journal of dental hygiene · 204 the journal of dental hygiene vol. 89 • no. 4 • august 2015...

202 The Journal of DenTal hygiene Vol. 89 • no. 4 • augusT 2015

•PerceptionsofDentalHygieneMaster’sDegreeLearnersAboutDentalHygieneDoctoralEducation

•Knowledge,PerceivedAbilityandPracticeBehaviorsRegardingOralHealthamongPediatricHematologyandOncologyNurses

•OralCareintheLong-TermCareofOlderPatients:HowCantheDentalHygienistMeettheNeed?

•TechnicalPerformanceofUniversalandEnhancedIntraoralImagingRectangularCollimators

•AnAssessmentModelforEvaluatingOutcomesinFederallyQualifiedHealthCenters’DentalDepartments:Resultsofa5YearStudy

•EvaluatingUtilityGlovesasaPotentialReservoirforPathogenicBacteria

•ASurveyofClinicalFacultyCalibrationinDentalHygienePrograms

•DentalFearandDelayedDentalCareinAppalachia-WestVirginia

Journal ofDentalHygiene

The american DenTal hygienisTs’ associaTion

August 2015 • Volume 89 • Number 4

Vol. 89 • no. 4 • augusT 2015 The Journal of DenTal hygiene 203

Journal of Dental Hygiene

CelesteM.Abraham,DDS,MSCynthiaC.Amyot,MSDH,EdDJoannaAsadoorian,AAS,BScD,MSc,PhDCarenM.Barnes,RDH,MSStephanieBossenberger,RDH,MSLindaD.Boyd,RDH,RD,EdDJenniferL.Brame,RDH,MSKimberlyS.Bray,RDH,MSColleenBrickle,RDH,RF,EdDLorraineBrockmann,RDH,MSPatriciaRegenerCampbell,RDH,MSMarieCollins,EdD,RDHMaryAnnCugini,RDH,MHPSusanJ.Daniel,BS,MSJaniceDeWald,BSDH,DDS,MSSusanDuley,EdD,LPC,CEDS,RDH,EdSKathyEklund,RDH,MHPDeborahE.Fleming,RDH,MSJaneL.Forrest,BSDH,MS,EdDJacquelynL.Fried,RDH,MSDanielleFurgeson,RDH,MSMaryGeorge,RDH,BSDH,MEDKathyGeurink,RDH,MA

JoanGluch,RDH,PhDMariaPernoGoldie,MS,RDHEllenB.Grimes,RDH,MA,MPA,EdDJoAnnR.Gurenlian,RDH,PhDAnneGwozdek,RDH,BA,MALindaL.Hanlon,RDH,PhD,BS,MedLisaF.HarperMallonee,BSDH,MPH,RD/LDHaroldA.Henson,RDH,MEDAliceM.Horowitz,PhDLynneHunt,RDH,MEd,MSOlgaA.C.Ibsen,RDH,MSHeatherJared,RDH,MS,BSJanetKinney,RDH,MSSalmeLavigne,RDH,PhDJessicaY.Lee,DDS,MPH,PhDDeborahLyle,RDH,BS,MSDeborahS.Manne,RDH,RN,MSN,OCNAnnL.McCann,RDH,MS,PhDGayleMcCombs,RDH,MSShannonMitchell,RDH,MSTanyaVillalpandoMitchell,RDH,MSTriciaMoore,EdDChristineNathe,RDH,MS

JohannaOdrich,RDH,MS,PhD,MPHJodiOlmsted,RDH,BS,MS,EdS,PhDPamelaOverman,BS,MS,EdDVickieOverman,RDH,MedCeibPhillips,MPH,PhDKathiR.Shepherd,RDH,MSDeanneShuman,BSDH,MS,PhDJudithSkeleton,RDH,Med,PhD,BSDHAnnEshenaurSpolarich,RDH,PhDRebeccaStolberg,RDH,BS,MSDHJulieSutton,RDH,MSSherylL.ErnestSyme,RDH,MSTerriTilliss,RDH,PhDLynnTolle,BSDH,MSMarshaA.Voelker,CDA,RDH,MSMargaretWalsh,RDH,MS,MA,EdDPatWalters,RDH,BSDH,BSOBDonnaWarren-Morris,RDH,MeDCherylWestphal,RDH,MSKarenB.Williams,RDH,MS,PhDNancyWilliams,RDH,EdDPamelaZarkowski,BSDH,MPH,JD

eDitorial review BoarD

TheJournal of Dental Hygieneistherefereed,scientificpublication of the American Dental Hygienists’Association. It promotes the publication of originalresearch related to the profession, the education,and the practice of dental hygiene. The Journalsupports the development and dissemination of adentalhygienebodyofknowledgethroughscientificinquiryinbasic,appliedandclinicalresearch.

Statement of PurPoSe

Please visit http://www.adha.org/authoring-guidelinesforsubmissionguidelines.

SuBmiSSionS

The Journal of Dental Hygiene is published bi-monthlyonlineby theAmericanDentalHygienists’Association, 444 N. Michigan Avenue, Chicago, IL60611. Copyright 2014 by the American DentalHygienists’Association.Reproductioninwholeorpartwithoutwrittenpermissionisprohibited.Subscriptionratesfornonmembersareoneyear,$60.

SuBScriPtionS

Chief Executive OfficerAnnBattrell,[email protected]

Chief Operating OfficerBobMoore,MA,[email protected]

Editor–In–ChiefRebeccaS.Wilder,RDH,BS,[email protected]

Editor EmeritusMaryAliceGaston,RDH,MS

Director of [email protected]

Staff [email protected]

Layout/DesignJoshSnyder

PresidentJillRethman,RDH,BA

President ElectBettyKabel,RDH,BS

Vice PresidentTammyFilipiak,RDH,MS

TreasurerDonnellaMiller,RDH,BS,MPS

Immediate Past PresidentKelliSwansonJaecks,MA,RDH

2015 to 2016 aDHa officerS

Volume 89 • Number 4 • August 2015

aDHA/JDH Staff


inSiDeJournal of DenTal hygiene

Vol. 89 • No. 4 • August 2015

featureS

eDitorial

reSearcH

206 Lasers and Nonsurgical Periodontal Therapy DeniseM.Bowen,RDH,MS

210 Perceptions of Dental Hygiene Master’s Degree Learners About Dental Hygiene Doctoral Education UrsulaGMTumath,MS,RDH;MargaretWalsh,MA,MS,EdD,RDH

219 Knowledge, Perceived Ability and Practice Behaviors Regarding Oral Health among Pediatric Hematology and Oncology Nurses AntianaD.Perry,RDH,BS;HirokoIida,DDS,MPH;LaurenL.Patton,DDS; RebeccaS.Wilder,RDH,MS

229 Oral Care in the Long-Term Care of Older Patients: How Can the Dental Hygienist Meet the Need? TraceeS.Dahm,BSDH,MS;AnnBruhn,BSDH,MS;MargaretLeMaster, BSDH,MS

238 Technical Performance of Universal and Enhanced Intraoral Imaging Rectangular Collimators K.BrandonJohnson,RDH,MS;SallyMMauriello,RDH,EdD;JohnB. Ludlow,DDS,MS;EnriquePlatin,RT,EdD

247 An Assessment Model for Evaluating Outcomes in Federally Qualified Health Centers’ Dental Departments: Results of a 5 Year Study SharonM.Grisanti,RDH,MCOH;LindaD.Boyd,RDH,RD,EdD;Lori Rainchuso,RDH,MS

258 Evaluating Utility Gloves as a Potential Reservoir for Pathogenic Bacteria KathyL.Grant,RDH,BS;E.DonaldNaber,EdD;WilliamA.Halteman,PhD

264 A Survey of Clinical Faculty Calibration in Dental Hygiene Programs NicholeL.Dicke,RDH,MDSH;KathleenO.Hodges,RDH,MS;EllenJ. Rogo,RDH,PhD;BeverlyJ.Hewett,RN,PhD

274 Dental Fear and Delayed Dental Care in Appalachia-West Virginia R.ConstanceWiener,DMD,PhD

205 Doctoral Education in Dental Hygiene: From Dream to Reality – Almost! RebeccaS.Wilder,RDH,BS,MS

critical iSSueS in Dental Hygiene

linking reSearcH to clinical Practice


DoctoralEducationinDentalHygiene:FromDreamtoReality–Almost!

eDiTorial

RebeccaS.Wilder,RDH,BS,MSThereareacoupleoftimesduringtheyearwhenone

tendstosetgoals.OneofthosetimesisonJanuary1standtheotheristhebeginningofanewschoolyear.Aswestartanewacademicyear,Iwonderwhatyourgoalsareforyourprofessionalcareer.

Agoalofourprofessionhasbeentocreateadiscipline–specificdoctoraldegreeindentalhygiene.Currentlythereareseveraldentalhygienistswithdoctoraldegrees,manyofwhomcontributetotheJDHEditorialReviewBoard.How-ever,eachofthesedentalhygienistshasbeenforcedtoob-tainadoctoraldegreeoutsideofthedentalhygienedisciplinebecausetherewassimplynootheroption.Whileobtainingadoctoraldegreeinanydisciplineisanachievementtowhichtheprofessionalshouldbeapplauded,nothavingadoctoraldegreeindentalhygienetakesawaytheopportunityforfo-cusedmentoringandlearningofextensivedisciplinespecificcontentindentalhygiene.

Whyisadoctoraldegreenecessary?Severalkeyarticleshavebeenwrittenonthissubject.Ortegaetalnotedthat“Doctoralprepareddentalhygienistswillbeneededtoteachmasters-levelgraduatedentalhygienelearnersandtoen-gageinadministrativeandleadershiproles inhealthcareorganizationswithimpendingchangesinhealthcarepoli-cies.”1Gurenlianetalhavewrittenaboutdoctoraleducationindentalhygieneandpredictthatifdentalhygienistswanttoassumeleadershippositionsinthefuture,theywillneedadoctoraldegree.2Thesepositionsincludeleadershipinuni-versitiesandcolleges,stateandfederalhealthcareagencies,professionalorhealthcareorganizations,researchleadershipin universities, corporations, federal agencies, health careadministrationforschooldistricts,healthcaremanagementorganizations,insuranceofficer,andhospitaladministration.2

StepsaremovinginthedirectionofaDoctorateinDen-talHygiene.TheADHApublished“DentalHygiene:FocusonAdvancingtheProfession”in2005wherearecommendationwasmadetocreatedoctoralprogramsindentalhygiene.3TheInternationalFederationofDentalHygienists’andAmer-icanDentalEducationAssociationhavediscussedtheneedforadentalhygienedoctoraldegree.4,5Amonumentalsym-posiumwasheldin2013,acollaborationwithADHAandtheSanteFeGroup.Theconclusionwaschangeisneededifdentalhygieneeducationistokeepupwiththeevolvinghealth-careenvironment.6

Thedreamofhavingadisciplinespecificdoctoraldegreeindentalhygieneishere…atleastalmost!Currently,thereisonePhDprogramindentalhygieneattheUniversityofNamseoulinSouthKorea.7Twootherprogramsareinthe

planningstagesatIdahoStateUniversityandtheUniversityofAlbertainCanada.Astheseprogramsbecomeofficialandstartacceptingdoctoralstudents,Ipredictthedemandwillsoar.

Finally,Iwouldliketohighlightoneofthepaperspub-lishedinthisissueoftheJDH.AuthorsUrsulaGMTumath,RDH,MS,andMargaretWalsh,RDH,MS,MA,EdD,con-ductedastudyofdentalhygienemaster’sdegreestudentstoassesstheirperceptionsaboutdoctoraleducation.Theyreportedthat77%indicatedadoctoraldegreeindentalhy-gieneisneededtoadvancetheprofessionandalmosthalf(43%)expressedinterestinenrollinginadoctoralprograminthenext5years.7Itisanexcitingtimeindentalhygiene!Thepossibilitiesareendless!

Sincerely,

RebeccaWilder,RDH,BS,MSEditor–in–Chief,JournalofDentalHygiene

1. Orgega E, Walsh MM. Doctoral dental hygieneeducation:insightsfromareviewofthenursingliteratureandprogramwebsites.J Dent Hyg.2014;88:5-12.

2. Gurenlian JR, Spolarich AE. Advancing the professionthroughdoctoraleducation.J Dent Hyg.2015;89:29-32.

3. Dental Hygiene: Focus on Advancing the Profession.ADHA[Internet].2005June[cited2013January27].Availablefrom:www.adha.org/resources-docs/7263_Fo-cus_on_Advancing_Profession.pdf

4. GurenlianJR.SummaryoftheInternationalFederationofDentalHygienistshouseofdelegatesworkshop.Int J Dent Hyg.2010;8(4):313–316.

5. GurenlianJR,SpolarichAE.Creatingthedoctoraldegreeindentalhygiene.AmericanDentalEducationAssociationAnnualSession.Tampa,Florida;March,2012.

6. Health Resources and Services Administration. Trans-formingDentalHygieneEducation,ProudPast,UnlimitedFuture:ProceedingsofaSymposium.U.S.DepartmentofHealthandHumanServices.2014.

7. TumathUGM,WalshM.PerceptionsofDentalHygieneMaster’sDegreeLearnersabouttheNeedforDentalHy-gieneDoctoralEducation.JDentHyg.2015;89(4):210-218.

referenceS


The Bottom Line

Lasershavebeen increasing inpopularity inden-talhygienepractice.Althoughtraditionalscalingandrootplaning(SRP)anddailyself-carebythepatienthavebeenshowntobeeffectiveinreducinginflam-mationandprobingdepthsandincreasingclinicalat-tachment,challengesassociatedwithdeeperpockets,rootmorphologyanddifficultaccessareasdecreasethe likelihood of healing following nonsurgical peri-odontaltherapy(NSPT).Adjunctssuchasantimicro-bials and lasers have been advocated to overcomethese limitations. Lasersmaybe used in the treat-mentofperiodontitisasamonotherapyorasanad-junct toSRPduring initial periodontal therapy, sur-gery,orperiodontalmaintenancetherapy;however,thisarticleaddressestheiruseasanadjuncttoSRPinNSPT.

Severaltypesof lasersareusedinthetreatmentofperiodontalandperi-implantdiseases:diodelasers(DLs)(809to980nm),Nd:YAG(1064nm),Er:YAGand Er,Cr:YSGG (2940 and 2780 nm, respectively)andtheCO2laser(10,600nm).1InNSPT,laserthera-pyisadvocatedforsulculardebridement,alsoknownassoft tissuecurettage,and forbactericidaleffectswithintheperiodontalpocket.Unlikeothertherapeu-ticproceduresusedbydentalhygienistsanddentists,thereisnostandardacceptedprotocolfortheuseoflasers.Asageneralrule,theperformanceofagiv-en laser is governed by its absorption, or depth ofpenetration intothetissues,andtheabsorptionde-pendsonthewavelength.2DiodeandNd:YAGlasersaredeeplypenetratingwhereasEr:YAG,Er,Cr:YSGGandCO2penetratesuperficially.Oneexceptiontothisgeneral rule is thephotodynamic therapy (PDT) di-odelaser(660to810nm),alow-powerlaserusedincombinationwithaphotosensitizingagentforantimi-crobialpurposesonly;therefore,thisarticledoesnotaddressPDT.Also,theresearchfindingspresentedinthisarticledonotapplytothelaser-assistednewat-tachmentprocedure(LANAP)usingtheNd:YAGlaser,asitisaspecificprotocoltrademarkedbyonecom-pany, requiringa fullyearof training,andreservedasmoreofadefinitivesurgicalprocedurefordentists

LasersandNonsurgicalPeriodontalTherapyDeniseM.Bowen,RDH,MS

ThepurposeofLinkingResearchtoClinicalPracticeistopresentevidencebasedinformationtoclinicaldentalhygienistssothattheycanmakeinformeddecisionsregardingpatienttreatmentandrecommendations.EachissuewillfeatureadifferenttopicareaofimportancetoclinicaldentalhygienistswithABOTTOMLINEtotranslatetheresearchfindingsintoclinicalapplication.

linking resarch To clinical PracTice

ordentalspecialistsonly.2Lasertherapy,alsoknownasperiodontalphototherapy,usedinconjunctionwithSRPinNSPT,isthefocusofthisarticle.

Theresearchstudiesdiscussedinthisarticleweredesigned toevaluate theeffectivenessofdiodeandNd:YAGlasersusedinconjunctionwithSRPbecauseoftheirpotentialtoperformsofttissuecurettageaswellastoreduceperiodontalpathogensintheperi-odontalpocket.2Neitherofthesetypesoflasersareused for calculus removal. Based on the findingsof these 2 studies, the ensuing conclusions can bedrawn:

• CliniciansneedtodistinguishthevarioustypesoflasersusedinNSPTandconsidertheevidencere-gardingeachtypewhenevaluatingtheeffective-nessoflasertherapy,orphototherapy,inpractice.

• Basedon thesystematic reviewandmeta-anal-ysisbySlotetal,theadjunctiveuseofthemostcommonlyemployeddiodelaser(809to980nm)asanadjuncttotraditionalmechanicalmodalitiesofperiodontaltherapyinpatientswithperiodonti-tisisquestionable.

• TheevidenceanalyzedintheSgolastraetalmeta-analysisindicatesthatNd:YAG+SRPhaspotentialforbenefitsbeyondSRPaloneduetothereduc-tioninPDandGCF;however,thelownumberofstudieseligibleforinclusionandtheriskofbiasforstudiesincludedleadstotheconclusionthatinsuf-ficientevidenceexiststosupporttheeffectivenessofNd:YAGadjunctivetoSRP.

