1 Volume 21 2022 e225337 Original Article Braz J Oral Sci. 2022;21:e225337http://dx.doi.org/10.20396/bjos.v21i00.8665337 1 Santa Casa of Belo Horizonte College, Belo Horizonte, MG, Brazil. 2 Newton Paiva University Center, Belo Horizonte, MG, Brazil. 3 Federal University of Minas Gerais - UFMG, Belo Horizonte, MG, Brazil. Corresponding author: Janice Sepúlveda Santa Casa de Misericórdia – Belo Horizonte, MG, Brazil Email: janicesepulveda@gmail.com Editor: Altair A. Del Bel Cury Received: April 19, 2021 Accepted: October 27, 2021 A validated instrument to assess dentists’ knowledge about diabetes: the dental -diabetes questionnaire Margarete Aparecida Gonçalves Melo Guimarães1 , Amanda Augusto de Oliveira Prates1 , Vladimir Reimar Augusto de Souza Noronha2 , Adriana Pagano3 , Aleida Nazareth Soares1 , Janice Sepúlveda Reis1,* Aim: To elaborate and validate an instrument for Brazilian Portuguese speakers, to assess dentists’ knowledge about care of patients with diabetes mellitus (Dental-Diabetes). Methods: Methodological study comprising four stages: a) Elaboration of instrument; b) Content validation (computing Content Validity Index - CVI) based on Expert Committee assessment; c) Pre-test with 30 dentists, followed by assessment of suggestions by Expert Committee; d) Psychometric validation through instrument application in a sample of 127 dentists by means of the web tool e-Surv. Cronbach’s alpha and intraclass correlation coefficients were used to evaluate, respectively, internal consistency and reproducibility. Results: The final version of the instrument consists of 22 questions (7 on sociodemographic data and 15 querying dentists’ knowledge) and those submitted for validation attained a CVI of 0.95 [95% CI 0.916-0,981], showing satisfactory internal consistency, with 0.794 Cronbach’s alpha [95% CI 0.741-0.842] and an intraclass correlation coefficient of 0.799 [95% CI: 0.746-0.846] between the test and retest scores. Conclusions: Dental-Diabetes is a comprehensive instrument, culturally adequate and validated to assess dentists’ knowledge about care of patients with diabetes. Keywords: Diabetes mellitus. Dentists. Knowledge. Validation studies as topic. https://orcid.org/0000-0003-2464-5789 https://orcid.org/0000-0001-7719-9773 https://orcid.org/0000-0002-2809-0859 https://orcid.org/0000-0002-3150-3503 http://orcid.org/0000-0002-2671-3661 http://orcid.org/0000-0002-2465-862X 2 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 Introduction Diabetes Mellitus (DM), a chronic disease, is a public health problem that affects a large number of individuals from all social backgrounds. In 2019, the Interna- tional Diabetes Federation (International Diabetes Federation, IDF) estimated that diabetes affected 9.3% of the world population, with an estimated prevalence of more than 10.9% people in 20451. If uncontrolled, systemic complications of DM can include heart attack, kidney disease, limb loss, blindness, and peripheral nerve damage2. Due to the complexity of diabetes, how well the disease is controlled is an important issue in dental treatment planning. Patients with DM manifest a high prevalence of oral problems such as periodontal disease, tooth loss, xerostomia, caries, burning mouth disorder, taste and salivary gland dysfunction, delayed wound healing, lichen planus, geographic tongue, and candidiasis3. Being a common disease in dental practice, dentists are expected to be part of a multidisciplinary team, collaborating especially with endocrinologists. They are expected to base their care on strategies to provide effective management of DM and its oral consequences, identifying oral disease impacting glycemic con- trol, which, in turn, can impact oral health4. They are also expected to be aware of the pathophysiology of DM, its oral manifestations, signs and symptoms, how to react in case of an emergency, risks involved, systemic repercussions of the use of medications and anesthetics, which can all add up to provide better care for patients5-7. Assessing