic effect of these factors on teeth with compromised mineral structure. This knowledge is of paramount importance for the development and direction of public health policies aimed at the prevention and appropriate treatment of these conditions, as well as the promotion of better oral health in the pediatric population. Currently, there is a gap in the literature regarding the precise quantification of the prevalence and the combined etiological factors contributing to early enamel wear in children, highlighting the need for comprehensive epidemiological studies to guide effective public health strategies.
The introduction of new concepts and indices is important for advancing the understanding and management of dental conditions. In this context, we present the Childhood Early Oral Aging Syndrome (CEOAS) and the associated index proposed for validation. This concept aims to unify the assessment of early enamel wear in the primary dentition by relying on observed signs and reported symptoms from patients, rather than focusing solely on isolated etiologies. The index seeks to integrate and evaluate various factors that may contribute to premature and non-physiological loss of dental structure, including both intact and hypomineralized enamel wear. The goal is to provide a more comprehensive and practical approach to diagnosing and treating early wear, considering the complex interaction of the involved factors. Thus, the proposed index may contribute to a more effective approach to identifying and managing early wear in children.
Therefore, the aim of the present study was the development and validation of a Childhood Early Oral Aging Syndrome index for the primary dentition as a diagnostic and epidemiological survey tool.
Materials and methods
Study design
The methods will be structured in two distinct steps. For clarity, we follow the recommendations for COSMIN (Consensus-based Standards for the selection of health Measurement Instruments).
- Development of the index
- Content validation by specialists
- 2.1 Creation of the content validation form
- 2.2 Selection of reviewers (specialists)
- 2.3 Determination of content validity
- 2.4 Review of items
- 2.5 Attributing a score to each item
- 2.6 Calculation of content validity index (CVI)
Development of CEOAS index
The aim of the Childhood Early Oral Aging Syndrome index is to investigate clinical signs and symptoms related to the early loss of dental structure associated with the most prevalent enamel defects, which significantly contribute to oral aging. The clinical management of tooth wear is also addressed in CEOAS scores 1, 2 and 3. Current indices used for non-carious conditions do not enable the concomitant investigation of enamel defects, which makes the proposed index innovative and of extreme important to epidemiological surveys. Understanding the prevalence of factors that either separately or synergically accelerate the process of early aging is useful to the establishment of novel treatment strategies.
The CEOAS index involves scores of 0 to 3 for the assessment of tooth wear and dental management, whereas scores of I, II and III are used concomitantly in cases of the presence of enamel defects, as shown in (Table 1).
CEOAS 0: Absence of signs and symptoms of CEOAS.
CEOAS 1: Clinical findings compatible with chronological age and oral age. First clinical signs (facets with initial wear on enamel level without altering function), without symptoms. Such cases require clinical follow-up.
Due to the lack of studies on the physiological wear pattern in the primary dentition, slight tooth wear without symptoms, functional or esthetic problems compatible with physiological wear is considered in this score.
CEOAS 2: Signs of wear not compatible with chronological age (facets with deep wear, with dentin exposure and compromised function) and symptoms of hypersensitivity. May have gingival recession. Such cases require restorative treatment and management of the sensitivity. Due to the lack of studies on the physiological wear pattern in the primary dentition, atypical tooth wear for the age of the patient (pathological wear), with symptoms as well as functional and esthetic problems are considered in this score.
CEOAS 3: Signs of severe wear not compatible with chronological age, with pulp involvement (inflammation or necrosis), compromising function and the stomatognathic system. May have tooth fissures, root fissures, tooth fractures, gingival recession and changes in the temporomandibular joint. Loss of the tooth may occur. Such cases require invasive treatment (endodontic, restorative, rehabilitative or extractive).
CEOAS I: In the presence of primary second molar hypomineralization (PSMH) with demarcated opacities and without post-eruptive breakdown (PEB), the CEOAS I score should be recorded concomitantly with the 1, 2 or 3 score detected in the clinical examination.
CEOAS II: In the presence of primary second molar hypomineralization (PSMH) with post-eruptive breakdown (PEB), the CEOAS II score should be recorded concomitantly with the 1, 2 or 3 score detected in the clinical examination.
CEOAS III: In the presence of dental fluorosis, the CEOAS III score should be recorded concomitantly with the 1, 2 or 3 score detected in the clinical examination.
Images exemplifying the index scores are presented below. In Fig 1, CEOAS 0 (A and B) and CEOAS 1 (C and D) scores are presented. In Fig 2, CEOAS 2 (E and F) and CEOAS 3 (G and H) scores are presented. In Fig 3, CEOAS 1 associated with CEOAS I (I and J) and CEOAS 1 associated with CEOAS II (K and L) scores are presented. In images I and J, enamel defects of the type Hypomineralization of Second Primary Molars (HSPM) without post-eruptive breakdown (PEB) in tooth 65 can be observed. In images K and L, enamel defects of the type Hypomineralization of Second Primary Molars (HSPM) with post-eruptive breakdown (PEB) in tooth 55 can be observed.
CEOAS 0 (A and B) and CEOAS 1 (C and D) scores.