• Thefindingsofbothofthesestudiessupportthefindingsofa2015systematic reviewandmeta-analysisonthenonsurgicaltreatmentofchronicperiodontitisbymeansofscalingandrootplaningwithorwithoutadjunctsconductedandpublishedbyapanelofexpertsconvenedbytheAmericanDentalAssociationCouncilonScientificAffairs.3

• Therewasalowlevelofevidencesupport-ingthenon-PDTDL(809to980nm)basedonasmallgaininCAL(0.21mm)comparedwithSRPalone,althoughtheADAfoundamoderatelevelevidencesupportedtheuseofthePDTDLinconjunctionwithapho-


tosensitizingagent(0.53mmgaininCAL).Again,thedifferencebetweenthenon-PDTDLstudiedbySlotetal.andtheDLusedinconjunctionwithaphotosensitizingagentforPDTshouldbenoted.

• Although the ND:YAG laser resulted in a0.41 mm gain in attachment, comparedwithSRPalone,theoveralllevelofcertain-tyoftheevidencewaslow.Only3studiescouldbeincludedinthemeta-analysisandtheriskofbiaswasmoderatetohigh.

• Moreover,theresultsofbothofthesesystematicreviews andmeta-analyses, aswell as theADAscientific panel’s systematic review and meta-analysis, support the Statement on the Efficacyof Lasers in the Non-Surgical Treatment of In-flammatory Periodontal Disease published bythe American Academy of Periodontology whichstates,inpart,thatthereisminimalevidencetosupportuseofalaserforthepurposeofsubgingi-valdebridement,asanadjuncttoSRP.4

Slot DE, Jorritsma KH, Cobb CM, Van der Weijden FA. The effect of the thermal diode laser (wave-length 808-980nm) in non-surgical periodontal therapy: a systematic review and meta-analy-sis. J Clin Periodontol. 2014;41(7):681-692.

FocusedQuestion:Whatistheadjunctiveeffectofadiodelaser(DL)followingnon-surgicalperiodontaldebridement (SRP) during the initial phase of peri-odontal therapy on the clinical parameters of peri-odontalinflammation?

Material and Methods: The MEDLINE-PubMed,Cochrane-Central Register of Controlled Trials andEMBASEdatabasesweresearcheduptoSeptember2013.Probingpocketdepth(PPD)andclinicalattach-mentloss(CAL)wereselectedasoutcomevariables.Alsoplaquescores(PS),bleedingscores(BS)andtheGingival Index (GI)were consideredoutcomemea-sures.Datawereextractedandameta-analysis(MA)wasperformedwhereappropriate.

Results:Independentscreeningof416uniquepa-pers resulted in nine eligible publications. The MAevaluatingPPD,CAL,PSshowednosignificanteffect.TheonlysignificancefavouringadjunctiveuseoftheDLwasobservedfortheoutcomeparametersGIandBS.

Conclusion:Thecollectiveevidenceregardingad-junctive use of the DL with SRP indicates that thecombinedtreatmentprovidesaneffectcomparabletothatofSRPalone.ThatisforPPDandCAL.ThebodyofevidenceconsideringtheadjunctiveuseoftheDLis judged tobe“moderate” forchanges inPPDandCAL.WithrespecttoBS,theresultsshowedasmallbutsignificanteffectfavouringtheDL,however,theclinical relevanceof thisdifference remainsaques-

tion.Thissystematicreviewquestionstheadjunctiveuse of DL with traditionalmechanicalmodalities ofperiodontaltherapyinpatientswithperiodontitis.

Commentary

Inthisarticle,Slotetalreportedtheresultsofasystematic review and meta-analysis designed toevaluatetheeffectofthediodelaser(DL,809to980nm)usedasanadjuncttoSRPduringinitialnonsur-gicalperiodontaltherapyonparametersofperiodon-titis and periodontal inflammation in patients withperiodontitis.Asystematicreviewisastudydesignedto answer a specific, focused research question bycomprehensivelycollectingandevaluatingpublishedstudies.Allofthestudiesthatmeetpre-establishedcriteriaforthehighestlevelofevidencearesystemat-icallyidentified,appraisedandsummarizedaccordingtoaprecisemethodology.Meta-analysisaddsanad-ditionalstepbystatisticallycombiningresultsofsomeoralloftheincludedstudies.Studiesthataresimilarenoughstatisticallytocombine,synthesizeandana-lyzearemergedasifthedataweregeneratedfromonestudy.Forresearchquestionsabouttherapiesorpreventivestrategies,asystematic reviewormeta-analysisofrandomizedclinicaltrials(RCTs)isconsid-eredthehighestlevelofevidenceavailable.

Asindicatedintheabstract,only9of419studiesreviewedwereincludedinthesystematicreviewandmeta-analysisbasedonthe8criteriasetforqualityand inclusion.OnlyRCTscomparingSRPalonewithSRP+DLininitialperiodontaltherapyforpatientswithperiodontitiswereincluded.Also,onlystudiesjudgedas having a low risk of bias were included. Sevenstudies used a split-mouth research design wheresidesof themouthreceivingeachtypeof interven-tionarerandomized,and2usedaparalleldesigninwhichpatientsarerandomizedforassignmenttodif-ferenttreatmentgroups.Aseparateanalysisofthese2 types of designs showedno significant differenceinfindings.Theimpactofsomeofthestudieshavingincludedsmokerscouldnotbeanalyzedduetoinad-equatereportingofdetailsregardingtobaccouse.Thesmallnumberofstudies(n=9) included inthissys-tematicreviewandmeta-analysisatteststothefactthatmuchinformationintheliteratureregardingad-vantagesoftheDLasanadjuncttoSRPforsofttissuecurettageandantimicrobialeffectsmightbebasedonlowerquality evidence than thewell-designedRCTsincludedinthissystematicreview.Dentalhygienistsareremindedtoseekthehighestqualityofevidencewhenmakingdecisionsregardingpatientcarethera-piesandstrategiesfordiseaseprevention.

The studies ofDL varied in the approach toSRPemployinghand,sonicand/orultrasonicinstrumentsand theDL parameters of energy setting, tip, pro-ceduresandcontacttime.Thisheterogenicityintheprotocols underscores the need to establish clinical


guidelinesorastandard,acceptedprotocolforlasertherapy. The evidence included in this review indi-catesthatuseoftheDL+SRPhadnosignificantef-fectonprobingpocketdepth (PPD), clinical attach-ment loss (CAL)orplaque scores (PS)beyondSRPalone.Thefocusofthisreviewwasnot intendedtobe reduced subgingivalmicrobiota; however, of the5 studies reporting theseoutcomes,only1 showedastatisticallysignificantreductioninbacterialloadinfavorofDL+SRP.Scores forbleeding(BS)andgin-gival inflammation(GI),however,didshowasmall,butstatisticallysignificant,advantageoftheDL+SRPoverSRPalone. Thesemeasures representgingivalinflammation.Themagnitudeofthisdifferenceinthemeansrepresentingtheoutcomesofthe2therapieswas -5.34%; therefore, the clinical significance ofthis differencewasquestionedby theauthors.Onewayclinicianscanconsidertheissueofstatisticalvs.clinicalsignificanceistothinkofthelatterasclinicalimportance.Dentalhygienistsandotherhealthpro-fessionalsconsideringtheevidenceshouldaskthem-selveswhether thedifferencereportedbetweenthenewandoldtherapybasedontheresultsofastudyarelargeenoughtoaltertheirpractice?Forthisrea-son,Slotetalhaveconcluded,basedonthecollectiveevidence, that the adjunctive use of DLwith tradi-tionalmechanicalmodalitiesofperiodontaltherapyinpatientswithperiodontitisisquestionable.

Thefindingsof this studysupport thefindingsofa2015systematicreviewandmeta-analysisonthenonsurgical treatment of chronic periodontitis bymeansofscalingandrootplaningwithorwithoutad-junctsconductedandpublishedbyapanelofexpertsconvenedbytheAmericanDentalAssociationCouncilonScientificAffairs.3Thatstudyfoundthat,althoughamoderatelevelevidencesupportedtheuseofthePDTDL(0.53mmgaininCAL),therewasalowlevelofevidencesupportingthenon-PDTDL(809to980nm)basedonasmallgain inCAL(0.21mm)com-paredwithSRPalone.Again,thedifferencebetweenthenon-PDTDLstudiedbySlotetalandtheDLusedinconjunctionwithaphotosensitizingagentforPDTshouldbenoted.

Sgolastra F, Severino M, Petrucci A, Roberto Gatto, Annalisa M. Nd:YAG laser as an adjunctive treatment to nonsurgical periodontal therapy: A meta-analysis. Lasers Med Sci. 2014;29:887–895.

Abstract:Ameta-analysiswasconductedtoinves-tigatewhethertheuseofNd:YAGlaseradjunctivetoscaling root planing (SRP) could provide additionalbenefitscomparedtoSRPaloneinpatientswithchron-icperiodontitis.Themeta-analysiswasperformedac-cordingtothePRISMA(PreferredReportingItemsforSystematic Reviews and Meta-analysis) statementand the recommendationsof theCochraneCollabo-ration. A literature searchwas performed on seven

databases, followed by amanual search.Weightedmeandifferencesand95%confidenceintervalswerecalculated for the clinical attachment level (CAL),probingdepth(PD),andchangesinplaqueindex(PI)andgingival crevicularfluid (GCF). Inter-studyhet-erogeneitywasassessedbytheI2test,andpublica-tionbiaswasanalyzedbythevisualinspectionofthefunnel plot for asymmetry, Egger’s regression test,and trim-and-fillmethod. All outcomeswere evalu-atedfrombaselinetotheendoffollow-up.Significantdifferences inPDandGCFreductionwereobservedin favor of SRP+Nd:YAG; no significant differenceswereobservedinCALgainorPIchange.Thefindingsofthismeta-analysissuggestthatuseoftheNd:YAGlaserasanadjunctivetherapytoconventionalnon-surgicalperiodontaltherapycouldpotentiallyprovideadditionalbenefits.However,allincludedstudieswerenotatlowriskofbias,andonlythreestudieswerein-cludedinthemeta-analysis.Asaresult,theevidenceisinsufficienttosupporttheeffectivenessofadjunc-tiveNd:YAGtoSRP.Future long-termwell-designedparallelrandomizedclinicaltrialsarerequiredtoas-sesstheeffectivenessoftheadjunctiveuseofNd:YAGlaser.Thesetrialsshouldalsoincludemicrobiologicalandadverseeventsanalyses.

Commentary

Thisstudywasawell-designedsystematicreviewandmeta-analysisconductedtoevaluatetheuseofaNd:YAGlaserasanadjuncttoSCPinnonsurgicalperiodontal therapy for patients with chronic peri-odontitis.Inadditiontomeasuringclinicaloutcomes,theresearchersalsoassessedthelevelofbiasofthestudiesincludedinthereview.Tencriteriawereusedforinclusionandexclusionin2phasestodetermineeligibility of studies included in the systematic re-view.Of438studiesevaluated,only3studiescouldbeincludedintheanalysis.AllofthesestudieswereRCTsthatusedlow-intensityNd:YAG(1064nm)lasertherapywithfibertipsrangingfrom0.2to0.6mm;however,contacttime,frequency,laserdosagesandenergy settings varied. Differences in the protocolsforNSPT,variabilityinthedefinitionsofchronicperi-odontitis,andtheinclusionofsmokersalsocontribut-edtoheterogenicityofdataincluded.Theauthorsde-terminedtheriskofbiastobemoderateforonestudyandhighfor2studiesofthethreestudiesanalyzed.

Allstudiesincludedinthisreviewandmeta-analysisusedasplit-mouthdesign.Thisdesignhastheadvan-tageof controlling for individual variationsbetweensubjects and allows for lower numbers of subjectsintheclinicaltrialwithoutalossofstatisticalpower.Within-patientcomparisonsmadeinsplitmouthde-signs, however,might be affected by differences indiseasepatternsononesideofthemouthversustheotherunlessrandomizedorcontrolled.Effectsofthe2 treatmentsmayalso carryover fromone sideofthemouthtotheother.Asplit-mouthdesignshould


onlybeusedwhenitisknownthatnosuchcrossoverexists.Alackofeffecthasbeenpresumedfor lasertherapy.

AsignificantreductioninmeanPDwasfound(0.55mm)infavorofNd:YAG+SRPcomparedtoSRPalone;however,nosignificantdifferencewasfoundforgainin CAL. The adjunctive use of Nd:YAG significantlyreducedtheamountofGCF,althoughnosignificantdifferencewasobservedinPI.GCFisareflectionofinflammation; thus, these results may support theabilityof laser therapyadjunctive toSRP to reduceinflammationinperiodontitis,liketheoutcomesoftheSlotetalreviewforDL+SRPwhichindicatedadiffer-enceinGIandbleeding.Noneofthestudiesincludedin the review by Sgolastra reportedmicrobiologicaloutcomes,althoughthisclaimisfrequentlymadeforlasertherapy.Asstatedintheabstract,theevidenceindicates,althoughthereductioninPDandGCFwithNd:YAG+SRPshowsthatthisapproachhaspotentialfor benefits beyond SRP alone, there is insufficientevidence to support the effectiveness of adjunctiveNd:YAGtoSRPduetolownumberofstudieseligibleforinclusionandtheriskifbiasforstudiesincludedinthesystematicreviewandmeta-analysis.

Thisfindingagreeswith thefindingsof the2015systematicreviewandmeta-analysisonthenonsur-gicaltreatmentofchronicperiodontitisbymeansofscalingandrootplaningwithorwithoutadjunctscon-ductedandpublishedbyapanelofexpertsconvenedbytheAmericanDentalAssociationCouncilonScien-tificAffairs.3TheADAreviewconcludedthat,althoughtheND:YAGlaserresultedina0.41mmgaininat-tachment,comparedwithSRPalone,theoveralllevelofcertaintyoftheevidencewaslow.

Summary

Dentalhygienistsarepreventiveprofessionalsre-sponsible for providing NSPT to address treatmentneeds of patients with periodontitis. Laser therapyusedaloneorasanadjuncttoSRPhasbeenincreas-inginpopularitybasedonreportedbenefitsinheal-ing followingNSPT. In fact, the evidence presentedin these articles indicates that insufficient evidenceexists to support use of DL+SRP or Nd:YAG+SRPwhencomparedtoSRPalone.Althoughlasertherapymayshowsomepromiseinreducinginflammationinperiodontitis, standard protocols for use in practiceandresearchareneeded.Robust,parallelstudiesareneededwithconsiderationgiven toaccepteddefini-tionsoftheextentofperiodontitisandthepotentialimpactofsmokingontreatmentoutcomes.Microbio-logicoutcomesalsoneedtobeevaluatedinrelationtoclinicaloutcomes.

Denise M. Bowen, RDH, MS, is Professor Emeritus in Dental Hygiene at Idaho State University. She has served as a consultant to dental industry, as well as numerous government, university and private orga-nizations and presently is a member of the National Advisory Panel for the National Center for Dental Hy-giene Research in the U.S. She has served as Chair of the American Dental Hygienists’ Association Council on Research and Chair of the Research Committee for the Institute for Oral Health and has received national awards for excellence in dental hygiene. Professor Bowen is widely known through her published articles and textbook chapters and dynamic continuing edu-cation programs related to nonsurgical periodontal therapy, preventive oral self-care, research method-ology, and dental hygiene education.

1. Cobb CM, Low SB, Coluzzi DJ. Lasers and thetreatmentofchronicperiodontitis.Dental Clinics of North America.2010;54:35–53.

2. AokiA,MizutaniK,SchwarzF,etal.Periodontalandperi-implanthealing following laser therapy.Periodontol 2000.2015;68(1):217-69.

3. SmileyCJ,Tracy,SL,AbtE,etal.Systematicre-viewandmeta-analysisonthenonsurgicaltreat-mentofchronicperiodontitisbymeansofscalingandrootplaningwithorwithoutadjuncts.JAmDentAssoc.2015;146(7):508-524.