dentists’ conduct regarding DM is crucial to understand their knowledge, contributing to establishing targets for their training in public and private services and teaching institutions and defining guidelines for educational content and con- tributing to better care for patients with DM. Given the importance of dentists’ role and the lack of tools to assess their knowledge about DM, an instrument was felt to be needed to gather information about dentists’ knowledge and promote their education on related topics. A specific instrument for this purpose is not currently available. The aim of the study was to develop and validate an instrument for the assessment of dentists’ knowledge about diabetes (Dental-Diabetes). Materials and Methods This is a methodological and exploratory study carried out from January 2017 to August 2018 in the city of Belo Horizonte, in the State of Minas Gerais, Brazil. The project was approved by the Ethics and Research Committee Involving Human Beings (CAAE number 65656117.6.1001.5138) at Santa Casa of Belo Horizonte Hos- pital. Agreement to participate in the study was obtained by using a Free Informed Consent Form signed by participants when accessing an electronic questionnaire by means of the webtool e-Surv. An Expert Committee made up of five dentists, a nurse, an endocrinologist, a linguist and a statistician took part in elaboration of the instru- ment and assessed all stages until its final version (Figure 1). 3 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 STAGE 1 - Instrument’s development Prior to elaboration of the instrument, three authors (M.A.G.M.G., A.A.O.P., J.S.R.) conducted a literature review in PubMed (U.S. National Library of Medicine), LILACS (Latin American and Caribbean Literature in Health Sciences databases), and SciELO (Scientific Electronic Library Online) databases to obtain state-of-the-art information about diabetes, national and international recommendations on dental treatment of people with diabetes and questionnaires used to assess professionals’ knowledge about a particular disease. The descriptors used for the queries were ‘Diabetes mel- litus’, ‘Dentists’, ‘Knowledge’, and ‘validation studies’. National and international pub- lications yielded by the database queries were screened2,5-13. Based on the gathered insights we decided to elaborate an instrument in the form of a questionnaire. In establishing a general conceptual structure dentistry-endocrinology interface, our instrument was developed in two parts: the first section focusing on dentists’ socio- Figure 1. Stages in the instrument’s elaboration. V1: First version of the instrument; V2: Second version of the instrument; V3: Third version of the instrument *05 dentists; 01 nurse; 01 endocrinologist; 01 linguist; 01 statistician **22 dentists; 05 linguists; 06 endocrinologists • Judge Committee assessment** • Expert Committee assessment* • Content Validity Index (CVI) Instrument development Content Validation Pre-test Validation • Literature review • Construct definition • Elaboration of items • Expert Committee assessment* • Face-to-face tests • Expert Committee assessment* • Test • Retest • Analysis of internal consistency and temporal stability V1 V2 V3 Instrument Validated 4 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 demographic profile (7 questions); and the second section aimed at assessing den- tists’ knowledge about key aspects of DM and related care expected to be performed as part of their work (16 questions) (Version 1-V1). STAGE 2 - Content validation For content validation, a web address to access a web assessment form was sent by e-mail to 22 dentists, six endocrinologists and five linguists (Judges’ Committee), who evaluated each item of the instrument’s first version (V1). Criteria for participa- tion in the Committee were either to be a professional dentist with or without clini- cal practice implicating diabetes (dentist profile); or have taken part in questionnaire elaboration or translation in the healthcare area (linguist profile); or to have clinical practice in diabetes (endocrinologist profile). Judges were selected based on their curriculum vitae. The Judges’ Committee assessed clarity and relevance of each item in V1 and rated them with the following options: one star standing for need for full reformulation; two stars, partial reformulation (substantial revision needed); three stars, need for partial reformulation, with minor editing to enhance text style; and four stars in case of no need for reformulation. A comment box was also provided for the experts’ remarks and suggestions. Once the evaluation was completed, the Content Validity Index (CVI – the level of agreement of experts on adequacy of the items) was computed: number of scores 3 and 4 divided by total number of scores by all Committee members. CVI indicates the degree to which a scale has an adequate sample of items to represent a construct of interest - that is, whether a domain of content for the construct is adequately repre- sented by the items. Results higher than or equal to 0.78 are considered acceptable14. Upon computing CVI (higher than 0.78) and implementing the Committee’s sugges- tions to improve, V2 was obtained. V2 is substantially similar to V1, except for minor editing and spelling correction. STAGE 3 – Pre-test The author (M.A.G.M.G.) carried out the pre-test through face-to-face interviews with 20 dentists15,16 in 10 meetings following participants’ schedules - 2 group meetings with 5 dentists, 2 pair meetings and 6 individual meetings. First, the whole instrument was read by each participant individually; secondly, items were discussed to ensure whether they were clear, accurate, relevant and adequately arranged. Participant’s feedback was then assessed by the Expert Committee, who considered all relevant comments and redrafted those items that obtained less than 80% agreement14. Ver- sion 3 (V3) was thus obtained and tested on a newly selected group of 10 dentists (in 8 individual meetings and 2 in pair meetings). STAGE 4 - Validation A web address to access V3 in digital format on the e-Surv platform was sent via e-mail to 127 dentists selected by convenience from both public and private services and universities. The sample size was adequate considering a level of significance equal to 5%, test power equal to 80%, standard deviations equal to the test and retest 5 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 scores and a correlation coefficient equal to 0.30 (minimum value detected in the consistency assessment). A minimum sample size requirement was 85 profession- als. Retest was performed with those 127 dentists with a minimum interval of 7 days and a maximum of 21 days between the tests (average 16 days)17. Statistical analysis Absolute and relative frequencies were used to describe the sample characteristics and the proportion of correct answers to the instrument items. Internal consistency and reproducibility were verified to analyze the reliability of the construct. Cronbach’s alpha (CA) was used to assess the internal consistency of the instrument. Internal consistency is an assessment of whether items intended to measure the same con- struct produce similar scores. A high degree of internal consistency indicates that items meant to assess the same construct yield similar scores. There are a variety of internal consistency measures. Usually, they involve determining how highly these items are correlated and how well they predict each other. Cronbach’s alpha is a com- monly used measure. The instrument’s reproducibility was evaluated through test-retest (temporal sta- bility), computing the intraclass correlation coefficient (ICC). The Kappa index was added for reproducibility and refers to the percentage of concordant responses in the test and retest, defined as the ratio between the number of individuals who selected the same answer (regardless of being correct or incorrect) at both test and retest and the total number of individuals16,18. Floor and ceiling effects were