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Data quality evaluation of the dental fluorosis clinical assessment data from the National Health and Nutrition Examination Survey, 1999–2004 and 2011–2016
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  • ISBN:
    084060694X
  • Description:
    Introduction: This report provides a technical review of the 1999–2004 and 2011–2016 National Health and Nutrition Examination Survey (NHANES) dental fluorosis clinical assessment data.

    Methods: Dental examiners conducted fluorosis assessments on participants at the mobile examination center, scoring up to 28 teeth per participant according to Dean’s Fluorosis Index (DFI). Person-level values were assigned based on the value for the lesser of the two most affected teeth to determine fluorosis prevalence, overall and by severity. Data quality was evaluated by comparing dental and reference examiners’ repeat examinations to determine how consistently examiners rated the extent of fluorosis. Kappa statistics and percent agreement were calculated to assess this. Additionally, a synthetic cohort of youth aged 6–9 years in 2001–2004 and 16–19 years in 2011–2014 was analyzed to determine if the percentage with fluorosis was constant with age, as would be expected given that fluorosis develops before teeth erupt.

    Results: Weighted kappa statistics comparing person-level scores between dental and reference examiners across different weighting schemes for five dental examiners in 1999–2004 ranged from 0.51 to 0.87 and for four examiners in 2011–2016 from 0.60 to 0.98. Weighted kappa statistics comparing person-level scores for the same participant by the same examiner in 1999–2001 ranged from 0.56 to 0.72. Percent agreement between dental and reference examiners in defining very mild or greater fluorosis was 88.8% in 1999–2004 and 89.4% in 2011–2016; for moderate or severe, agreement was 97.1% and 94.4%, respectively. Variability in fluorosis prevalence estimates by DFI category was seen across 2-year NHANES cycles. Adjusted prevalence of mild or greater fluorosis in first permanent molars for the synthetic cohort was 9.5% (standard error [SE] = 0.01) in youth aged 6–9 years in 2001–2004 but 46.9% (SE = 0.04) in youth aged 16–19 years in 2011–2014.

    Conclusions: Two-year fluorosis prevalence estimates by DFI category demonstrated variability within and across the 6-year time periods. Inter-examiner reliability statistics found that agreement ranged from 0.51 to 0.98 for the nine primary dental examiners. These values indicate moderate (0.41–0.60) to almost-perfect (0.81–0.99) agreement based on Landis and Koch, and mostly adequate agreement (33 out of 36 kappas ≥ 0.6) based on McHugh. There was also high percent agreement in defining very mild or greater fluorosis. The proportion of the total number of examinations for which a gold standard examination was conducted, however, was low and the DFI scoring method has high examiner subjectivity. The observed increase in dental fluorosis prevalence with age between 2001–2004 and 2011–2014, based on the synthetic cohort analyses, is not biologically plausible. This suggests that there may have been some change in the way the examiners evaluated the level of fluorosis over time. The quality assessment findings in this report should be strongly considered when determining whether these data are appropriate for the user’s analytic objectives, including studies of prevalence and trends.

    Suggested citation: National Center for Health Statistics, National Center for Chronic Disease Prevention and Health Promotion. Data quality evaluation of the dental fluorosis clinical assessment data from the National Health and Nutrition Examination Survey, 1999–2004 and 2011–2016. National Center for Health Statistics. Vital Health Stat 2(183). 2019.

    CS303088

    sr02_183-508.pdf

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