CEOAS 2 (E and F) and CEOAS 3 (G and H) scores.
CEOAS 1 associated with CEOAS I (I and J) and CEOAS 1 associated with CEOAS II (K and L) scores.
The CEOAS index can be used in the simplified version with the score of the greatest severity found. In the complete version, the CEOAS index can be used followed by an odontogram on which each tooth is assigned a score (Table 2).
Content validation by specialists
Creation of content validity form
Selection of reviewers (specialists).
The selection of specialists for the assessment will be based on the individual experience of doctoral professors specializing in pediatric dentistry, who will be chosen to ensure content validity, following recommendations. Following recommendations for content validation, at least six specialists will be selected [6]. The recruitment period for specialists will take place between July 29, 2024, and September 16, 2024.
Determination of content validity.
Content validation will not be performed in person. The online content validation form will be sent to the specialists with the items and criteria to be assessed (Table 3). A deadline for evaluation will be requested, and the entire process will be monitored. The images used to validate the Early Childhood Oral Aging Syndrome index for deciduous dentition were collected at the Dental Clinic of the Metropolitan University of Santos (UNIMES), in the Pediatric Dentistry discipline and in the Pediatric Dentistry Specialization program between April 1, 2024, and May 31, 2024. After obtaining written consent from parents or guardians, children were also informed, in appropriate language, about the objectives and procedures of the research and agreed to participate voluntarily, expressing their assent, which was recorded in the Informed Assent Form. The protocol for this study was approved by the Human Research Ethics Committee of the Metropolitan University of Santos-UNIMES (certificate number: 77036723.7.0000.5509) and the protocol registered in clinical trials (S1 File). The original research project submitted to the Research Ethics Committee, in both the original language and in English, can be found in the (S2 and S3 Files), respectively.
Review of items.
During the validation process, the specialists will be asked to critically review the content prior to assigning scores. Verbal or written suggests for improving the content will be encouraged.
Attributing a score to each item.
After the review, the specialists will attribute a score to each item (Table 3) corresponding to their assessments in terms of the relevance, clarity and applicability of the content and send their assessments before the deadline stipulated for the process. To assess the content, if a specialist indicates "1" on Table 3 (Not relevant/Not clear), a discussion meeting will be held with the group of specialists. This meeting will address and clarify any doubts or issues raised, ensuring consensus and accuracy in the content evaluation.
Calculation of content validity index (CVI).
The CVI will be calculated on a scale level based on the universal agreement method (S-CVI/UA). The classification of relevance should be recoded as 1 (scale score of 3 or 4) or 0 (scale score of 1 or 2). The universal agreement (UA) score is given as 1 when the item achieves 100% agreement among the specialists (only scores 3 and 4 for all items). Otherwise, the UA score is given as 0. The S-CVI/UA is equal to the sum of the UA scores divided by the number of items.
Sum of UA scores
S-CVI/UA = ______________________
Number of items
CVI values higher than 0.83 will be considered acceptable [7].
After the validation of the index, an observational study will be conducted to identify the prevalence of early wear in the primary dentition using the Childhood Early Oral Aging Syndrome index (CEOAS), and to investigate possible associated etiological factors. The study report will adhere to the STROBE guidelines for cross-sectional studies.
Supporting information
S1 File. ClinicalTrials.gov protocol registration.
https://doi.org/10.1371/journal.pone.0310543.s001
(PDF)
Acknowledgments
We thank the guardians of the patients for consenting to the authorization for the dissemination of images within the scope of this study.
References
- 1. Martignon S, Bartlett D, Manton DJ, Martinez-Mier EA, Splieth C, Avila V. Epidemiology of Erosive Tooth Wear, Dental Fluorosis and Molar Incisor Hypomineralization in the American Continent. Caries Res. 2021;55(1):1–11. pmid:33440378
- 2. Taji S, Seow WK. A literature review of dental erosion in children. Aust Dent J. 2010 Dec;55(4):358–67; quiz 475. pmid:21133936
- 3. Loomans B, Opdam N, Attin T, Bartlett D, Edelhoff D, Frankenberger R, Benic G, Ramseyer S, Wetselaar P, Sterenborg B, Hickel R, Pallesen U, Mehta S, Banerji S, Lussi A, Wilson N. Severe Tooth Wear: European Consensus Statement on Management Guidelines. J Adhes Dent. 2017;19(2):111–119. pmid:28439579
- 4. Martignon S, Bartlett D, Manton DJ, Martinez-Mier EA, Splieth C, Avila V. Epidemiology of Erosive Tooth Wear, Dental Fluorosis and Molar Incisor Hypomineralization in the American Continent. Caries Res. 2021;55(1):1–11. pmid:33440378
- 5. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008 Mar;12 Suppl 1(Suppl 1):S65–8. pmid:18228057
- 6. Yusoff MSB. ABC of content validation and content validity index calculation. Education in Medicine Journal. 2019;11(2):49–54. https://doi.org/10.21315/eimj2019.11.2.6
- 7. Lynn MR. Determination and quantification of content validity. Nursing Research. 1986;35(6):381–5. pmid:3640358