4. AmericanAcademyofPeriodontology.Statementontheefficacyoflasersinthenon-surgicaltreat-mentofinflammatoryperiodontaldisease.J Peri-odontol.2011;82:513–514.

referenceS


Nursing,physicaltherapyandaudiologyhavede-velopeddoctoralprogramstopreparegraduatestoengageindiscipline-specificresearch,educationandpractice(Table I).1-4However, todate therearenodental hygienedoctoral programs in theU.S.Sev-eral dental hygiene scholars maintain dental hy-giene doctoral programs are needed to preparedental hygienists to conduct rigorous research toaddressthediscipline’suniqueperspectives.5-8Theyposit dental hygiene doctoral programs are criticaltopreparedentalhygieneresearcherstoaskques-tions related tooraldiseasepreventionandhealthpromotioncentraltothedentalhygienediscipline.9Suchresearchquestionsnotonlywouldincreasethediscipline’s knowledge base, but also would bringdental hygiene’s unique perspective to interdisci-plinaryproblemsolvingtoimprovethepublic’soralhealth.4-7,10-12Atpresent,dentalhygienistswhowishtopursueadoctoraldegreemustdosooutsidethedental hygiene discipline as exemplified by the 29dental hygienists with doctoral degrees who serve

PerceptionsofDentalHygieneMaster’sDegreeLearnersAboutDentalHygieneDoctoralEducationUrsulaGMTumath,MS,RDH;MargaretWalsh,MA,MS,EdD,RDH

AbstractPurpose:Todetermineperceptionsaboutdentalhygienedoctoraleducationamongdentalhygienemaster’sdegreeprogramenrollees.Methods:Inthiscross-sectionalnationalstudy,alldentalhygienemasterdegreeprogramdirectorsweresentanemailrequestingtheyforwardanattachedconsentformandonline-survey-linktotheirgraduatelearners.The29-itemonlinesurveyassessedtheirperceptionsaboutneedfor,importanceofandinterestinapplyingtoproposeddentalhygienedoctoraldegreeprograms.Asecond-requestwassent1monthlatertocapturenon-responders.Frequenciesandcross-tabulationsofresponseswereanalyzedusingtheonlinesoftwareprogram,Qualtrics.TM

Results: Ofthe255graduatelearnersenrolledin2014reportedbydentalhygieneprogramdirectors,159completedthesurveyfora62%responserate.Themajorityofrespondents(77%)indicatedthatdoctoraleducationindentalhygieneisneededfortheadvancementofthedentalhygienedisciplineandsuchprogramsareimportanttothedentalhygieneprofession(89%).AlthoughmostrespondentssupportedboththePhDindentalhygieneandtheDoctorofDentalHygienePractice(DDHP)degrees,morewereinterestedinapplyingtoaDDHPprogram(62%)thantoadentalhygienePhDprogram(38%).Inaddition,43%expressedinterestinenrollinginadoctoraldegreeprograminthenext1to5yearsandmostpreferredahybridonline/onsiteprogramformat.Themostfrequentlyreportedreasonsforpursingadoctoraldegreewere:tobecomeabetterteacher,toexpandclinicalpracticeopportunities,tobecomeabetterresearcherandtoincreasesalary.Conclusion:Mostdentalhygienemasterdegreelearnersinthisstudybelieveddoctoraldentalhygieneeduca-tionisneededandimportanttothedentalhygienedisciplineandprofession,andwereinterestedinapplyingtosuchprograms.Futureresearchisneededinthisarea.Keywords:doctoraldentalhygieneeducation,doctorateofdentalhygienepractice,master’sdegreeindentalhygiene,dentalhygienegraduateeducationThisstudysupportstheNDHRApriorityarea,Professional Education and Development: Assesshowedu-catorsaresocializingstudentstoresearch.

criTical issues in DenTal hygiene

introDuction

ontheEditorialReviewBoardoftheJournalofdentalhygiene.4-7,9,13Itisimportanttoapplaudtheseaca-demically-motivateddentalhygienistsandrecognizethatthelackofdentalhygienedoctoralprogramsdidnotstop them fromachievingadoctoraldegree inanotherdiscipline,frommakingsignificantcontribu-tionstothescientificliterature,orfromprovidingapotentialpooloffacultyfordentalhygienedoctoralprogramsonceestablished.Nevertheless, italso isimportanttorecognizethatifthedentalhygienedis-ciplineasawholedoesnotofferadoctoraldegreeindentalhygiene,thenthisomissionwilllimitprog-ress inthedisciplinebyresultinginfewerpassion-ate dental hygiene research scholarswho ask andanswerdentalhygienediscipline-specificquestions,and depriving them of a formal focused academiccontext within which to address discipline-specificproblems.5,6,12Althoughonecanmakeacontributiontothescientificliteraturewithoutholdingadoctoraldegree, doctoral programs allow time and focusedmentoring for the learner to acquire and hone re-


searchandgrant-writingskillsenablingthemtocon-ductresearchona largerscale thanresearchcon-ductedbynon-doctoralpreparedresearchers.

Currently,onlyNamseoulUniversityinSouthKo-reaoffersaPhDindentalhygiene.Twootherdentalhygienedoctoralprogramsare in thedevelopmen-talstage:oneintheU.S.atIdahoStateUniversity(Gurenlian, personal communication, September2014)andoneinCanadaattheUniversityofAlber-ta (Compton, personal communication, September2014).Asdentalhygienedoctoralprogramsbecomeestablished, it is reasonable toexpectasignificantpartoftheirapplicantpoolwouldcomefromgraduatelearnersenrolledincurrentdentalhygienemaster’sdegreeprograms.Nopublished research,however,hasbeenreportedonperceptionsofdentalhygienemaster’sdegreelearnersaboutdentalhygienedoc-toral education. Therefore, the research questionsforthisstudyare:WhataretheperceptionsofU.S.dental hygienemaster’s degree learners about theneedfor,andimportanceof,dentalhygienedoctoraleducationtothedentalhygienedisciplineandtheirinterestinpursuingsuchadegree?Toaddressthesequestions,weconductedanon-linesurveyin2014ofdentalhygienistsenrolledindentalhygienemas-ter’sdegreeprogramsintheU.S.

metHoDS anD materialS

Study Design and Population

This cross-sectional study surveyed all graduatelearnersenrolledinU.S.dentalhygienemaster’sde-greeprogramsin2014todeterminetheirperceptionsofdoctoraldentalhygieneeducation.ThisstudywasapprovedbytheInstitutionalReviewBoard,knownastheCommitteeonHumanResearch(CHR),attheUniversityofCalifornia,SanFrancisco(UCSF).

The Survey

The10-minuteself-administeredconfidentialon-linesurveywasdevelopedanddeliveredusing theQualtricsTMsystem,awebbasedsoftwareprogram.14The survey was pilot tested for face validity by apanel of 8 dental hygienists and revised based onfeedbackabout clarityand lengthof survey items,andtimerequiredtocompletethesurvey.Thefinalsurveyconsistedof29itemsthatincluded11demo-graphicitems:

• Currentenrollmentinadentalhygienemaster’sprogram

• Format of theirmaster’s program (on-line, on-siteorhybrid)

• Age• Gender• Race• Year of graduation from entry-level dental hy-

gieneprogram• Type of entry-level dental hygiene credentialawarded

• Yearreceivedbaccalaureatedegree• Typeofbaccalaureatedegreereceived• Whetherornotcurrentlyadentalhygieneeduca-

tor• AmemberoftheAmericanDentalHygienists’As-sociation(ADHA)

Alloftheseitemsweremeasuredeitherbyyes/noormultiplechoiceresponseoptions.

Inaddition,18itemsmeasuredattitudestowardsdoctoraldegreesindentalhygieneconsistingofde-clarativestatementsrelatedto:

• The importanceofdentalhygienedoctoralpro-gramstothedentalhygienedisciplineandpro-fession(measuredona5-pointLikertscalerang-ingfrom1=ExtremelyImportantto5=NotatAllImportant)

• Theneed for dental hygienedoctoral programsfordisciplineprogress

• Generalinterestinapplyingtoadentalhygienedoctoralprogram

• Interest in applying to a program that wouldaward a PhD in dental hygiene or a Doctor ofDentalHygienePractice(DDHPwhenthedegreewasdefined,butnottheprogramorientationandlength)

• Perceivedsupportbydentalhygienistsandden-tistsoverallforPhDindentalhygieneandDDHPdegree programs (all measured on a 5-pointLikert scale ranging from 1=Strongly Agree to5=StronglyDisagree)

Inaddition,laterinthesurvey,2itemsaskedaboutinterestinapplyingtopotentialdentalhygienepro-gramsandrelateddegreesthatincludedthefollow-ingprogramdescriptions:a3to5yearPhDdoctoraldental hygiene program thatwould prepare dentalhygiene researchers, and a 1 to 2 year Doctor of

ResearchDoctoralDegree

ProfessionalDoctoralDegree

Nursing PhDinNursing DNP(DoctorateofNursingPractice)

PhysicalTherapy

PhDinRehabilitationScienceProgramDPTSc(DoctorateofPhysicalTherapy

Science)

DPT(DoctorateofPhysicalTherapy)

Audiology PhDinAudiology AuD(DoctorofAudi-ology)

TableI:ResearchandProfessionalDoctoralDegreesinOtherHealth-relatedDisciplines


DentalHygienePractice(DDHP)programthatwouldpreparemid-level advanced dental hygiene practi-tionersabletoprovidecareinavarietyofsettingsundergeneralsupervisionofphysiciansordentists.These latter 2 items weremeasured on a 5-pointLikertscale,rangingfrom1=VeryLikelyto5=VeryUnlikely.

Threeadditional itemsweremeasuredbymulti-plechoiceresponseoptions:2askedabout formatpreferences for thePhD indental hygieneand theDDHPprograms,respectively(online,onsiteorhy-brid), and 1 item asked about when they thoughttheywouldapplytoadoctoraldegreeprogram(inthenextyear,next5years,whenadoctoraldegreeindentalhygieneprogrambecameavailable,neverandIdonotknow).

Recruitment and Informed Consent

Initially,anemailwassenttoall16graduateden-talhygieneprogramdirectors in theU.S. listedontheADHAwebsite,requestingthenumberofgradu-atelearnersenrolledintheirprogram.Alldentalhy-gieneprogramdirectorsrespondedreportingacom-binedtotalof255graduatedentalhygienelearnersenrolledin2014.Asubsequentemailwassenttothesameprogramdirectorstoexplainthestudypurposeand to request that they forward to theirgraduatedentalhygienelearnersanattached“learnerrecruit-ment/consent letter” with the survey link to com-pletethesurvey.

The “learner-recruitment/consent letter” ex-plainedthestudypurpose,methods,risksandbene-fits,andincludedtheinvestigator’scontactinforma-tiontoansweranystudyquestions.Italsoinstructedthegraduatelearnerthatclickingonthesurveylinkwithintheletterwouldindicatetheirconsenttopar-ticipate in the studyandallow themaccess to thesurvey.

Thelearnerrecruitmentemailalsoexplainedthatas a token of appreciation for study participation,theresearcheratthecompletionofthestudywouldholdarafflefora$100Starbucksgiftcard.Iftheywishedtoparticipate in theraffle, therespondentswereaskedtoincludetheiremailaddressinthelastsurveyitem.

Data Analysis

ResponsestothesurveysweretabulatedforeachrespondentusingMicrosoftExcel,andthemeanre-sponsefrequencyforeachsurveyitemwascalculat-ed. “StronglyAgree”and“Agree” responseoptionswerecollapsedintooneresponsecategoryforanaly-sisasweretheresponseoptions“StronglyDisagree”and “Disagree” responses. In addition, “ExtremelyImportant” and “Important” response options, and

reSultS

Of the255eligiblegraduate learnersenrolled in2014reportedbytheprogramdirectors,159com-pleted theonline survey for a62% response rate.Most respondents were female, Caucasian, ADHAmembers, received their baccalaureate degree indentalhygieneandattendedanonlinemaster’spro-gram.Lessthanhalfwerefull-timeorpart-timeden-talhygieneeducators.Thelargestagegroupwas24to34yearsold(TableII).

The majority of respondents strongly agreed oragreed that the establishment of dental hygienedoctoraldegreeprograms is important to theden-talhygienedisciplineandprofession(TableIII),thatdoctoraleducationindentalhygieneisneeded,andthey perceived that overall most dental hygienistswouldsupportaDDHPprogramoraPhDindentalhygieneprogram.Incontrast,only13%ofrespon-dents agreed that dentists would support a DDHPdegree,andlessthanhalf(43%)agreedthatden-tistswouldbesupportiveofaPhDdegreeindentalhygiene(TableIV).

Whenaskedaglobalquestionregarding interestin applying to aDDHPprogramor a PhDprogramindentalhygiene,61%expressedinterestinapply-ing to a DDHP program, and 60% also expressedinterestinapplyingtoaPhDprogram.Only15%ofrespondentshadnointerestinattaininganytypeofdoctoral degree (Table IV). Half (50%) of respon-dents indicated that they would pursue a doctoraldegree even if no dental hygiene doctoral degreeprogrambecameavailable.OncedescriptionsoftheDDHPprogramsandPhDindentalhygieneprogramswereprovidedlaterinthesurvey,however,theper-centageofthoselikelytoapplytoaDDHPprogramslightly increasedto62%,butthelikelihoodofap-plyingtoaPhDprogramdroppedto38%(TableV).

Youngerrespondents,morerecentdentalhygieneentry-levelgraduates,andthosewithabaccalaure-atedegree indentalhygieneweremore interestedinapplyingtodentalhygienedoctoralprogramsthanolderrespondents,lessrecentgraduatesandthose

“Very Likely” and Likely” responses similarly alsowerecollapsedrespectivelyforanalysisaswere“Ex-tremelyUnimportant”and“Unimportant”and“VeryUnlikely”and“Unlikely”responses.

Using the online software program QualtricsTM,cross-tabulationsofparticipants swho stated theywere“VeryLikely”or“Likely”toapplytoaspecificdoctoraldegreeprogramwhenavailablebyrespon-dent demographic characteristics were analyzed.Cross-tabulationsofresponseswith“age”and“whentherespondentthoughttheywouldapplytoadoc-toralprogram”alsowereanalyzed.


Percent nAge(years)(n=150)24to3435to4445to5455to64

3430306

5145459

Gender(n=150)MaleFemale

397

5145

DHEducator(n=150)YesNo

3763

5694

Race(n=149)White/CaucasianAfricanAmericanHispanicAsianNativeAmericanPacificIslanderOther*

87125013

130238015

ADHA(n=150)MemberNon-Member

8119

12228

TypeofGraduateProgram(n=159)On-siteOn-lineHybridon-siteandon-line

87914

1212522

Entry-levelDHCredential(n=150)CertificateAssociateBachelors

36335

49452

DHentry-levelgraduation(year)(n=149)1970to19791980to19891990to19992000to20092010to2013

111254616

217376924

YearofBaccalaureateDegree(n=137)1980to19891990to19992000to20092010to2013

3183742

4245158

TypeofBaccalaureateDegree(n=146)DHNon-DHNoBaccalaureateDegree**

66277

973910

nvaluesmayvaryduetomissingdata.*Otherincluded:Bi-racial,Arab,AsianIndian.**Onegraduateprogramisabridgeprogram,whichby-passesabaccalaureatedegree.

Table II: Percent and Number Related toCharacteristicsofStudyPopulation

withnon-dentalhygienebaccalaureatedegrees re-spectively(TableVI). Inaddition,whenaskedrea-sonsforpursuingadentalhygienedoctoraldegree(TableVI),aboutonethirdofthose“VeryLikelyor“Likely”toapplytothedentalhygienePhDprogramstated,“tobecomeabetterteacher”(31%)and“tobecomeabetterresearcher”(27%).Reasonsstatedby almost half of those “Very Likely or “Likely” toapplytotheDDHPprogramstated“tobecomeabet-ter teacher (44%), “to expandmy clinical practiceopportunities” (43%), and “to increasemy salary”(39%). One-third stated “to become a better re-searcher”andtobecomeadentalhygieneprogramdirector(31%).

ForPhDindentalhygieneprograms,mostrespon-dents(47%)preferredahybridonline/onsiteformat;whereasforDDHPprograms,twothirds(76%)ofallrespondentspreferredahybridonline/onsiteformatwithclinicalexperienceinavarietyofsettings(TableVII).

Whenaskedaboutwhenrespondentswouldapplytosometypeofdoctoraldegreeprogram,10%stat-edinthenextyear,33%statedinthenext5years,and17%statedtheywouldwaituntiladoctoralpro-gramindentalhygienewasestablished.Half(50%)of respondents indicated that theywouldpursueadoctoral degreeeven if nodental hygienedoctoraldegreeprogrambecameavailable.Ofthoseinterest-edinapplyingtoadoctoralprograminthenextyearto5years,15%werebetweentheagesof24to34,12%werebetweentheagesof35to44,12%werebetweentheagesof45to54,and3%werebetweentheagesof55to64(TableVIII).

DiScuSSion

Inthisstudy,themajorityofU.S.dentalhygienemaster’sdegree learnersenrolled ingraduatepro-gramsin2014agreedthatdentalhygienedoctoraleducationisneededandisimportanttothedentalhygiene profession.Moreover, over half of the re-spondentswere interested in applying to a dentalhygienedoctoraldegreeprogramwhenonebecameavailable,andalmosthalfwereinterestedinapply-ingtosuchaprograminthenext1to5years.Thisinterestinpursuingadoctoraldegreewasnotlim-ited toaspecificagegroupsince those interestedrangedinagefrom24to64years.Although17%of respondents reportedwillingness towaituntiladental hygiene doctorate degree program becameavailable,50%statedtheywouldseekdoctoralleveleducationinanotherdisciplineifthedentalhygienedisciplinedidnotofferadoctoraldegree.