measured by the number of respondents receiving the minimum and maximum scores, respectively. The significance level adopted for the statistical tests was 5%. For data analysis, SPSS version 20.0 was used. Results Instrument development and Content validation The development spanned 6 months. V1 of the instrument consisted of 23 questions. After reviewing V1 following the experts’ suggestions, a second version (V2) was obtained, with 23 questions. The instrument achieved a good score by the committee regarding clarity and relevance, with a total CVI of 0.95 [95% CI 0.916-0,981]. Pre-test In face-to-face tests, which lasted 3 months, 30 dentists participated. 67% were female; 47% had a Diploma course and were working in different areas such as sur- gery, dentistry, endodontics, periodontics and others; 47% had more than 20 years’ experience; 100% reported having provided dental care to patients with diabetes; 67% declared not having had any training to treat patients with diabetes; however, 63% reported feeling empowered to provide care for Diabetes patients. (Table 1). https://en.wikipedia.org/wiki/Construct_(philosophy) https://en.wikipedia.org/wiki/Construct_(philosophy) 6 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 As an outcome of the first meeting, with suggestions by 20 dentists, 2 questions were merged in order to adapt terms and increase understanding, a total of 22 items remaining in the questionnaire, yielding a third version (V3). V3 was tested with ten other dentists, no need for further redrafting having been requested. V3 was hence considered adequate to be submitted to psychometric validation. The 15 questions on knowledge about diabetes were then submitted for validation (Table 2). Table 1. Sociodemographic data of participants in the adaptation and validation stages. Variables   Pre-test (n=30) Validation (n=127) N (%) N (%) Sex Female 20 (67) 89 (70.1) Male 10 (33) 37 (29.1) I’d rather not say 1 (0.8) Education First degree 09 (30) 45 (35.4) Diploma course 14 (47) 68 (53.5) Master’s degree 02 (07) 8 (6.3) Doctor’s degree 04 (13) 6 (4.7) Post-Doctoral degree 01 (03) 0 Main area of professional expertise General Clinic 11 (37) 52 (40.9) Surgery 2 (7) 5 (3.9) Dentistry 1 (3) 6 (4.7) Endodontics 2 (7) 17 (13.4) Pediatric Dentistry 1 (3) 6 (4.7) Orthodontics 0 21 (16.5) Periodontics 1 (3) 11 (8.7) Lecturing 6 (20) 0 Research 1 (3) 0 Others 5 (17) 9 (7.2) First degree obtained Less than 1 year ago 03 (10) 9 (7.1) 1 to 5 years ago 06 (20) 19 (15) 5 to 10 years ago 0 11 (8.7) 10 to 20 years ago 07 (23) 21 (16.5) More than 20 years ago 14 (47) 67 (52.8) Have you ever provided dental treatment to any patient with diabetes? Yes 30 (100) 120 (94.5) No 0 7 (5.5) Have you ever taken any training or course about Diabetes? Yes 10 (33) 10 (7.9) No 20 (67) 117 (92.1) Do you feel empowered to provide care for Diabetes patients? Yes 19 (63) 73 (57.5) No 11 (37) 54 (42.5) 7 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 Validation This stage lasted about 28 days and 127 dentists answered the final version of the instrument (test and retest) (Table 1). 70% were female, 53.5 % had a Diploma course, 40.9% had expertise in general clinical practice., and 52.8% had obtained their first degree 20 years ago. 94.5% had already provided dental care to people with diabetes. The total CA alpha value was 0.794 (95% confidence interval 0.741- 0.842). Floor effects (percent with minimum score) were 0%, and ceiling effects (percent with max- imum score) 3,2%. An ICC value of 0.799 (95% CI: 0.746-0.846) was obtained. The Kappa coefficient, which assesses the degree of agreement, varied between 0.5-1.0 (mean: 0.80). When the alpha absence index was calculated, there was a slight impact on reducing AC and no questions needed to be removed (Table 3). Table 2. Items reviewed along the process of elaboration and adaptation. V1 V2 V3 Initial number of questions (Part 1/ Part 2) 23 (7/16) 23 (7/16) 22 (7/15) Number of questions requiring redrafting or exclusion (Part 1/ Part 2) 