Recently Namseoul University in Korea estab-lishedthefirstPhDindentalhygieneprogramwith6 dental hygiene doctoral students currently en-rolled.15Withsomanyotherprofessionsmovingto-


StatementExtremelyimportant

Somewhatimportant Noopinion Somewhat

unimportantNotimportant

atallPercent n Percent n Percent n Percent n Percent n Mean

Howimportanttothedentalhygieneprofessionistheestablishmentofdentalhygienedoctoraldegreepro-grams?(n=154)

53 81 36 56 6 10 3 4 2 3 1.65

Table III:Percent,NumberandMeanResponses related toRespondents’ LevelofPer-ceivedImportance*ofDentalHygieneDoctoralEducationtoDentalHygieneProfession

*Measuredona5-pointLikertscalewhereascoreof1=“ExtremelyImportant”andascoreof5=“NotImportantatAll”

StatementStronglyAgree/

Agree NoOpinion Disagree/StronglyDisagree

Percent n Percent n Percent n MeanDoctoraldentalhygieneeducationisneeded(n=154) 77 118 14 21 10 15 1.97Ifdentalhygienedoctoraldegreeavailable,Iwouldbeinterestedinapplying(n=154) 62 95 19 30 19 29 2.34

MostdentalhygienistswouldsupportaDDHPprogram*(n=153) 78 118 13 20 9 15 1.95

MostdentistswouldsupportaDDHPprogram(n=152) 13 19 26 40 61 93 3.66MostdentalhygienistswouldsupportaPhDindentalhygieneprogram(n=151) 83 125 11 17 6 9 1.80

MostdentistswouldsupportaPhDindentalhygieneprogram(n=151) 43 65 26 40 31 46 2.97

IfaDDHPprogramwasavailable,Iwouldbeinterestedinapplying(n=151) 61 92 21 31 18 28 2.35

IfaPhDindentalhygieneprogramwasavailable,Iwouldbeinterestedinapplying(n=150) 60 91 19 28 21 31 2.35

Notinterestedinanytypeofdoctoraldegree(n=150) 15 23 17 25 68 102 3.87Ifdentalhygienedoctoralavailable,interestedindoctoraldegreeotherthandentalhygiene(n=151) 22 32 26 40 52 79 3.44

Ifnodentalhygienedoctoralavailable,interestedindoc-toraldegreeotherthandentalhygiene(n=150) 50 75 23 35 27 40 2.66

TableIV:Percent,NumberandMeanResponsesRelatedtoRespondents’LevelofAgree-ment**withStatementsRelatedtoDoctoralDentalHygiene-RelatedStatements

nvaluesmayvaryduetomissingdata*=DoctorofDentalHygienePractice**Measuredona5-pointLikertscalewhereascoreof1=“StronglyAgree”andascoreof5=“StronglyDisagree”

wardsdoctoraleducationastheirterminaldegree,itisgratifyingtoseethatdentalhygienehasopeneditsfirstdoctoralprogram.Thefindingssupporttheneedanddemandfordentalhygienedoctoraledu-cationintheU.S.andareconsistentwithpublishedideasrelatedtotheneedforadvancededucationindentalhygienebeyondthemaster’sdegree.4-10,16Forexample, the 2005 ADHA report entitled, “DentalHygiene Focus on Advancing the Profession,” con-cluded that creatingadoctoral degreeprogram indentalhygienewasamajorgoalfordentalhygieneeducationtoassistintheadvancementofthepro-fessionandtohelpmeettheneedsofthepublic.17

Otherreportsintheliteraturehavepresentedcur-riculumcontentneededfordevelopingdoctoralden-talhygieneprogramsandhaverecommendthattheADHAcreateataskforcetocreatesuchacurricu-lum,justasitdidfortheAdvancedDentalHygienePractitioner(ADHP)model.10,11,16,18

Indeed,dentalhygienescholarshavepointedoutintheliteraturethatdentalhygienedoctoraldegreeprogramswouldbenefitthepublic’soralhealthnotonlybyprovidingwellqualifiedmid-levelpractitio-ners, but also highly qualified educators and re-searcherswhowouldcontributetotheknowledge-


StatementVeryLikely/Likely Undecided Unlikely/Very

UnlikelyPercent n Percent n Percent n Mean

ApplicationtoPhDinDHpro-gram*(n=150)

38 57 27 40 35 53 2.95

ApplicationtoDDHPprogram**(n=150)

62 93 20 30 18 27 2.37

TableV: Percent,Number andMeanResponsesRelated toRespondent Level of Likeli-hood***ofApplyingtoPhDorDDHPProgramsOnceProgramDescriptionWasProvided

*3to5yearPhDdoctoraldentalhygieneprogramthatwouldpreparedentalhygieneresearchers,wouldberesearchbased,andhaveonlineandon-sitecomponents,andtake3-5yearstocomplete**1to2yearDoctorofDentalHygienePractice(DDHP)programthatwouldpreparemid-leveladvanceddentalhygienepractitionersabletoprovidecareinavarietyofsettings(medical,dental,publichealth)undergeneralsupervisionofphysiciansordentists***Measuredona5-pointLikertscalewhereascoreof1=“VeryLikely”andascoreof5=“VeryUnlikely”

Characteristic PhDindentalhygienePercent(n)Responding“VeryLikely/Likely”

DDHPPercent(n)Responding“VeryLikely/Likely”

Age(n=150)24to34 15(23) 25(37)35to44 11(16) 17(26)45to54 10(15) 15(23)55to64 2(3) 5(7)CurrentdentalhygieneEducator(n=150)Yes 15(22) 23(34)No 23(35) 39(59)YearofdentalhygieneentrylevelGraduation(n=149)1970to1979 0(0) .6(1)1980to1989 4(6) 7(11)1990to1999 10(15) 13(19)2000to2009 17(25) 29(43)2010to2013 7(10) 12(18)TypeofBaccalaureateDegree(n=150)dentalhygiene 25(37) 41(61)Non-dentalhygiene 13(19) 20(29)Reasonsforpursuingadoctoraldegreeindentalhygiene*TobecomeabetterTeacher 31(45) 44(65)TobecomeabetterResearcher 27(39) 31(46)Toincreasemysalary 21(31) 39(57)Tobecomeemployedintheoralhealthproductindustry 9(13) 13(19)

Tobecomeadentalhygienistspro-gramdirector 22(33) 31(46)

Toexpandmyclinicalpracticeop-portunities 23(34) 43(63)

TableVI:ParticipantDataRegardingApplicationtoanAvailableDentalHygienePhDPro-gramoranAvailableDoctorateinDentalHygienePractice(DDHP)

*Respondentswereallowedtoselectmorethanoneanswer(n=147)


PhDinDentalHygiene(n=152)

DDHP(n=152)

ProgramFormats* Percent(n) Percent(n)On-lineonly 40(61) 10(15)On-site 7(11) 10(15)Hybridon-line/on-site 47(72) 76(115)Idonotsupport 3(4) 3(5)Noopinion 3(4) 1(2)

TableVII:PercentandNumberofRespons-es Related to Participants’ Preferences forFormatofPhDinDentalHygieneandDDHP(n=159)

*Measuredbymultiplechoiceitems

baserelated tooraldiseasepreventionandhealthpromotion.9Inaddition,byvirtueoftheiradvanceddegree,dentalhygienistswithadoctoraldegreeindentalhygienemayhavegreateropportunitytopar-ticipateonoralhealthcarepolicydevelopmentcom-mitteesatthelocal,stateandnationallevel.Bring-ingthedoctoral-leveldentalhygieneperspectivetothedecision-makingtablewouldprovidesalientin-formationtoassistwithaddressingoralhealthcarechallengesassociatedwithoralhealthdisparities.

Studyparticipantswereaskedabouttheirpercep-tions in general of dentists’ and dental hygienists’supportoftheproposeddentalhygienedoctoralde-greeprogramstoexplorepotentialperceivedbarri-ers.AlthoughoverhalfoftherespondentsbelieveddentalhygienistswouldsupportbothPhDindentalhygieneandDDHPprograms,lessthanhalfagreedthatmost dentistswould support the PhD in den-talhygieneandonly13%agreedthatmostdentistswould support DDHP programs. These findings ofperceivedlessdentists’supportforDDHPprogramsneeds to be further explored in future qualitativestudiesofdentistsanddentalhygienists.Apossibleexplanationforthefindingofrespondents’perceivedlowersupport forDDHPprogramsbydentistsmaybeduetoexpectationsthatdentistswouldperceivedentalhygienistswithaDDHPdegreeasunwantedcompetition. Indeed, the goal of DDHP programswouldbetoprepareadvanceddentalhygieneprac-titionersabletoprovidecareinavarietyofsettingsundergeneralsupervisionofphysiciansordentists.Forexample,graduatesofDDHPprogramscouldbeeducated to act as liaisons betweenmedicine anddentistryinmedicalsettingsandthuscouldfunctionasasourceofnewreferralstodentists.Thelitera-turesupportsprofitabilityfordentistsasaresultofcollaboratingwithdentalhygienistsinclinicalprac-tice.19Itisimportanttonotethataboutaquarterofrespondents had no opinion aboutwhether or notmostdentistswouldsupporteitherthePhDortheDDHPprogramssuggestingalackofanopportunityto discuss dental hygiene doctoral education withthedentiststheyknow.

Findings from the current research also showedthatmostrespondentsweremoreinterestedinap-plyingtoaDDHPprogramthanaresearch-focusedPhDprogramonceeachtypeofdegreeprogramwasdescribedlaterinthesurvey.ThisfindingmightbeexplainedbythefactthattheDDHPwouldtakelesstimethanthePhD,andisconsistentwithourfind-ings that almost half of the respondents reportedpursuingadentalhygienedoctoraldegreetoexpandtheirclinicalpracticeopportunities.

The findings support the literature on the needtoexpandtheroleofdentalhygienistsandontheever increasing need for evidence-based mid-lev-eloralhealthcareproviderstohelpmeettheoral

healthneedsof thepublic.4,6,8,16,18 Thepotential ofaDDHPprogramtoprovideanewhighlyqualifiedmidleveloralhealthcareproviderispromisingandis consistentwith theneedposedby theADHA in2008forsometypeofmidlevelprovider,whichtheycalledtheADHP.18Since2008,MinnesotaandMainebothhaveapprovedmidleveloralhealthcarepro-vidercategories,whichrequireeducationbeyondabasicpreparationdentalhygieneprogramrequiredfor a RDH license.16,19 Yet each of thesemid-leveloralhealthcare licenses isverydifferent.CreatingaDDHP program could help standardizemid-levelprovidereducationalstandardsforADHPprograms.HavingboththePhDandtheDDHPdegreesavail-able is consistent with research-oriented and ap-plieddegreesawarded inotherdisciplinessuchasthePhDandEdDinEducation,thePhDandtheDoc-torofNursingPractice (DNP) forNursing,and thePhD and the Doctor of Physical Therapy (DPT) inPhysicalTherapy.

Indeed, theADHAhasprovidedworkshopssuchas “DentalHygiene inaChangingWorld,” that fo-cusonexpandedrolesfordentalhygienistsrequir-ingadvancededucation toaugment theirscopeofclinicalpractice.20Othershavedescribedtheneedtodevelopascholarlyidentitythroughdoctoraldentalhygieneprogramsthatwouldprovidemoretimeformentoringtodevelopskillsandexperiencesneededto evolve into independent researchers, and lead-ers required for thecontinueddevelopmentof thedental hygienediscipline.10Othersalsohavehigh-lightedpotential roles fordoctoralprepareddentalhygieniststocontributetotheadvancementoftheprofession and the public’s oral health by exercis-ingleadershipskillsinresearch,education,privateindustry,healthcareadministrationandpolicyde-velopment.4-6,8,9

Thesestudyfindingsaddtothecurrentliteratureregardingdoctoraleducationindentalhygieneand


Age(years)ofRespondents24to34 35to44 44to54 55to64 Total

Statement Percent n Percent n Percent n Percent n Percent nInthenextyear 2 (3) 3 (4) 3 (5) 2 (3) 10 (15)Inthenext5years 13 (20) 9 (14) 9 (13) 1 (2) 33 (49)WhenadoctoralprograminDHbecomesavailable 6 (9) 5 (8) 4 (6) 1 (2) 17 (25)

Iamnotplanningonap-plyingtoadoctoraldegreeprogramever

4 (6) 6 (9) 7 (10) 1 (1) 17 (26)

Idon’tknow 9 (13) 7 (10) 7 (11) 1 (1) 23 (35)

TableVIII:Percent,AgeandNumberofParticipantResponsestotheQuestion“WhenDoYouThinkYouMightApplytoaDoctoralDegreeProgram?”(n=150)

concluSion

Thefindingsindicatethatdentalhygienemaster’sdegreelearnersenrolledin2014wereinterestedinandsupporteddentalhygienedoctoraleducationandthoughtitisveryimportanttoprogressinthedentalhygienediscipline.ThesefindingsalsosuggestthatDDHPprogramsmaybemorepopularthanPhDpro-gramssincemanystudyparticipantswereinterestedinexpandingclinicalpracticethroughdoctoraledu-cation.Futurequalitativeresearchisneededtoex-plorereasonsdentalhygienemastersdegreelearn-erswouldapplytoeitheraPhDindentalhygieneorDDHPprogram,andtoexplaintheirperceptionsofdentists support for theseprograms.Moreover, fu-ture research is needed among current dental hy-gieneeducators,cliniciansanddentalhygienistswithdoctoraldegreestoexploretheirperceptionsaboutdoctoraldentalhygieneeducation.

Ursula GM Tumath, RDH, MS, currently works in a clinical practice in San Francisco. Margaret Walsh, RDH, MS, MA, EdD, is a Professor Emerita, Depart-ment of Preventive and Restorative Dental Sciences, University of California, San Francisco.

contributetotherichcontextthatinformsthedoc-toraleducationdiscussionmovingforward.Toaddtothison-goingdiscussion,futurequalitativeresearchisneededtoexplorereasonsdentalhygienemastersdegreestudentswouldbeinterestedinapplyingtoeither a PhD in dental hygiene orDDHP program.Ourfindingsindicatethataboutaquarterofthere-spondents were undecided about applying to anydoctoralprogram;andwhenaskedwhytheywouldapplytoadentalhygienedoctoralprogram,lessthanhalf(48%)stated“tobecomeabetterresearcher.”Moreover,futureresearchisneededamongcurrentdentalhygienistswithdoctoraldegreesinotherdis-ciplinestoexploretheirperceptionsaboutdoctoraldentalhygieneeducation.

Inthecurrentstudy,mostrespondentspreferredahybridon-line/on-siteformatforboththePhDindentalhygieneandDDHPprograms.Thisfindingisinterestingbecausemostrespondentswereenrolledinon-linemastersdegreeprograms.Additionalre-search is needed to identifyprogram formats thatwouldbeappropriate.

Limitations:Thereareseverallimitations.First,although the entire population of U.S. learners indental hygienemaster’s degree programs enrolledin 2014 were surveryed, the findings are limitedtothatspecificgroupandcannotbegeneralizedtootherdentalhygienistswhomayhaveverydifferentthoughts about doctoral dental hygieneeducation.In addition, although there was a 62% responserate, individuals who responded may have beenmore positively disposed toward dental hygienedoctoraleducationthanthosewhodidnotrespond.Thesefindingsalsomaybelimitedbythemethodol-ogythatreliedonthemaster’sdegreeprogramdi-rectorstoforwardthestudysurveytotheirlearners.

Thebiggestchallengetoconductingthestudywasnotbeingabletohavedirecte-mailcontactwiththepopulationattemptingtobesurveyed.Theauthorsreliedonthemaster’sprogramdirectorstoforwardthesurveytwiceandmayhaveaddedtotheburdenoftheprogramdirectorssuchthatsomemayhavenothadtimetosendoutthesurveyespeciallyforasecondtime.Finally,althoughthesurveywaspilottested for face validity and clarity of the items, itwasnotmeasuredforreliabilityandthereforeisun-abletoaccountfortheeffectsoffatigueorguessingrelatedtoresponses.


1. University of Pittsburgh. Doctor of Philosophy(PhD) Nursing [Internet]. Pittsburgh (PA) [cited2013Aug7].Availablefrom:http://www.nursing.pitt.edu/academics/phd.jsp

2. Physicaltherapist(PT)educationoverview[Inter-net].Alexandria(VA):AmericanPhysicalTherapyAssociation.2014September17[cited2015July27].Availablefrom:http://www.apta.org/PTEdu-cation/Overview/.

3. AmericanAcademyofAudiology.AuDFacts[Inter-net].[cited2013Sept3].Availablefrom:http://www.audiology.org/education/students/Pages/audfacts.aspx

4. HensonHA,Gurenlian JR,BoydLD.Thedoctor-ateindentalhygiene:hasitstimecome?Access.2008;22(4):10,12,14.

5. Darby ML. Dental hygienists with master’s anddoctoral degrees are in high demand and havecareer options in many areas, from educationto business to public health. DimensDent Hyg.2004;2(9):12-14,16.

6. Gurenlian JR, Spolarich AE. Advancing the pro-fession throughdoctoral education. JDentHyg.2013;87(Suppl1):29-32.

7. CobbanS,EdgingtonE,ComptonS.Anargumentfordentalhygienetodevelopasadiscipline.IntJDentHyg.2007;5(1):13-21.

8. OrtegaE,WalshMM.Doctoraldentalhygieneedu-cation:Insightsfromareviewofnursingliteratureandprogramwebsites.JDentHyg.2014;88(1):5-12.

9. Bowen D. History of dental hygiene research. JDentHyg.2013;87(Suppl1):5-22.

10.WalshMM,OrtegaE.Developingascholarlyiden-tityandbuildingacommunityofscholars.JDentHyg.2013;87(Suppl1):23-28.

11.Boyd LD, Henson HA, Gurenlian JR. Vision forthe dental hygiene doctoral curriculum. Access.2008;22(5):16-19.

12.CobbanS,EdgingtonE,MyrickF,KeenanL.Adis-courseonthenatureofdentalhygieneknowledgeandknowing.IntJDentHygiene.2009;7(1):10-16.

13.Editorial Board. The Journal of Dental Hygiene[Internet].2013[cited2015August7].Availablefrom:http://jdh.adha.org/site/misc/edboard.xht-ml

14.Qualtrics FAQs [Internet]. Edwardsville (IL):Southern Illinois University Edwardsville; n.d.[cited2015July27].Availablefrom:http://www.siue.edu/its/qualtrics/pdf/QualtricsFAQs.pdf

15.Starting with the first PhD Dental HygieneSchool6people[Internet].Seoul,SouthKorea;2013December 18 [cited 2014May 19]. Avail-able from: http://www.dentin.kr/news/article.html?no=2729.

16.Emmerling H. The ADHP initiative: a nationaloverview.RDH.2009;29(8):18.