21 (7/14) 9 (0/9) 0 Suggestions deemed necessary by the Expert Committee 17 5 NA Questions excluded due to agreement below 80% 0 1 NA Final number of questions (Part 1/ Part 2) 23 (7/16) 22 (7/15) 22 (7/15) V= version; Part 1: socio-demographic assessment; Part 2: knowledge assessment; NA: not applicable. Table 3. Correlation between test and retest, answers agreement percentage and Cronbach’s alpha coefficient for the Dental- Diabetes Instrument. Item* Kappa index Percentual Agreement Test-Retest Cronbach’s Alpha if item is removed 95% CI for alpha Q1 0.629 76.27 0.813 0.763 – 0.857 Q2 0.368 61.34 0.787 0.729 – 0.837 Q3 0.658 79.17 0.797 0.743 – 0.845 Q4 0.594 88.50 0.798 0.745 – 0.846 Q5a 0.174 69.75 0.796 0.741 – 0.844 Q5b 0.22 85.12 0.796 0.741 – 0.844 Q5c 0.158 85.12 0.798 0.744 – 0.845 Q5d 0.501 97.58 0.797 0.743 – 0.845 Q5e 0.195 72.48 0.8 0.747 – 0.847 Q6 0.474 83.76 0.804 0.751 – 0.850 Q7a 0.335 91.13 0.794 0.794 – 0.842 Q7b 0.601 97.64 0.795 0.741 – 0.843 Q7c 0.315 76.72 0.792 0.736 – 0.840 Continue 8 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 The mean final score during test was 19.40, with a standard deviation of 4.49. At the time of the test, the percentages of minimum and maximum correct answers were 8.7% (question 2) and 95.3% (question 5d), respectively. All participants spent between 22 and 16 minutes on testing and retesting. The final version of the instrument is available in Supplementary Material. Discussion The treatment of patients with diabetes requires knowledgeable professionals, den- tists being fundamental member in a multidisciplinary team; therefore, dentists are expected to be updated regarding diabetes and its implications for daily care, with a greater knowledge about the onset, duration and control of the disease, resulting in a more effective and satisfactory approach19. A good interaction between the dentist and the multidisciplinary team is essential for a safer dental treatment, with lower chances of complications for the patient20. Given the importance of the dental approach for the patient with DM, elaborating and validating an instrument to evaluate the dentists’ knowledge about DM was consid- ered important to identify possible flaws in the knowledge of diabetes of these pro- fessionals that could impact treatment decisions and the objectives of the patient. In Brazil, dentists are not yet part of teams in diabetes centers as is the case in other countries, despite the clear need for these professionals to share the knowledge and duties of a multidisciplinary team. Continue Q7d 0.368 77.87 0.799 0.746 – 0.846 Q8 0.605 87.70 0.778 0.718 – 0.830 Q9 0.434 69.72 0.784 0.727 – 0.835 Q10 0.418 80.36 0.786 0.729 – 0.837 Q11 0.352 70.09 0.8 0.747 – 0.847 Q12a 0.478 79.65 0.8 0.746 – 0.847 Q12b 0.191 89.47 0.799 0.745 – 0.846 Q12c 0.239 85.84 0.796 0.741 – 0.844 Q13 0.675 89.34 0.798 0.744 – 0.845 Q14a 0.534 86.09 0.794 0.739 – 0.842 Q14b 0.391 80 0.793 0.738 – 0.842 Q14c 0.263 69.57 0.795 0.740 – 0.843 Q14d 0.3 7.27 0.796 0.741 – 0.844 Q15a 0.563 77.27 0.785 0.728 – 0.836 Q15b 0.464 76.85 0.787 0.730 – 0.837 Q15c 0.549 76.32 0.781 0.722 – 0.832 Q15d 0.464 84.35 0.781 0.723 – 0.833 Q15e 0.544 73.50 0.784 0.727 – 0.835 * Instrument in Supplementary File. 9 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 The collaborative work by the Expert Committee pooling expertise in diabetes, den- tistry and language issues made it possible to elaborate a comprehensive instrument, solving problems encountered during the process of drafting and adapting concepts and terms to the language used by the target subjects13,16,18,21-23. Interaction between healthcare professionals and applied linguists is a fundamental piece in the elabora- tion and cultural adaptation of new instruments. Assessment by the Expert committee through the web tool e-Surv is a reliable and efficient methodology24, allowing for remote application and quick data extraction, avoiding potential errors in transcriptions and gathering of results25. The instrument