17.American Dental Hygienists’ Association. Dentalhygiene: focusonadvancing theprofession[In-ternet]. Chicago (IL): American Dental Hygien-ists’Association;2005June[cited2014May19];16-18. Available from: http://www.adha.org/re-sources-docs/7263_Focus_on_Advancing_Profes-sion.pdf

18.CompetenciesfortheAdvancedDentalHygienePractitioner (ADHP) [Internet]. Chicago (IL):American Dental Hygienists’ Association; 2008March 10 [cited 2014May 15]. Available from:http://www.adha.org/resources-docs/72612_ADHP_Competencies.pdf

19.ADHAsupportscreationofdentalhygienethera-pistsinMaine[Internet].Chicago(IL):AmericanDental Hygienists’ Association; 2014 May [cited2014May 7]. Available from: http://www.adha.org/resources-docs/ADHA_Supports_Creation_of_Dental_Hygiene_Therapists_in_Maine.pdf

20.Dental hygiene in a changing world [Internet].Chicago (IL):AmericanDentalHygienists’Asso-ciation;n.d.[cited2014May15].Availablefrom:http://www.adha.org/dental-hygiene-changing-world.

referenceS


Information gathered from the National CancerDataBase(NCDB)andtheSurveillance,Epidemiol-ogy,andEndResults(SEER)registries,bothofwhichcollectdatarelatingtothediagnosisandtreatmentofindividualswithcancer,revealthattherewereanestimated13.7millionAmericanswithahistoryofcanceraliveonJanuary1,2012.Thepopulationofcancer survivors is projected to increase to nearly18millionbyJanuary1,2022.1Althoughchildhoodcancers,frombirthtoage14,areconsideredrare,affectinglessthan1%ofallnewcancerdiagnoses,nearly59,000Americansaresurvivorsofchildhoodcancers.1 Improved survival rates are largely dueto newly implemented aggressive treatment strat-egies.2 It is predicted that nearly 80% of childrendiagnosedwithcancerin1990willsurviveintoadult-hood due to these treatmentmodifications.2-4 But,

Knowledge,PerceivedAbilityandPracticeBehaviorsRegardingOralHealthamongPediatricHematologyandOncologyNursesAntianaD.Perry,RDH,BS;HirokoIida,DDS,MPH;LaurenL.Patton,DDS;RebeccaS.Wilder,RDH,MS

AbstractPurpose:Oralcomplicationsarecommoninchildrenundergoingheadandneckradiationandchemo-therapy.Thepurposeofthisstudyistoexaminetheknowledge,perceivedabilityandpracticebehaviorsofpediatriconcologyandhematologynursesinassistingwiththevariousoralhealthcareneedsofpe-diatriconcologypatientsandtoidentifypediatriconcologynurses’previoustraining/education,practicetypesandotherdemographiccharacteristicsthatarerelatedtotheiroralhealthcompetencies.Methods:AsurveyofaconveniencesampleofPediatricOncologyandHematologyNurseswascon-ductedduringtheAssociationofPediatricOncologyandHematologyNurses’(APHON)36thAnnualCon-ferenceandExhibit.DescriptiveanalysisandtheexploratoryfactoranalyseswereperformedusingSASversion9.2(SASInstitute,Inc.,Cary,NC).Results: Amongthe300surveysthatweredistributed,235surveyswerecompleted(78%responserate)bypediatriconcologyorhematologynurseswhoprovidedirectpatientcareintheU.S.Approxi-mately75%reportedreceivinglessthan3hoursoforalhealthrelatededucation/training.Sixtypercentdidnothaveaclinicalrequirementregardingtheassessmentoftheteethandgumsduringtheirnursingschooleducation.Bivariateanalysesindicatedthatnurseswhohadclinicalrequirementsregardingoralhealthassessmentduringnursingeducation/trainingpresentedgreateroveralloralhealthcompetenciesincludinghavinggreaterconfidenceinexaminingoralcomplicationsthanthosewhodidnot.Conclusion:Pediatriconcologynurses’knowledge,perceivedabilityandpracticeinassistingpatient’soralhygienecare,preventingandmanagingoral complicationsvaryby topicandmight reflect theireducationalpreparedness.Thisstudymayprovidevaluableinformationpertainingtotheneedandop-portunityforinterprofessionaloralhealthcareeducationandcollaborationwithnursinganddentalpro-fessionals,inordertoincreaseaccesstocomprehensiveoralcareforpediatriccancerpatients.Keywords:knowledge,nurse,oralhealth,pediatriconcology,perceivedability,practicebehaviorsThisstudysupportstheNDHRApriorityarea,Health Promotion/Disease Prevention: Validateandtestassessment instruments/strategies/mechanismsthat increasehealthpromotionanddiseasepre-ventionamongdiversepopulations.


introDuction

thesenewcuresmaybeassociatedwithlong-termeffectsthathaveadverseeffectsonthequalityoflifeofsurvivors.2

Oralcomplications,suchasmucositis,herpessim-plexvirus(HSV) infections,erythematousorpseu-domembranouscandidiasis,xerostomia,dentalcar-ies, and dental anomalies are common in childrenundergoingheadandneckradiationandchemother-apyduetocompromisedimmunesystems,damagetosalivaryglandsand/ordevelopingdentition.2,5-8Asoralcomplicationspersistwithchemotherapyorradi-ationtherapyandworsenwithprolongedtreatment,patientsmayexperiencedebilitatingpainwhenper-formingsimpletasks,suchaseating,drinkingand/ortalking.5,9Secondarytothisdebilitatingpaininthemouthandcompromisednutrition,patientsmayalso


experiencedelayedwoundhealing,decreasedtreat-menteffectsanddiminishedqualityoflife.5,10,11

It is widely accepted throughout the literaturethatbasicoralhygienepractices,suchasbrushing,flossing and using mouth rinses help in reducingthe oralmicrobial flora in themouth and prevent-ingoralcomplicationsassociatedwiththetreatmentofcancer.12,13Furthermore,earlyandradicalprofes-sionaldental interventionreducesthe frequencyofproblems,minimizingtheriskfororalandassociatedsystemic complications.14-18 Therefore, it is recom-mendedthatallnewlydiagnosedpediatriconcologypatientsseekearlydentalconsultationtoallowad-equate time for necessary dental care to be com-pletedpriortoinitiatingcancertherapyandcontinuetoplaceemphasisonpreventiveinterventions.14

Nurses are often frontline clinicians who triageoutpatient’s conditions and needs and spendmoretimewithinpatientsandtheirfamiliesthandophy-sicians. In thepediatriconcologyunit,nursesmayfirsthandseetheincidenceoforalcomplicationsthatmayaffectpatients’qualityoflifeandtreatmentsuc-cess.10Baselinesurveysfrom2demonstrationproj-ects,whosepurposewas to eventually developanoralcareprotocolforuseincancercareunitsintheU.S.,indicatedthatnurseswerecapableofidentify-ingsimpleoralcomplications,suchasmucositisandoralcandidiasis,butwerenotabletodiagnosemoresevere oral complications, such as xerostomia.19,20Thesestudiesalsofoundthatthenurseslackedcur-rent knowledge on oral care recommendations forpediatriconcologypatientsandwerenotperformingoralassessmentsandreferralsonaregularbasis.

Itisimportanttodeterminetheneedandoppor-tunityforinterprofessionaloralhealthcareeducationandcollaborationinordertoincreaseaccesstocom-prehensive oral care for pediatric cancer patients.Therefore,thepurposeofthisstudywastoexaminetheknowledge,perceivedabilityandpracticebehav-iors of pediatric oncology and hematology nursesinassistingwiththevariousoralhealthcareneedsof pediatric oncology patients and to identify theirtraining/education,practice typesandotherdemo-graphiccharacteristicsthatarerelatedtotheiroralhealthcompetencies.


This cross-sectional survey research study was ap-provedbytheBiomedicalInstitutionalReviewBoardoftheUniversityofNorthCarolinaatChapelHill(UNC-CH).Thesurvey instrumentwasdevelopedwith input fromquestionnairesusedin2previousstudies,19,20inputfrom3 committeemembers (1 pediatric dentist, 1 generaldentistand1dentalhygienist),asurveymethodologyconsultant fromtheH.W.OdumInstitute forResearchinSocialScienceatUNC-CH,andtherecommendations

setforthbytheAmericanAcademyofPediatricDentistry(AAPD).21Thesurveyincluded21questionsthatsoliciteddemographicandpracticeinformation;knowledge,prac-ticebehaviors,andtheirreportedconfidencetoassistwiththeoralhealthcareneedsofpediatriconcologypatients,whichwereintendedtomeasurethenurses’oralhealthcompetencies.Thesurveyinstrumentwaspilottestedby2pediatriconcologynursesandtheirsuggestionswereincorporated in thefinalsurvey.AscannableTeleFormquestionnairewasdevelopedbytheUNCSchoolofDen-tistryDataCoordinatingandStatisticalConsultingUnittoreducepotentialentryerrors.

Threehundredsurveysweredistributedtoaconve-niencesampleofnursesataboothintheexhibithalldur-ingtheAssociationofPediatricHematologyandOncologyNurses’(APHON)36thAnnualConferenceandExhibitonOctober4 to6,2012 inPittsburgh,Pennsylvania.TheAPHON is a professional organization for pediatric he-matology/oncologynursesandalliedhealthcareprofes-sionals,anditcurrentlyhasapproximately3,381activemembers.Bythelastdayoftheconference,272surveyswerereturned.

Data Analysis

ThedatawereanalyzedusingSASversion9.2(SASInstitute,Inc.,Cary,NC).Frequencieswerecomputedtosummarizedemographicsandpracticecharacteristicsaswellasknowledge,confidenceandpracticebehaviorsofpediatriconcologynurseswithregardtooralhealth.Exploratoryfactoranalysiswasusedtoidentifythefac-torpatternanddomainofquestionitemsmeasuringthenurses’ oral health competencies. Chronbach’s alpharangedfrom0.7to0.95forthe6domainsidentifiedfornurses’perceivedabilityandpracticebehaviors.Among5oralhealthrelatedknowledgequestionsshowninFig-ure1,theknowledgeitemslistedas“dailyinspectionofmouth by caregivers,” “use of fluoridated toothpaste”and“referralstoadentistpriortocancertherapy”ap-pearedto formadomain, thus included inthe furtheranalysis. Bivariate analyses were conducted with theMantel-Haenszel test to identify thepediatriconcologynurses’previous training/education,practice typesandotherdemographiccharacteristicsthatwereassociatedwiththe7domainsoforalhealthcompetencies,withsta-tisticalsignificancesetatp<0.05.

reSultS

Ofthe272surveysthatwerereturned,235sur-veys were completed by those who are currentlyemployedasapediatriconcology,pediatriconcologyorhematologynurse,givingaresponserateof78%.ThedemographicandprofessionalcharacteristicsofthesurveyrespondentsaresummarizedinTableI.Themajorityoftherespondentswerewomen(97%)andreportedlywork36hoursormoreaweek(70%).Slightlymorethanhalfofrespondentsworkascerti-fiedpediatriconcology/hematologynursesandhave


Figure1:KnowledgeofOralHealthCareRecommendationsforPediatricOncologyPatientsamongSurveyRespondents(n=235)

100

90

80

70

60

50

40

30

20

10

0

PercentageofCorrectResponses

PotentialOral

Complication

DailyInspectionof

MouthbyCaregivers

UseofSoft

BristledToothbrush

UseofFluoridated

Toothpaste

ReferralstoaDentist

forConsultationPrior

toCancerTherapy

been employed as a pediatriconcologynursefor10ormoreyears(54%and53%,respec-tively).Approximately75%ofthe respondents reported re-ceiving3hoursorlessofedu-cation and/or training relatedto oral health care in nursingschool,andabout60%didnothave a clinical requirementregarding the assessment ofthe teeth and gums duringtheirnursingschooleducation.While 91% of survey respon-dents expressed a desire totakecontinuingeducation(CE)coursesrelatingtheoralhealthcareforpediatriconcologypa-tients in the future,only25%hadtakensuchaCEcourseinthelast5years.

Knowledge

Themajorityofrespondentswere aware of potential oralcomplicationsrelatedtocancertreatment(100%)andprofes-sionaloralhealthcarerecom-mendationsforpediatriconcol-ogy patients such as the useof a soft bristled toothbrush(97%)anddaily inspection ofthe child’s mouth by his/hercaregivers to determine thepresence or absence of oral complications (87%)(Figure 1). However, the use of fluoridated tooth-pasteandreferralstoadentistforconsultationpriortocancertreatmentreceivedlowerratesofcorrectresponses (57% and 29%, respectively). Overall,only14%ofsurveyparticipantsrespondedcorrect-ly to all informative questions that assessed theirknowledgeoforalhealthcarerecommendationsforpediatriconcologypatientsundergoingcancertreat-ment.

Perceived Ability

The majority of the respondents reported thattheyarecomfortableperformingoralproceduresonpatients(77%),andareadequatelytrainedtopro-vide oral health care instructions/education to pa-tients (72%) and to performoral care procedures(84%).Whenaskedabouttheirlevelofconfidenceinperformingvariousoral health related tasks forpediatriconcologypatients,morethan70%ofsur-vey respondentswere reportedlyveryconfident inexamining for thepresenceoforalpain,providingoralhygieneinstructions,anddiscussingtheimpor-tance of seeking routine professional dental care

(Figure2).However, less thanhalfof respondentsreportedthattheywereveryconfidentintheirabili-tytoexaminethehealthofteethandgumsforcom-plicationsoftrismus,dysphagia,andxerostomia.

Practice Behaviors

Whilemorethan60%ofrespondentsreportedex-aminingalloftheirpatientsforthepresenceoforalpathologyororalpain(63%and69%,respectively),abouthalfofsurveyparticipantsexaminealloftheirpediatriconcologypatients’teethand/orgums,de-tectdysphasia,andprovideinstructionsfororalhy-giene care andmanagement of oral complications(Figure3).Onlyabout40%orlessofrespondentsreportedexaminingallpatientsforthepresenceofxerostomia,trismus,anddiscussingtheimportanceofseekingroutineprofessionaldentalcare.

Figure 4 shows survey respondents’ practice ofpatientreferralstodentalprofessionals.Morethanone-thirdofsurveyrespondents reportedreferringpatients to dental professionals prior to the initia-tionofcancertreatmentand/orduringcancertreat-ment(39%and31%,respectively).Twentypercent


n** Percent(%)

GenderMale 6 2.6Female 226 97.4

JobtitleCertifiedoncology/hematol-ogynurse+ 126 53.6

Others++ 109 46.4Yearsemployedasapediatriconcologynurse

3yearsorless 29 13.44to10years 74 34.110yearsormore 114 52.5

Hours/weekworkedindirectpatientcare<36hours 62 30.4>36hours 142 69.6

Havearesourceofreferrals,dentist(s)/dentaloffice(s),forpatientswithsevereoralcomplica-tions

Yes 139 59.7No 94 40.3

Hoursofeducation/trainingrelatedtooralhealthcareinnursingschool

3hoursorless 169 74.5>3hours 58 25.5

Clinicalrequirementregardingtheassessmentoftheteethandgumsduringnursingeducationand/ortraining

Yes 92 39.7No 140 60.3

HastakenaCECourserelatingtooralhealthcareforpediatriconcologypatientsinthelast5years

Yes 58 24.9No 175 75.1

DesiretotakeCECoursesrelatingtooralhealthcareinthefuture

Yes 211 90.6No 22 9.4

• *Responserate78%(235/300)• **TotalmaynotadduptoNbecauseofmissingdata• +Includes certifiedpediatric oncologynurse (CPON),oncologycertifiednurse(OCN),andcertifiedpediatrichematologyoncologynurse(CPHON)

• ++Includesregisterednurse(RN),nursepractitioner(NP),certifiedpediatricnurse(CPN),certifiedpediatricnursepractitioner(CPNP),certifiedfamilynurseprac-titioner(CFNP)

Table I: Demographic and ProfessionalCharacteristics of the Survey Participants(n=235)*

ofsurveyrespondentsreportedneverreferringpa-tientstodentalprofessionals.

Oncology Nurses’ DemographicCharacteristics and Oral HealthCompetencies

ExtractedoutcomesofbivariateanalysesareshowninTablesIItoIV.Overall,nurses’characteristicssuchas having had a clinical requirement regarding oralhealthassessmentduringnursingeducation/training,having taken oral health related CE courses in thepast5years,andnumberofyearsworkedasape-diatriconcologynursewereassociatedwithdomainsoforalhealthcompetencies.Surveyrespondentswhohadaclinical requirement regardingoralhealthas-sessmentduringnursingeducationpresentedgreat-er oral health related knowledge and confidence inexaminingpatient’smouth,detectingoralcomplica-tionsandprovidingoralcaremanagementwhiletheywerealsolikelytoprovideoralcareinstructionsandexaminethepatient’smouthmoreoftenthanthosewhodidnot(p<0.02).HistoryofhavingtakenanoralhealthrelatedCEcourseinthepast5yearswasas-sociatedwithalldomainsoforalhealthcompetenciesexceptforthedomainsofpracticeofandconfidencein examining for oral complications (p<0.007). Theleveloforalhealthrelatedknowledge,confidenceandpracticeweregreateramongsurveyrespondentswhoworkedasapediatriconcologynurseforalongertimethan thosewith a shorter history of specialty prac-tice(p<0.05).However,nodifferencewasobservedintheconfidenceinandpracticeofexaminingfororalcomplicationssuchasxerostomia,dysphagiaandtris-muswiththelengthofprofessionalworkexperienceasapediatriconcologynurse(p>0.1).Morenurseswhoworkfull-timeindirectpatientcareandhaveasource for dental referrals responded tooral healthknowledgequestionscorrectlythanthosewhodon’tworkfull-timeindirectpatientcare.Jobtitle,suchaswhethertheywereacertifiedoncologynurseornot,aswellashoursspentinoralhealtheducation/train-ing during nursing schoolwere not associatedwithoralhealthcompetencies.

DiScuSSion

This study identified gaps in pediatric oncologynurses’knowledge,confidenceandpracticeinassist-ingwiththeoralhealthcareneedsoftheirpatients,dependingontheareaoforalhealthtopicassessedand the survey respondents’ educational back-ground.Inconjunctionwiththefindingsfromprevi-ousstudies,thedataimpliedthatpediatriconcologynursesarelearninginthefieldaboutoralhealthandoralcomplicationsamongpediatriconcologypatientsasopposed tohavingbeen formally trained in thishealthknowledgeareainnursingschool.Mostofthesurvey respondents reported having received lessthan3hoursofformaltrainingand/oreducationre-


latingoralhealthcare,nordid theyhaveaclinicalrequirementregardingtheassessmentoftheteethand/orgums,whileinnursingschool.Thisstudyre-vealed thatoveralloral competenciesweregreateramongindividualswhohadworkedlongerasanon-cologynurse.

Previousstudieshavesurveyedinternistsanden-docrinologists, nurse practitioners and nurse mid-wives, and diabetes educators to determine theirknowledge, opinions andbehaviors regarding peri-odontal disease and adverse health outcomes.22-24Owenset al found that internists andendocrinolo-gistsknowledgeaboutperiodontaldiseasewashigh,but they lacked training and education relating to

periodontaldiseaseandoralhealthcare.22Wootenetalfoundthatnursepractitionersandcertifiednursemidwives had limited knowledge about periodontaldiseaseandoralhealthcare.23Lopesetalfoundthatthe majority of diabetes educators had no formaleducationand/ortrainingrelatedtooralhealthcare,nordidtheyhaveanycontinuingeducationoncetheybegan their careers.24 All 3 studies suggested thatacollaborativeeffortbetweenhealthcareprovidersanddentalprofessionalswouldpositivelybenefitpa-tientsinvariousareasofthehealthcaresystem.22-24

While on-the-job training or taking CE coursesmayimproveoncologynurses’confidenceandprac-ticebehaviorofprovidingoralexamsandoralcare

Figure2:PerceivedAbilityinPerformingOralHealthRelatedTasksonPediatricOncologyPatientsamongSurveyRespondents(n=235)

ProvideInstructiontoManageOralComplications

PresenceofOralPathology

PresenceofOralAppliances

HealthofTeethand/orGums

RoutineProfessionalDentalCare

ProvideOralHygieneCareInstructions

PresenceofOralPain

Xerostomia

Dysphagia

Trismus

0 10 20 30 40 50 60 70 80 90 100Percentage

Responserateof78%(235/300)

Notatallconfident

Somewhatconfident

Veryconfident

OralPain

andCare

OralExamand

Management

ExaminingOral

Complications


instructionsovertime,thedatasuggeststhatthesefactorsmaynotsufficientlyimproveconfidenceandpracticerelatedtooralcomplicationsamongnurses.Confidence and practice behaviors related to ex-amination for oral complications (i.e. xerostomia,dysphagia, trismus) were greater among surveyrespondentswhohadoralhealthrelatedclinicalre-quirementsduringnursingschoolthanthosewhodidnot. Previous studies also found that while nursescouldreadilyidentifysimpleoralcomplications,theycouldnotdiagnoseortreatmoresevereoralcompli-cationspriortothe implementationofastructured

oralhealthprotocolandreceivingadditionaltraininginchildren’shospitals.19Thesefindingsthusindicatetheimportanceofincorporatingoralhealtheducationand/or training into nursing schools’ curricula andfindinginnovativewaystomotivatenursestoadheretoevidence-basedoralhealthcarerecommendationsforpediatricpatientswhoundergocancertreatment.Althoughonlylessthan25%ofsurveyrespondentsreportedhaving takenaCEcourse relating tooralhealthcareinthelast5years,itisencouragingthatalmostallsurveyparticipants(91%)desiretotakeaCEcourserelatingtooralhealthcareinthefuture.

Figure3:FrequencyofPerformingOralHealthRelatedTasksonPediatricOncologyPa-tientsamongSurveyRespondents(n=235)

PresenceofOralPain

PresenceofOralPathology

ExamineHealthofTeethand/orGums

ProvideInstructiontoManageOralComplications

RoutineProfessionalDentalCare

ProvideOralHygieneCareInstruction

Xerostomia

Dysphagia

Trismus

0 10 20 30 40 50 60 70 80Percentage

Responserateof78%(235/300)

Dental

Exam

OralCare

Instruction

ExamforOral

Complications

None

Morethanhalfbutnotall

All

Abouthalf

Someofthembutlessthanhalf


Figure4:StageinWhichSurveyRespondentsUsuallyReferPediatricOncologyPatientstoaDentalProfessional(n=235)

40

35

30

25

20

15

10

5

0

Percentage

UponAdmission

PriortotheInitiation

ofCancerTherapy

FollowingthePresentation

ofOralSymptom

s

AttheRequestof

thePatient’sParent

DuringCancer

Therapy

AfterCancer

Therapy

Other

NeverReferPatients

toDentalProfessionals

Responserateof78%(235/300)Percentagesdonotaddupto100%becausemultiplechoicesweregiven

TheInstituteofMedicine(IOM)reportin2011,Ad-vancing Oral Health in America,statesthat“Nurses,physicians,andotherhealthcareprofessionalshavegenerally not been trained in providing oral healthservices or screenings. In addition, dental profes-sionals are generally educated and trained sepa-rately from other health care professionals, whichreinforces theseparationofcareaswellas lackoftraininginappropriatereferralsbetweenprofession-als.”25Asthecomplexityofhealthcarecontinuestoincrease,ithasbeenrecommendedthathealthcareproviderslearntoworkmorecollaborativelyinordertoprovidequalitycare.26Ithasbeenshownthatin-terprofessionalcollaboration,withnursingandden-tal professionals, positively affects quality of care,patientsatisfaction,effectivenessofhealthcareser-vices,healthcarecostsandcommunicationamonghealth care professionals.26-28 In order to improvecompliancewithevidence-based recommendations,perceivedabilitiesandpracticebehaviorsofpediatriconcology nurses as related to oral health care, aninterprofessionalapproachwithemphasisplacedonimplementinganoralhealthcareprotocolandcon-tinuousstaffeducationandtrainingateachpediatriconcologyunitmightbeimportant.

Strengthsof thisstudy include thebroadergeo-graphicrepresentationofpediatriconcologyandhe-matology nurses. While 2 similar previous studies

OralHealthRelatedCorrectKnowledge

25% Median 75%Hadaclinicalrequirementregardingtheassessmentofteethandgumsduringnursingschool

p<0.05

Yes 1 2 2No 1 2 2

HavetakenaCECourserelatingtooralhealthcareinthepast5years p<0.05

Yes 2 2 2No 1 2 2

Yearsworkedasanoncologynurse p<0.001<3years 1 1 2

4to10years 1 2 2

>10years 1 2 2

TableII:QuantileforDomainofOralHealthRelatedKnowledgebySurveyRespondents’BackgroundCharacteristics(n=235)

Knowledgewasmeasuredasascorefortrue/falseormul-tiplechoicequestions:correctanswer=1vs.incorrectan-swer=0


ConfidenceExaminingfororalcomplications Oralexamandmanagement Oralpainandoralcare

25% Median 75% 25% Median 75% 25% Median 75%Hadaclinicalrequirementregardingtheassessmentofteethandgumsduringnursingschool

p<0.05 p<0.001Yes 1 1.67 2 1 1 1.33 1 1.25 1.5No 1 1.67 2 1 1 1.33 1.25 1.5 1.75HavetakenaCECourserelatingtooralhealthcareinthepast5years

p<0.05 p<0.001Yes 1 1.33 2 1 1 1 1 1 1.5No 1 1.67 2 1 1 1.67 1 1.5 1.75Yearsworkedasanoncologynurse

p<0.05 p<0.05<3years 1.42 2 2 1 1.33 2 1.5 1.5 1.754to10years 1 1.67 2 1 1 1.33 1 1.5 1.75

>10years 1 1.67 2 1 1 1.33 1 1.25 1.75

TableIII:QuantileforDomainsofConfidenceinPerformingOralHealthRelatedTasksbySurveyRespondents’BackgroundCharacteristics(n=235)

Perceivedabilitywasmeasuredin3-pointLikertscalerangingfrom1=veryconfident,2=somewhatconfident,and3=notatallconfident

PracticeExaminationsfororalcompli-

cations Dentalexams Oralcareinstructions

25% Median 75% 25% Median 75% 25% Median 75%Hadaclinicalrequirementregardingtheassessmentofteethandgumsduringnursingschool

p<0.05 p<0.05Yes 1 1.67 3 1 1 2 1 1.33 2.67No 1 2.33 3.67 1 1.67 2.33 1.33 2.33 3.33HavetakenaCECourserelatingtooralhealthcareinthepast5years

p<0.05 p<0.05Yes 1 1.67 3 1 1 1.67 1 1.33 2.33No 1 2.17 3.67 1 1.67 2.33 1.33 2.33 3.33Yearsworkedasanoncologynurse

p<0.05 p<0.001<3years 1.67 2.83 3.67 1.17 2 3.33 1.67 3 44to10years 1 2 3.33 1 1.33 2 1.33 2.17 3

>10years 1 2 3.33 1 1 2 1 1.83 2.67

TableIV:QuantileforDomainsofPerformingOralHealthRelatedTasksbySurveyRespon-dents’BackgroundCharacteristics(n=235)

Frequencyofpracticewasmeasuredin5-pointLikertScalerangingfrom1=allpatients,2=morethanhalfofpatients,3=abouthalfofpatients,4=lessthanhalfpatients,and5=nopatient


concluSion

Pediatric oncology nurses’ knowledge, perceivedability,andpracticebehaviors inassistingpatient’soralhygienecareandpreventingandmanagingoralcomplicationsvaryby topicandmight reflect theireducationalpreparedness.Interprofessionalcollabo-ration between dental and nursing schools in pro-vidertrainingaswellasinstitutionaleffortsinimple-mentation of evidence-based oral health practicesmightbeneededinordertoimprovepediatriccancerpatients’andsurvivors’oralhealth.

Antiana Perry, BSDH, MS, completed this project in partial fulfillment of the Master of Science degree in Dental Hygiene Education at the University of North Carolina Chapel Hill School of Dentistry. Hiroko Iida, DDS, MPH, is currently a director of the New York State Oral Health Center of Excellence and was an assistant professor at UNC Department of Pediat-ric Dentistry when this study was conducted. Lauren Patton, DDS, is a Professor and Department Chair-person of the Dental Ecology Department. Rebecca S. Wilder, RDH, MS, is a Professor and Director of Graduate Dental Hygiene Education and also Direc-tor of Faculty Development at the University of North Carolina Chapel Hill School of Dentistry.

1. SiegelR,DeSantisC,VirgoK,etal.CancerTreat-mentandSurvivorshipStatistics,2012.CACANCERJCLIN2012;62:220-241.

2. EstiloCL,HurynJM,KrausDH,etal.Effectsofther-apyondentofacialdevelopment in long-termsur-vivors of head and neck rhabdomyosarcoma: theMemorialSloan-Ketteringcancercenterexperience.JPediatrHematolOncol2003;25:215-222.

3. Van Eys J. The truly cured child? Pediatrician1991;18:90-95.

4. Bleyer WA. The impact of childhood cancer ontheUnitedStatesandtheworld.CACancerJClin1990;40:355-367.

5. BelfieldPM,DwyerAA.Oralcomplicationsofchild-hoodcancerandit’streatment:currentbestprac-tice.EurJCancer2004;40:1035-1041;discussion1042-1044.

6. LeggotP.OralComplicationsinthepediatricpopula-tion.NCIMonographs1990;9:121-131.

7. MedeyaM.Oralcomplicationsfromcancertherapy:partI–pathophysiologyandsecondarycomplica-tions.OncolNursForum1996;23:801-807.

8. MinicucciEM,LopexLF,CrocciAJ.Dentalabnormali-ties in children after chemotherapy treatment foracutelymphoidleukemia.LeukRes2003;27:45-50.

9. BorbasiS,CameronK,QuestedB,OlverI,ToB,Ev-ansD.Morethanasoremouth:patient’sexperienceoforalmucositis.OncolNursForum2002;29:1051-1057.

10.HoganR.Implementationofanoralcareprotocoland its effects on oral mucositis. J Pediatr OncolNurs2009;26:125-135.

11.DoddM,MiaskowskiC,GreenspanD,ShisA,Fa-cioneN.Radiation-inducedclinical trialofmicron-izedsucralfateversussaltandsodamouthwashes.CancerInvest2003;21:21-23.

12.McGuireDB, CorreaME, Johnson J,Wienandts P.Theroleofbasicoralcareandgoodclinicalprac-ticeprinciplesinthemanagementoforalmucositis.SupportCareCancer2006;14:541-547.

13.RubensteinEB,PetersonDE,SchubertM,etal.Clin-icalpracticeguidelinesforthepreventionandtreat-mentofcancertherapy-inducedoralandgastroin-testinalmucositis.Cancer2004;100:2026-2046.

referenceS

surveyedpediatriconcologynurses in local institu-tions,thecurrentstudywasabletocapturenursesfromvariousgeographicregions,whichwas identi-fiedbythemailingaddressesrespondentsplacedonthe raffle tickets. Respondents also included thosewithvarious certificationsanddifferingeducationalbackgroundsandtraining.Thelimitationofthisstudyincludesmissingdatafoundinvarioussectionsofthesurveywhichmadeperformingmultivariableanalysisinfeasible.Furthermore,theattendeesoftheprofes-sionalmeetingmaybemoreinvolvedineducationalactivitiesthanthosewhodonotattend.Therefore,thefindingsofthisstudymaynotberepresentativeofallU.S.pediatrichematologyandoncologynursesnorallthememberoftheAPHONprofessionalorga-nization.Lastly,althoughthestudyidentifiedseveraldomainsrelatedtooralhealthknowledge,perceivedability and practice behaviors in assisting pediatriconcologypatients,therewasnovalidatedtoolavail-abletomeasureoralhealthcompetenciesofoncol-ogynurseswhenweconductedthisstudy.Despitethis,weprovidedinitialevidenceofthedomainsoforalhealthcompetenciesamongpediatriconcologynurses and gained insight into the type of demo-graphiccharacteristicsofnursesthatmayinfluencetheirknowledge,confidenceandpracticebehaviorsinassistingchildpatients’oralhealthneeds.


14.daFonsecaMA.Dentalcareofthepediatriccancerpatient.PediatrDent.2004Jan-Feb;26:53-7.

15.SchubertMM,EpsteinJB,PetersonDE.Oralcompli-cationsofcancertherapy.In:YagielaJA,NeidleEA,DowdFJ,eds.PharmacologyandTherapeuticsforDentistry.4thed.St.Louis:Mosby-YearBookInc;1998:644-655.

16.GreenbergMS,CohenSG,McKitrick JC,CassilethPA.Theoralfloraasasourceofsepticemiainpa-tientswithacuteleukemia.OralSurgOralMedOralPathol.1982;53:32-36.

17.WahlinYB.Effectsofchlorhexidinemouthrinseonoral health in patients with acute leukemia. OralSurgOralMedOralPathol.1989;68:279-287.

18.Toth BB, Martin JW, Fleming TJ. Oral and dentalcare associatedwith cancer therapy. Cancer Bull.1991;43:397-402.

19.TewogbadeA,FitzGeraldK,PrachylD,ZurnD,Wil-sonC.Attitudesandpracticesofnursesonape-diatric cancer and stem cell transplantward: ad-aptationofanoralcareprotocol.SpecCareDent2008;28:12-18.

20.PattonLL,AsheTE,ElterJR,SoutherlandJH,StraussRP. Adequacy of training in oral cancer preven-tionandscreeningasself-assessedbyphysicians,nursepractitioners,anddentalhealthprofessionals.OralSurgOralMedOralPatholOralRadiolEndod2006;102:758-764.

21.American Academy of Pediatric Dentistry (AAPD).Guidelineonmanagementofdental patientswithspecial health care needs. Pediatr Dent. 2008-2009;30:107-11.

22.OwensJB,WilderRS,SoutherlandJH,etal.NorthCarolina internists’ and endocrinologists’ knowl-edge,opinions,andbehaviorsregardingperiodon-taldiseaseanddiabetes:Needandopportunityforinterprofessionaleducation.JDentEduc2011;75:329-38.

23.WootenKT,LeeJ,JaredH,etal.Nursepractitioners’andcertifiednursemidwives’knowledge,opinionsand practice behaviors regarding periodontal dis-easeandadversepregnancyoutcomes.JDentHyg2011;85:122-131.

24.LopesMH,SoutherlandJH,BuseJB,etal.Diabe-tes educators’ knowledge, opinionsandbehaviorsregardingperiodontaldiseaseanddiabetes.JDentHyg2012;86:82-90.

25.Institute of Medicine. Advancing Oral Health inAmerica.2011.

26.BrootenD,YoungblutJM,HannanJ,Guido-SanzF.Theimpactofinterprofessionalcollaborationontheeffectiveness,significance,andfutureofadvancedpractice registered nurses. Nurs Clin North Am.2012Jun;47:283-94.

27.NaylorMD.Viewpoint: Interprofessionalcollabora-tionandthefutureofhealthcare.AmericanNurseToday, 6(6). Available at: http://www.american-nursetoday.com/article.aspx?id57908&fid57870.Accessed:May16,2012.

28.KenaszchukC,MacMillanK,vanSoerenM,ReevesS.Interprofessionalsimulatedlearning:short-termassociations between simulation and interprofes-sionalcollaboration.BMCMed2011;9:29.