successfully passed the Committee’s examination in terms of clarity and relevance, with an excellent CVI (0.95). It should be noted that the maximum value for CVI is equal to 1, the results achieved being close to the maximum score18 , well above the CVI cutoff point of 0.80 for new instruments18,26. In the pre-test, the face-to-face meetings with a sample of dentists proved success- ful, favoring adjustments in the instrument, and ensuring the prospective understand- ing of the items by the target audience27,28. In carefully developed instruments, two or three face-to-face tests can be satisfactory, which was the case in our study, with two rounds being required21. For validation (test-retest), a CA index of 0.794 was obtained, which indicates good internal consistency29-32. The time span for retest met the recommendations in the lit- erature: a 7 to 21 day interval (a mean of 16 days). There are controversies regarding interval between test and retest, a desirable interval being not too short for partici- pants to recall their answers in the test and too long for the study to be impacted33-35. There are recommendations of an interval of one to two weeks between test and retest; however, no fixed amount of time is prescribed, the main concern being the need to account for whatever interval span chosen36. The time interval in our study adhered to the above recommendations, variation being due to participants’ agendas. Our CA, ICC (0,799) and Kappa index (mean 0.80) indicate that our instrument showed adequate stability, reproducibility and confidence18. ICC being satisfactory, we com- puted Kappa to corroborate it. Items with a low Kappa (5a, 5c e 5d, 12b e 12c) revealed topics that were less familiar to dentists. CA absence index was carried out. Removing items (1, 5e, 6, 11 e 12a) yielded alpha scores higher than those for the whole set of items. Therefore, no questions were excluded, due to the small difference that would result in the final CA37 and the possi- bility of leaving out important information13. In addition, the value was above 0.799 for all items and thus considered satisfactory. When we analyzed the performance of dentists in the test, the questions that had the lowest percentage of correct answers were question 2 (time period considered in the glycated hemoglobin test to assess mean blood glucose levels); 5 (hypogly- cemia and signs of mood change and/or irritability); and 14c (use of sedatives). This percentage of incorrect answers was somehow predictable, since those are the most common questions asked to endocrinologists by dentists before dental procedures in daily care. In this respect, it is worthy of note that both in the pre-test and the val- idation stages, the majority of participants had over twenty years’ experience and 10 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 had provided dental care to patients with diabetes; nevertheless, most had had no training whatsoever in diabetes care. Still, despite the lack of training, most reported feeling confident to treat patients with diabetes. This finding reveals a major problem in diabetes education and clinical practice regarding a highly prevalent condition as is diabetes and showcases the need for questionnaires such as the one we have elab- orated and validated in our study as an instrument to assess the level of knowledge about diabetes by dentists and propose educational initiatives to contribute to better dental treatment for people with diabetes. No studies were found describing the development and validation of instruments to assess dentists’ knowledge about diabetes, which did not allow for our results to be compared. Our instrument comprises items implicating knowledge compatible with themes indicated as priorities for dentists’ care of patients with diabetes: diagnostic criteria, symptoms, urgency and emergency, dental risk, conduct in care, clinical signs in the oral cavity and use of anesthetics and medications. In conclusion, our study yielded an instrument that proved useful, reliable and stable for use by dentists. The instrument is useful to evaluate dentists’ knowledge and pro- mote professionals’ training, with potential impact to enhance treatment for people with diabetes. Author Contribution MAGMG and AAOP participated in all steps of the study and was a major contributor in writing the manuscript. ASP and VRASN took part in pre-test. ANS analyzed and interpreted data and results. JSR and ANS provided guidance to MAGMG and AAOP. All authors read and approved the final manuscript and actively actively participated in the discussion of the manuscript’s findings. Disclosure No potential conflict of interest is relevant to this article. References 1. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2019 Nov;157:107843. doi: 10.1016/j.diabres.2019.107843. 2. Brazilian Diabetes Society. [Guidelines of the Brazilian Diabetes Society 2019-2020]. São Paulo: Clannad; 2019 [cited 2021 Feb 22]. 289 p. Available from: https://www.diabetes.org.br/profissionais/ images/DIRETRIZES-COMPLETA-2019-2020.pdf. Portuguese. 3. Indurkar MS, Maurya AS, Indurkar S. Oral manifestations of diabetes. Clin Diabetes. 2016 Jan;34(1):54-7. doi: 10.2337/diaclin.34.1.54. 4. Kudiyirickal MG, Pappachan JM. Diabetes mellitus and oral health. Endocrine. 2015 May;49(1):27-34. doi: 10.1007/s12020-014-0496-3. 5. Brazil, Ministry of Health of Brazil, Notebooks for Basic Care. [Strategies for care of the person with chronic disease: diabetes mellitus]. Brasília: Ministry of Health; 2014. p.138-41. Portuguese. 11 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 6. Mauri-Obradors E, Estrugo-Devesa A, Jané-Salas E, Viñas M, López-López J. Oral manifestations of Diabetes Mellitus. A systematic review. Med Oral Patol Oral Cir Bucal. 2017 Sep;22(5):e586-e594. doi: 10.4317/medoral.21655. 7. Nazir MA, AlGhamdi L, AlKadi M, AlBeajan N, AlRashoudi L, AlHussan M. The burden of diabetes, its oral complications and their prevention and management. Open Access Maced J Med Sci. 2018 Aug;6(8):1545-53. doi: 10.3889/oamjms.2018.294. 8. Brazil, Ministry of Health of Brazil. [Oral health]. (Series A. Standards and Technical Manuals - Basic Care Notebooks; 17). Brasília: Ministry of Health; 2008 [cited 2021 Feb 25]. 92p. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/saude_bucal.pdf. Portuguese. 9. Beagley J, Guariguata L, Weil C, Motala AA. Global estimates of undiagnosed diabetes in adults. Diabetes Res Clin Pract. 2014 Feb;103(2):150-60. doi: 10.1016/j.diabres.2013.11.001. 10. Pilatti LA, Pedroso B, Gutierrez GL. [Psychometric Properties of Assessment Instruments: A Necessary Debate]. RBECT. 2010;3(1):81-91. Portuguese. doi: 10.3895/S1982-873X2010000100005. 11. Pasquali L. [Psychometrics]. Rev Esc Enferm USP. 2009;43(spe):992–9. Portuguese. 12. Leite SS, Áfio ACE, Carvalho LV, Silva JM, Almeida PC, Pagliuca LMF. [Construction and validation of an Educational Content Validation Instrument in Health]. Reben. 2018;71(suppl 4):1635–41. Portuguese. doi: 10.1590/0034-7167-2017-0648. 13. Fernandes BSM, Reis IA, Pagano AS, Cecilio SG, Torres HC. [Development, validation and cultural adaptation of the COMPASSO protocol: Adherence to self-care in diabetes]. Acta Paul Enferm. 2016;29(4):421–9. Portuguese. doi: 10.1590/1982-0194201600058. 14. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007 Aug;30(4):459-67. doi: 10.1002/nur.20199. 15. Borsa JC, Damásio BF, Bandeira DR. [Cross-cultural adaptation and validation of psychological instruments: some considerations]. Paidéia (Ribeirão Preto). 2012 Dec;22(53):423–32. Portuguese. doi: 10.1590/S0103-863X2012000300014. 16. Coluci MZO, Alexandre NMC, Milani D. [Construction of measurement instruments in the area of health]. Cien Saude Colet. 2015 Mar;20(3):925-36. Portuguese. doi: 10.1590/1413-81232015203.04332013. 17. Souza AC, Alexandre NMC, Guirardello EB. Psychometric properties in instruments evaluation of reliability and validity. Epidemiol Serv Saude. 2017 Jul-Sep;26(3):649-659. doi: 10.5123/S1679-49742017000300022. 18. Alexandre NM, Coluci MZ. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas [Content validity in the development and adaptation processes of measurement instruments]. Cien Saude Colet. 2011 Jul;16(7):3061-8. Portuguese. doi: 10.1590/s1413-81232011000800006. 19. Terra BG, Goulart RR, Bavaresco CS. [Dental care for patients with type 1 and 2 diabetes mellitus in primary health care]. Rev APS. 2011;14(2):149–61. Portuguese. 20. Tavares GR, Lima AL, Tavares SSS, Castro RD, Padilha WW. [Multiprofessional boarding to the carrying patient of diabetes in dentistry attendance]. Rev Flum Odontol. 2010; 16(33):52-59. Portuguese. 21. Martins GA. [About reliability and validity]. RBGN. 2006;8(20):1-12. Portuguese. 22. Braga CG, da Cruz DA. Contribuições da psicometria para a avaliação de respostas psicossociais na enfermagem [Psychometric contributions to the assessment of psychosocial responses in nursing]. Rev Esc Enferm USP. 2006 Mar;40(1):98-104. Portuguese. doi: 10.1590/s0080-62342006000100014. 23. Keszei AP, Novak M, Streiner DL. Introduction to health measurement scales. J Psychosom Res. 2010 Apr;68(4):319-23. doi: 10.1016/j.jpsychores.2010.01.006. 12 Guimarães et al. Braz J Oral Sci. 2022;21:e225337 24. Torres H de C, Chaves FF, Silva DDR da, Bosco AA, Gabriel BD, Reis IA, et al. [Translation, adaptation and validation the contents of the Diabetes Medical Management Plan for the Brazilian context]. Rev Latino-Am Enfermagem. 2016; 24:e2740. DOI: 10.1590/1518-8345.1138.2740. Portuguese. 25. Walter OM. [Analysis of free tools for conducting online surveys]. Produto & Produção. 2013;14(2):44-58. Portuguese. doi: 10.22456/1983-8026.22172. 26. Medeiros RK, Ferreira Júnior M, Pinto D, Vitor A, Santos V, Barichello E. [Pasquali’s model of content validation in the Nursing researches]. Rev Enf Ref. 2015;4(4):123-31. Portuguese. doi: 10.12707/RIV14009. 27. Diniz KKS, Pagano AS, Fernandes APPC, Reis IA, Pinheiro Júnior LG, Torres HC. Development and validation of an instrument to assess Brazilian healthcare professional providers’ knowledge on sickle cell disease. Hematol Transfus Cell Ther. 2019 Apr-Jun;41(2):145-52. doi: 10.1016/j.htct.2018.08.003. 28. Silva TON, Alves LBO, Balieiro MMFG, Mandetta MA, Tanner A, Shields L. [Cross-cultural adaptation of an instrument to measure the family-centered care]. Acta Paul Enferm. 2015 april;28(2):107–12. Portuguese. 29. Maroco J, Garcia-Marques T. [How reliable is Cronbach’s alpha? Old issues and modern solutions?] Lab Psicol. 2006;4(1):65–90. Portuguese. doi: 10.14417/lp.763. 30. Streiner DL. Being inconsistent about consistency: when coefficient alpha does and doesn’t matter. J Pers Assess. 2003 Jun;80(3):217-22. doi: 10.1207/S15327752JPA8003_01. 31. Leal DL, Werneck MAF, Borges-Oliveira AC. [Validation of the oral health version of the Instrument for Diagnosis of the Developmental Stage of the Healthcare Network]. Rev Pan-Amaz Saude. 2017;8(4):65-75. doi: 10.5123/s2176-62232017000400011. Spanish. 32. Vituri DW, Évora YDM. Reliability of indicators of nursing care quality: testing interexaminer agreement and reliability. Rev Latino-Am Enfermagem. 2014;22(2):234–40. 33. Frost MH, Reeve BB, Liepa AM, Stauffer JW, Hays RD. What is sufficient evidence for the reliability and validity of patient-reported outcome measures? Value Health. 2007;10 Suppl 2:S94-S105. doi: 10.1111/j.1524-4733.2007.00272.x. 34. Fayers P, Machin D. Quality of life: the assessment, analysis and interpretation of patient-reported outcomes. 2 ed. Chichester: John Wiley & Sons; 2007. 544 p. 35. DeVon HA, Block ME, Moyle-Wright P, Ernst DM, Hayden SJ, Lazzara DJ et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39(2):155-64. doi: 10.1111/j.1547-5069.2007.00161.x. 36. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007 Jan;60(1):34-42. doi: 10.1016/j.jclinepi.2006.03.012. 37. Valim MD, Marziale MH, Hayashida M, Rocha FL, Santos JL. Validity and reliability of the Questionnaire for Compliance with Standard Precaution. Rev Saude Publica. 2015;49:87. doi: 10.1590/S0034-8910.2015049005975.