Thirteen percent of the U.S. population is con-sideredolder,orovertheageof65,with increas-esexpected to reach20%by2030,or92millionAmericans.1,2Datafromthemostrecent2010cen-susrevealedthattheolderpopulationisincreasing15%more than theoverallU.S.population.3Cur-rently,about4%ofolderAmericansresideinlong-term care facilities (LTCFs); in 2007 alone, therewere15,827LTCFsproviding24-hourcarebynurs-esandotherstaffmemberstooverseeandmonitorhealthcareneeds.4Itisestimatedthat63%ofthetotalnumberofpatientsresidinginLTCFsareolder,andby2040,20%ofolderAmericanswill requirelong-termcare.5-7

Several limitationsexistwithin LTCFs related tooralhygiene,sincemany long-termolderpatients(LTOPs) are medically compromised and are un-abletoprovideoralhygieneself-care.8Olderadultsretain26ormore teeth throughout their lifetime,typically losing6 teethor less;onlyone-fourthoftheolderpopulationisfullyedentulous.6,7LiteratureconfirmsthatthehighincidenceofcertainsystemicconditionsintheLTOPsmaybelinkedwithpoororalhygiene, which include: diabetes, cardiovasculardiseases,nursinghomeaspirationpneumoniaandphysical/mental disorders.9-12 As LTOPs increase,oralhealthcareforthisdisparagedpopulationmustbecome a priority with registered dental hygien-

OralCareintheLong-TermCareofOlderPatients:HowCantheDentalHygienistMeettheNeed?TraceeS.Dahm,BSDH,MS;AnnBruhn,BSDH,MS;MargaretLeMaster,BSDH,MS

AbstractPurpose:Itisestimatedthattheolderpopulation,aged65andolder,willmakeupover20%oftheU.S.populationbytheyear2030.Researchacknowledgesabout4%oftheolderpopulationresidesinlong-termcarefacilities(LTCFs),wherethelong-termolderpatient(LTOP)isundertheformalsuper-visedcareorcustodyofinstitutionswithskillednurses.Bytheyear2040,4milliongeriatricresidentsarepredictedtomoveintoLTCFsintheU.S.In2000,theSurgeonGeneralreportedLTOPsinLTCFshavegreateroralhygieneneedsthananyothersegmentofthepopulationtoinclude:rootcaries,periodontaldisease,xerostomia,fungalinfectionsandotheroralhealthconcerns.SerioussystemichealthconditionsoccurringathighincidencerateshavebeenlinkedtopoororalhygieneintheLTOP.Thepurposeofthismanuscriptistoidentifysystemichealthconditions,oralhealthconditions,barrierstooralcareforLTOPsandtoofferrecommendationsforincreasedaccesstocarewithinLTCFsthroughtheuseofregistereddentalhygienists(RDHs).Keywords:geriatric,dental,elderly,dentalcare,long-termcare,dentalhygiene,oralhealthandsys-temicdiseaseThis study supports theNDHRApriority area,Health Services Research: Determine theextent towhichdentalhygienists’workingincollaborativepracticesettingswithotherhealthprofessionalsoror-ganizationsimprovesthecost-effectivenessandqualityofhealthcareoutcomes.


introDuction

ists(RDHs)playingalargerrole intheacquisitionofcare.ThereisagreatneedforLTCFstoemployRDHs to provide preventive and therapeutic oralcare to thesepatientswith the intent of reducingbothoralhealthdiseaseandsystemichealthcondi-tions.Thepurposeofthismanuscriptistoidentifysystemichealth conditions,oralhealth conditions,and barriers to oral care within LTOPs and to of-fer recommendations for increasedaccess to carewithinLTCFsthroughutilizationofRDHs.

Systemic Health Concerns

TypeIandTypeIIdiabetesaffectsapproximately25%ofLTOPs,andresearcherspredictthegreatestincreasewill occur in the75andolder agegroupover the next 40 years.13,14 Concern for the LTOPwith diabetes exists due to age-related complica-tionsthataffecttreatmentandcomorbiditiessuchaspolypharmacy,renalinsufficiency,increasedfallrisk,visualimpairment,andcognitiveimpairment.14Uniqueguidelineshavebeenestablishedfortreat-ingLTOPswithdiabetesbasedon lifeexpectancy,cognition,andmedicationregimensfordentalpro-fessionals.13 Medications are a difficult treatmentoptionastheycannotalwaysbeprescribedtotheLTOPdue to compromisedmetabolismand riskofmultipledruginteractions.13Arecentreportstatedthatdiabeticswere28%morelikelytobecomefully


orpartiallyedentulous;1inevery5casesofeden-tulismislinkedtodiabetes.15PoorglycemiccontrolinthosewithdiabetesalsoplacesLTOPsatriskduetothewellestablisheddirectrelationshipbetweenbloodglucoselevelsandperiodontaldisease.15In-vestigatorshavereportedthatinflammationresult-ing from periodontal disease exacerbates chronicsystemic inflammation to influence the initiationandprogressionofdiabetes, typicallyType IIdia-betes.9,11 Increased inflammation, ormore severeuncontrolledperiodontaldisease,iscorrelatedwithinsulinresistanceandmorecomplications.9,11Inad-dition,diabetesplacestheLTOPatahigherriskfororalCandidainfectionsduetothehighbloodsugarlevels promoting the growth of the Candida albi-cans.9Longitudinalstudiesonpatientswithdiabe-tesandperiodontaldiseaseshowthosewithbettercontrolledglycemicindiceshadlesssevereinflam-matory responses with their periodontal disease;thus,thediseasesreflectoneanother.9

Cardiovascular disease (CVD), including hyper-tension, heart failure, coronary heart disease, ar-rhythmias,peripheralvasculardisease,andvalvu-larheartdisease,affects38.2%ofolderadults.16,17CVDhasbeenreportedtobethenumberonecauseofdeathintheolderpopulation.15FortypercentofdeathsfromCVDoccurbetweentheagesof75and85,while48%occuroverage85.17AstudybyPers-sonetalevaluatedperiodontalstatusbymeasuringbone loss on the radiograph, vertical defects andfurcationslocalizedtothemolars;radiographicevi-dence of periodontitiswas found in 48.5%of thesubjects, and carotid calcificationwas detected in18.6%.18AgewasdeterminedaprimaryriskfactorforCVDdueto increasedcarotidcalcificationsde-tectedfrompanoramicradiographs.18,19AsystemicreviewbyLametalreportedthatpatientspresent-ingwithperiodontaldiseasewere1.14to2.2timesmorelikelytodevelopCVD.10Researchersarenotinagreement that a correlation between periodontaldiseaseandCVDisassociatedwithsystemicinflam-mationexpressedinserummarkers:interleukin-6,whitebloodcellcounts,andfibrinogen.10LTOPsthathaveendothelialdysfunctionandcarotidintimame-diathicknessarealsoatincreasedriskforCVDandperiodontaldisease.Thisisbecausechronicmicro-organisms such as Chlamydophila pneumonia aresaidtocauseatherosclerosis,andtheDNAoforalbacteriacanbeamplifieddirectlyfromatheroscle-rotic plaques.10,11 Providing care to the LTOP withCVDcanbechallengingsincemedicationsareoftennot realistic due to polypharmacy, and surgery isoftencontraindicated.17Whenmedicationsareusedto treat CVD, they often have a damaging effecton the oral cavity including: xerostomia, gingivalhyperplasia,andulcerations.10Due to thecorrela-tionbetweenCVD,age,andperiodontaldisease,itisimperativethatLTOPsreceiveroutinepreventiveandtherapeuticoralhealthservicestoincludeeval-

uation of the gingival pocket depths and alveolarboneloss.18

Nursing home aspiration pneumonia (NHAP) iscommon in the LTOPwithexistingbreathingdiffi-culties,andisdefinedaspneumoniadevelopingaf-terthecollectionofcolonizedoropharyngealorgan-ismsinthelowerrightlunglobeoftheLTOP.12,20,21,22StreptococcusaureusandPseudomonasaeruginosaarethemainmicrobescontributingtoNHAP.20,21,23-25Oneof thehighestmortality rates for theLTOP isassociatedwithNHAPduetoexcessgramnegativeaerobic rods and Staphylococcus aureus collect-ing intheoralcavity.11,12LTOPsbreathethemintotheir lungs and contract the disease.11,12 EvidenceshowsriskfactorsthatmaketheLTOPmoreproneto NHAP as poor functional status, presence of anasogastric tube (NG), dysphagia, occurrence ofan unusual event, chronic lung disease, presenceofa tracheostomy, increasingage,andmalegen-der.12When diagnosed, the disease is often in anadvancedstage,withfewtreatmentoptionsavail-able.20,21,25NHAPshouldnotbemistaken forothertypesofpneumoniasalsocommonlyfoundamongthe geriatric. Aspiration pneumonitis is an acutelung injury after inhalationof regurgitatedgastriccontents,typicallywhileunconscious.12Inaddition,nosocomialpneumoniaoccursmorethan48hoursafterhospitaladmission,butwasnotpresentatad-mission to the hospital.12 Hospital acquired pneu-moniafirstappears3daysafterapatientisadmit-ted to the hospital.12 Finally, ventilator associatedpneumoniaisdefinedaspneumoniathatoccursaf-ter48to72hoursofendotrachealintubationduetodysphagia.12WhileNHAPcanbetreatedwithanti-biotics,theoptimumantibioticregimenforNHAPisunknown.12SinceoralbiofilmcancollectandenterthelungsbyglidingdownthetrackoftheNGtube,theLTOPonaNGtubeisatahigherriskfordevel-opingNHAP.12Typically,35%ofLTOPsinaLTCFwillrequireaNGtube;oftenaNGtubeisnecessaryduetodysphagia,ordifficultyswallowing.12

Sarin et al examined 613 LTOPs,with an aver-age age of 84, to determine direct links betweenNHAP and 9 common risk factors.21 The risk fac-torswere inadequateoral care,difficulty swallow-ing,lackofinfluenzavaccination,depression,feed-ingpositionoflessthan90°fromhorizontal,activesmoking, recipient of sedative medication, recipi-entofgastric-acidreducingmedicationanduseofangiotensin-convertingenzymeinhibitors.21Resultsindicatedthatonly2riskfactorsassociatedwithde-velopingNHAPwereidentified:difficultyswallowingand inadequate oral care.21 A similar study inves-tigated how preventative oral hygiene treatmentcouldreducethechanceofdevelopingNHAPintheLTGP.20 In a meta-analysis conducted by Sjogrenandcolleagues,publishedliteraturerelatedtooralhygiene,NHAP, and the LTOPwas reviewed.20 Fif-


teen articles were cal-culated to include anabsolute risk reduc-tion, numbers neededto treat, and positivelycorrelated professionaloral hygiene care with reduced cases of NHAP intheLTGP.20Resultsdemonstratedthatafterpartici-pantswereprovidedwithroutineoralcare,absoluteriskreductionincreasedfrom6.6%to11.7%,andnumbersneededtotreatincreasedfrom8.6to15.3individuals.20

Adachietalevaluatedtheeffectofprofessionaloral care delivery on respiratory disease of LTOPsin edentulous and dentate populations to deter-mine ifprofessionaloralhygienetherapyadminis-tered by RDHs reduced NHAP.25 The experimentalgroup consisted of 48 LTOPs who received dailybrushingfromanRDHusingatoothbrushandfluo-ridated toothpaste, while the control group of 40LTOPsreceiveddailybrushingwithwaterandfoamswabsbyacertifiednursingassistant(CNA) fora6monthperiod.25ResultsconcludedthosepatientsreceivingdailyoralhealthcarefromaCNAusingafoam swab had higher incidences of Staphylococ-cusspecies,PseudomonasaeruginosaandCandidaalbicans than theexperimentalpatientswhowereprovidedoralcarebyRDHs.25Thechanceofdevel-oping NHAPwas lower in the experimental group(p<0.05).25 Systematic reviews and experimentalstudiesallconcludethatprofessionaldailyoralhy-gieneandareducedbacterialcountintheLTOPwillultimatelydecreasethechanceofNHAP.12,20-23

Oral Health Concerns

Oral hygiene is imperative in LTCFs, since, nat-ural teeth are more susceptible to dental caries,periodontaldisease,demineralization,andgingivalrecessionduetoage,diet,genetic factors,brush-inghabits,andlifestylefactorsovertime.8,13-18,26-32Morethanhalfofolderadultpatientshaveenamelandrootsurfacecaries,placingthematthehighestriskdue togingival recession,heavyconsumptionof fermentable carbohydrates, poor oral hygieneanddecreasedfluorideexposure.32,33Morerecurrentcaries is evident along the coronal surfaces frommarginalbreakdownorotherfailingrestorativema-terials;fermentablecarbohydratescanalsocollectaround crowns, bridges, and implants, leading tocariouslesions.34

Investigatorshavereportedthatperiodontaldis-ease occurs at a rapid pace for the LTOPs, oftenworsening with age.2,34-37 Twenty-three percent ofthe total older population has severe periodontaldisease,withsymptomsofinflamed,painfulgingi-valtissue,recessionandmobility.38Periodontaldis-easeintheLTOPisaresultofseveralfactorsinclud-

ing:chronicdiseasesanddisabilities,race,gender,medications,incomeandaccesstooralcarepriortoadmittance.38,39

LTOPswith removable prosthetics are at an in-creased risk of oral diseases and lesions, includ-ing oral candidiasis anddenture stomatitis result-ing from Candida albicans.37,40,41 A cross-sectionalstudy,withanaverageageof85,aimedtoinves-tigate fungal infections on 233 denture wearingLTOPs.41Swabswereperformedontheparticipants’buccal mucosa to determine themicro floral sta-tus.41 Results demonstrated that oral candidiasisandhigheroralyeastcountsarecommonlyseenintheLTOPandareattributedtolackofdailydenturecleaning.41

TheLTOPismoresusceptibletosalivarychangesandoral lesionsbecauseofadecrease insalivaryglandfunction.32,42Reportssuggestthat15to30%ofLTOPsexperiencexerostomia,mostlikelyduetoan average of eight daily prescribed medications(Table I).32,42 Research points to increased xero-stomialeadingtohighercariesratesintheLTOP.32Xerostomiaalsogiveswaytodysphagiaduetoanadequate amount of salivary flow needed to helppushthefoodtowardsthetrachea.43

Between15 to60%ofLTOPsmaypresentwithanutritionaldeficiencydue tomedication sideef-fectsoranoverall reduction inappetite.44,45Loosedenturesordecayed,brokenandmissingteethcancausedifficultyconsumingnutritiousfood.44,45Sev-eral studies reported LTOPs with broken, missingandseverelydecayedteethhadachiefcomplaintofinabilitytomasticate;thestudiesalsofoundLTOPstohavepoor-fittingdentures.45 Inaddition,6mil-lionolderpatientsareatriskfordysphagia.43Dys-phagiaoccursoftenwithincreasingageduetothenaturaldeteriorationofthemusclemassandcon-nectivetissueelasticity,resultinginlossofstrengthandrangeofmotion.43Asaresult,manyLTOPshavedysphagiaandoftenbecomemalnourisheddue tothelimitedchoicesoffoodtoprovidenutrients.43

Physical disabilities from falls, deterioration ofthebodywithage,arthritis,stroke,spinalcordin-juriesandblindnessallaffectoralhygienecapabili-ties.23,30,31CommoncognitivedisabilitiesintheLTOPsuchasdementia, strokeandAlzheimer’s diseasemakepreventiveoralcareevenmoredifficult.23,30,31DescriptivestudieswhereRDHsexaminedoralhy-giene and oral health status confirms LTOPs withboth mental and physical disabilities were often

•Anticholingergics•Antihypertensives•Diuretics

•Antidepressants•Analgesics•Cytotoxics

•Antihistamines•Sedatives/Tranquilizers•AntiparkinsonDrugs

TableI:CommonMedicationsforLTOP


unable to care for the oral cavity without assis-tance.23,30,31,40Furthermore,ithasbeenestablished,thoseLTOPsinseverestagesofphysicalandmentaldisabilitieshadtheworstoralhygiene;asthesys-temicdiseaseprogressedtheiroralhealthdeterio-rated.23,30,31,40

Barriers to Oral Care

TheOmnibusBudgetReconciliationActof1987(OBRA)addressedmanyconcernsregardingcareinLTCFsbyestablishingnewstandardsbetterfocusedtowards the LTOP’s quality of life.OBRAwas alsopraisedforestablishingMinimumDataSets(MDS)tobecompletedonallLTCFsrequiringMedicareandMedicaidreimbursement.15,23LTCFsarereimbursedbyMedicaidandbecauseMedicaidisanentitlementprogram, LTCFsmust provide the specialized oralcare to anyone eligible according to the Federalgovernment.47 LTCFs must provide routine dentalservicesandemergencydentalservicestotheex-tent which they are covered under the state, ac-cordingtoMedicaid.47DentalbillsthatarenotfullypaidwithMedicaremayalsobecoveredunderanincurredmedicalexpense,sothattheLTCFcanbereimbursed.48 In as many as 15 states, Medicaidwilldirectly reimburseRDHsprovidingcare to theLTOP.49

NursesarerequiredtocompletesectionsKandLoftheMDSthatpertaindirectlytooralhealth.42Thesesectionsaresupposedtotriggerintervention,care planning, and improvements in oral health.42Still,therearenumerousconcernsaboutthequal-ity of oral care received, since payroll for nursestendstoaccountforthebiggestoverheadandfundsarelimited.7Limitationsandrestraintsarealsoseenas feworalhygieneorhealthconcernsare identi-fied; the MDS simply records what services werecompleted and cannot effectively enforce suitablecare to every patient.42 It has been shown thatnurses canbedishonest aboutdaily routines thathave been carried out with the patient, includingoralcare.24Furthermore,MDSscoresaretakenintoaccount for an LTCFs overall evaluation, andpoormarkscouldjeopardizethefacility’sfundingagen-cies and regulation records.24 Since oral hygienemarksontheMDSscorearenotconsideredvitaltothe scoringprocess, an incomplete recordof careoftenoccurs.24

Multipleinterviewswithnursingstaffhavegiventhemost insight as to why care of the oral cav-ity is not given more emphasis in LTCFs (TableII).27,28,42,50 Many nurses found that oral hygienewasminimally covered in their education; only 1to3%of thenursingworkforce is trained inolderadult oral care.27,28,42,50 The small amount of timespent learningaboutoral care for the LTOPmadeitseemlessinterestingandunimportant,withless

than30minutesdevotedtoolderadultcareinnurs-ingcurricula,andevenlesstimeisspentintheCNAcurricula.51Also,nursingstaffreportedoralcareasachallengeforfearofbeingbittenorforcingcareuponthepatient,especiallythosewithmentalim-pairments.26-28SomeCNAsfoundcaringfortheoralcavity to be filthy, unnecessary and unimportant,particularlywhen cleaning dentures or partials.5,28CNAsthatdeemedoralhygienean importantpartofthedailyroutinereceivedlittlesupportfromoth-erhealthcarestaffattheLTCF.5,24,28LTCFsarebe-comingovercrowded-addingoralhygienecare inconjunction with other needs can be difficult andoverwhelming for the nursing staff.7,23,24,29,52Whenprovidinganadequatenumberof staff andallow-ingamoderateamountoftimetocompletetheoralcare routine, nurses not only found oral hygieneeasier to perform, but also felt more responsibleforprovidingtheseservicestotheirpatients.27,53-55Interprofessional collaboration between RDHs andnurses of all skill levels needs to be established.Formingabetterrelationshipbetweenhealthdisci-plineswouldallowtheRDHtoprovidetheLTCFnurs-ingstaffmoreassistancewhenitcomestotreatingtheoralcavityoftheLTOP.ThereareseveralgapsintheimportanceandrecognitionofpropercareandtherelationshipsbetweenoralhealthandsystemichealththatanRDHcouldaddress.56

Inadequatefundingcanalsogreatly impactoralcarefortheLTOP.Nursingstaffhavereportedtheyoftencannotcarefortheirpatient’soralcavitydueto inadequate supplies.27,28,42Moreoften thannot,thenursingstaffisprovidedwaterinsteadofaflu-oridated toothpaste,and foamswabs insteadofatoothbrush,althoughithasbeenshownthatLTOPsdonotreceiveenoughfluorideuptakeandthatfoamswabscannoteffectivelyremoveplaque.57Aninves-tigationalstudyidentified41LTOPswhohadreduc-tionsingingivalbleedingandplaquescoresover3weeksafter receivingoral hygieneaids,while thenursingstaffreceivedoralhealtheducationfromanRDH.28Theeducationforthenursingstaffconsistedof hands-on training in tooth brushing techniques

LackofprofessionalsuppliesLackofRDHinterestinthispopulationgroupLong-termgeriatriccareisnotmadeapriorityinden-tal,dentalhygiene,ornursingschoolsCaregiversdonotseeoralhygieneasapriorityCaregiversdonotrecognizetheimportanceofprovid-ingdailyoralhygieneResidentresistancetooralcare

TableII:ReasonsfortheLackOfDentalHy-gieneCareInLTCFfortheOlderAdultPa-tient


whenusinganelectric toothbrushandchlorhexi-dinegluconate1%gel©.28

LTOPshave theright to refuseprofessionaloralhygiene care (Table III).24,27,28,58 Questionnaires tonursesworkinginLTCFsrevealedthatoftennursesfeltconfusedandfrustratedonproperprotocol.Thenurseshadtomakeachoice:allowtheLTOPtore-fusenecessarytreatmentorforcedentalcareuponaresistantLTOP.58ResearchhasarguedthatLTOPsmaybereluctanttoseekoutdentalcareduetofi-nancialrestraintsasmanydonothavedentalinsur-anceandhavelimitedpersonalfunds.2,36,59,60OtherresearchdescribessomeLTOPsnotrecognizingtheseverity of their self-care deficit and refusing tohavehelpprovidedtothemfortheoralcavity.56Asmanyas83%ofLTOPshavehealthconcernssuchas sensory problems and intubation tubes, whichlimittheirabilitytokeeptheiroralcavityhealthy.56

RDHsfacemultiplebarrierswhenitcomestopro-viding increased access to care for the LTOP. Fewstatesareimprovingtheneedtoprovidebetterac-cesstocarefortheLTOP.Only45%ofU.S.statesand territories have legislative policiesworking toprovide increased access to the LTOP.61 Currently,governing legislation allows a RDH to practice inan LTCFwithout direct supervision from a dentistinsomestates;however,whatservicesareprovid-edandrequirementsoftheRDHvary(TableIV).62However, RDHs receive limited specialized educa-tiontowardsworkingwiththeLTOP.63-66Dentalhy-gienecurriculavarybyschoolprograms,andoften,students reportnot receivingenougheducation intreating theLTOP.63,64Most instructive lessonsandclinical education for dental hygiene students arefocusedoncaringfortherelativelyhealthy,mobileolderadultpatient;veryfewcoursesoffersupportfocusedon theLTOP.65Noneof theover500resi-denciesestablishedbytheAmericanDentalEduca-tion Association (ADEA) specialized in older adulttraining.2TheCommissiononDentalAccreditation(CODA) requires dental hygiene students to workwith the older adult population and community-basedprograms;however,it isnotmandatedthatthey work in LTCFs.66 Adapting school curriculumischallengingduetolimitedprogramfundingthatmust be shared among multiple subject mattersandtopics;however, facultywithindentalhygieneschoolsneed todemonstrate increased interest inregardtooralcarefortheLTOP.66

Recently,theadvanceddentalhygienepractitio-nerwasestablishedinsomestates,allowingRDHstoprovideaccesstocare,sincethismodelincludesabroaderrangeofdutiesthatcanbeperformed.67Furthermore, researchshows thatRDHsaremorelikelytovolunteerbasedontheirlevelofeducation,job satisfaction, membership in their professionalorganization, and sensitivity to underserved pa-

DiScuSSion

With the first of the baby-boomers turning age65 recently, literaturehasbegun to focusonwhatchangeswill be needed to accommodate this verylarge segment of the American population.1-3 Sev-eralacademicjournalsallrecognizethatLTOPsareatanincreasedriskfromthelackofdentalcarepro-videdwhenadmittedintoaLTCF.8,13-18,27-32SystemichealthconditionscommonlyfoundinLTOPsnaturaldeterioration,slowingofthehumanbodyandvari-ousmedicationsallcauseanincreasedneedfororalcareinLTOPs(TableI).32,42Unfortunately,theLTOPthemselvesoftendonotrecognizetheimportanceofroutineoralcareandmayrefusetreatmentforvari-ous reasons (Table III).24,27,28,58Despitehealthcareproviders attending to the LTOPs needs in a LTCF,literaturehasshownavoidincollaborationbetweenprovidersthatcouldhelpreducethelackofroutineoralcare.56,67Attentionneedstobebroughttothismatter inhopesthatLTCFscouldreceiveadequatefundingtopurchaseoralhygieneaids,increasestaff-ing,andeducatethestaff,LTOPs,andfamilymem-bers on the importance of routine oral care (TableII).27,28,42,50RDHscouldpotentiallysavelivesbypro-viding routine oral prophylaxis to the LTOP; thus,reducingheavylevelsofbacteriaintheoralcavity.BasedonwhathasbeenconferredaboutthelackofdentalhygienecareanditsrelationshiptotheLTOP,theauthorsbelievethat theRDHcouldprovide in-creasedaccesstocareforLTOPsinLTCFsbydoingthefollowing:

1. Provideprofessionaloralcaretoscreenforcariouslesions,fungalinfections,orallesions,periodon-taldisease,andassesssalivaryfunction.8,13-18,27-32

2. Performpreventivemeasurestodecreasethein-cidence of carious lesions in the LTOP, throughfluoride applications (varnish) and dental seal-ants.

3. Perform non-surgical periodontal therapy. Treatanunresponsiveperiodontalpocketwiththead-ministrationoflocalizedantimicrobials.

4. Provide education on topics such as nutritionalcounseling and side effects to commonly pre-

Table III:CommonReasonsLTOPsDoNotSeekOutDentalCare

FinancialconcernLTCFarenotequippedtoprovidedentaltreatmentPerceivedentaltreatmentisonlynecessarytoeliminatepainPerceivedailyoralhygienecareasunimportant

tients.63Untilmoredirectaccessbecomesavailablenationwide, many RDHs who are willing to workwiththeLTOPcannotdoso,despitethehugeneed.


concluSionscribedmedicationstotheLTOP.ALTOPcanhavetheirnutritionalstatusevaluatedwithaMiniNu-tritionalAssessment(MNA),asubjectiveassess-mentofhealthandnutritionfromaquestionnairepertainingtodiet.22

5. Assess, incorporate and distribute oral hygieneaidsbettersuitedforLTOPswithlimitationsfromphysicaldisabilitiestoreducehighbacterialfloracounts.

6. Provideoralcarespecializededucationalcoursesforlong-termolderadultcareproviders.

7. Staycurrentwith literatureonbestpracticeforolderadultsandoralhealthtokeepLTCFscurrentthroughoralhealtheducationtostaffinvolvedindirectpatientcare.

8. Potentiallydecreaseincidenceofsystemichealthconditions by reducing overall bacterial floralcountsintraorally.12,20-23

9. Advocate for interprofessional collaboration be-tweenRDHs,nursingstaff,LTCFadministrationsanddentists(TableII).27,28,42,50,52

10.Exposenecessaryradiographstoprovidedentalhygiene diagnoses of oral diseases that cannotbedetectedclinically.

11.AssesstheLTOP’soverallhealth,andrefertoanecessary DDS or DMD when oral health mayneedfurthertreatmentbeyondthescopeofden-talhygienepractice.

12.Advocateforspecializededucationallecturesandoff-siteclinicalexperiencesinLTCFswithindentalhygienecurriculum.65

13.ResearchU.S. dental hygiene schools to deter-minewhatspecializededucationiscurrentlybe-ingconductedforLTOPs.

14.Advocatethroughstatelegislationtoallowmorestates,overthecurrent33,toprovidedirectac-cesstocarethroughintegrationofRDHs(TableIV).62

As LTOPs increase and inadequate oral care isrecognized,opportunitiesforRDHstobecomeem-ployed in the public health sector will increase.3Sinceretainedteethpositivelycorrelateswithover-allhealth,RDHsareneededwithinLTCFs.AdequateoralcareforLTOPsandeducationtoadministrationandnursingstaffontheexpectedpositiveoutcomesof dental hygiene interventions is critical.8,13-18,26-32Systemic health concerns commonly seen in theLTOP,withretaineddentitions,areoftencorrelatedwithpoororalcare.RDHscanbecomebetterpre-pared toworkwith theLTOPby takingcontinuingeducationcoursesspecializingingeriatricdentistry,publichealthandinstitutionalfacilities.Also,RDHsareencouragedtostaycurrentonlegislativemove-mentstofindoutwhenmoreaccesstocareisgrant-edinthestateinwhichtheypractice.Inthenearfuture,government legislationmayallowRDHs toworkindependentlyinLTCFsnationwide.EmployingRDHswithinLTCFswouldnotonlyprovideaccesstooralcareforLTOPs,butwouldoffersupporttoLTCFstaff, who are currently unable to fullymeet oralhealthneedsinthisgrowingpopulation.

Tracee S. Dahm, BSDH, MS is a clinical practicing dental hygienist at LWSS Family dentistry and an adjunct faculty member at the Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University. Ann Bruhn, BSDH, MS, is an Assistant Professor at the Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University. Margaret LeMaster, BSDH, MS, is an Assistant Professor and Junior clinic coor-dinator at the Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University.

Alaska Arizona Arkansas California ColoradoConnecticut Florida Idaho Iowa KansasKentucky Maine Massachusetts Michigan MinnesotaMissouri Montana Nebraska NewHampshire NewMexicoNewYork Nevada Ohio Oklahoma Oregon

Pennsylvania SouthCarolina SouthDakota Texas VirginiaWashington W.Virginia Wisconsin - -

TableIV:StateswithDirectAccesstoCarefortheDentalHygienisttoworkinLTCFs


1. U.S.CensusBureau.2012nationalpopulationpro-jections.[Internet].Washington(DC):U.S.CensusBureau;2014December[cited2015July10].Avail-able from:http://www.census.gov/population/pro-jections/data/national/2012.html.

2. Dounis G, Ditmyer MM,McClain MA, Cappelli DP,MobleyCC.Preparingthedentalworkforcefororaldiseaseprevention inanagingpopulation.JDentEduc.2010;74:1086-1094.

3. U.S.CensusBureau.Theolderpopulation:2010-2010 census briefs. [Internet].Washington (DC):U.S.CensusBureau;2011November[cited2015July10].19p.Availablefrom:http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf.

4. Wiener JM, FreimanMP, Brown D. Nursing homecarequality:twentyyearsaftertheomnibusbud-get reconciliation act of 1987 [Internet]. MenloPark(CA):TheKaiserFamilyFoundation;2007De-cember[cited2015July10].53p.Availablefrom:https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7717.pdf.

5. ReznickS,MatearDW.Perceptionsofcaregiversre-gardingtheimportanceofdentalcareforinstitution-alisedseniors:apilotstudy.JRSocPromotHealth.2002;122(3):170-174.

6. Chronicdiseasepreventionandhealthpromotion-oralhealth:Preventingcavities,gumdisease,toothloss,andoralcancersataglance.CentersforDis-easeControlandPrevention[Internet].2011.[cit-edon2012March12].Availableat:http://www.cdc.gov/chronicdisease/resources/publications/AAG/doh.htm.

7. Lost 6 ormore teeth report. Centers for DiseaseControlandPrevention[Internet].[citedon2012March10].Availableat:http://apps.nccd.cdc.gov/nohss/ListV.asp?qkey=7&DataSet=2.

8. SumiY,OzawaN,MiuraH,MichiwakiY,Umemu-ra O. Oral care helps tomaintain nutritional sta-tus in frail older people. Arch Gerontol Geriatr.2010;51(2):125-128.

9. GharatAR.Periodontitisanddiabetes—acomplexrelationship.IntJDiabDevCtries.2011;31(3):128-132.

10.LamOL,ZhangW,SamaranayakeLP,LiLS,McGrathC.Asystematicreviewoftheeffectivenessoforalhealthpromotionactivitiesamongpatientswithcar-diovasculardisease.IntJCardiol.2011;151(3):261-267.

11.Scannapieco FA. The oralmicrobiome: its role inhealthandinoralandsystemicinfections.ClinicalMicrobiologyNewsletter.2013;35(20):163-169.

12.RaghavendranK,MylotteJM,ScannapiecoFA.Nurs-inghome-associatedpneumonia,hospital-acquiredpneumonia and ventilator-associated pneumonia:thecontributionofdentalbiofilmsandperiodontalinflammation.Periodontol2000.2007;44:164-177.

13.JohnsonEL,BrosseauJD,SouleM,KolbergJ.Treat-mentofdiabetesinlong-termcarefacilities:apri-marycareapproach.ClinDiabetes.2008;26(4):152-156.

14.FravelMA,McDanelDL,RossMB,MooresKG,StarryMJ.Specialconsiderationsfortreatmentoftype2diabetesmellitus in theelderly.AmJHealthSystPharm.2008;68(6):500-509.

15.PatelMH,KumarJV,MossME.Diabetesandtoothloss:ananalysisofdatafromtheNationalHealthandNutritionExaminationSurvey,2003-2004.JAmDentAssoc.2013;144(5):478-485.

16.HeartDiseaseandStrokeStatistics2008Update.AmericanHeartAssociation[Internet].[cited2012February12].Availableat:http://www.silverbook.org/browse.php?id=37.

17.RoseLF,MealeyB,MinskL,CohenDW.Oralcareforpatientswith cardiovasculardiseaseandstroke. JAmDentAssoc.2002;133(Suppl):37S-34S.

18.Persson RE, Hollender LG, Powell VL, et al. As-sessment of periodontal conditions and system-ic disease in older subjects II. J Clin Periodontol.2002;29(9):803-810.

19.MupparapuM,KimIH.Calcifiedcarotidarteryath-eromaandstroke:asystematicreview.JAmDentAssoc.2007;138(4):483-492.

20.SjogrenP,NilssonE,ForsellM,JohanssonO,Hoog-straateJ.Asystemicreviewofthepreventiveeffectoforalhygieneonpneumoniaandrespiratorytractinfectioninelderlypeopleinhospitalsandnursinghomes:effectestimatesandmethodologicalqualityof randomizedcontrolled trials. JAmGeriatrSoc.2008;56(11):2124-2130.

21.SarinJ,BalasubramaniamR,CorcoranA,Lauden-bachJM,StooplerET.Reducingtheriskofaspira-tionpneumoniaamongelderlypatientsinlong-termcare facilities through oral health interventions. JAmMedDirAssoc.2007;9(2):128-135.

referenceS


22.Ishikawa A, Yoneyama T, Hirota K,Miyake Y,Mi-yatake K. Professional oral health care reducesthenumberoforopharyngealbacteria.JDentRes.2008;87(6):594-598.

23.LampertNM,TepperLM.Preventionoforaldiseasefor long-term care and homebound elderly. N YStateDentJ.2010;76(5):42-45.

24.EttingerRL,O’TooleC,WarrenJ,LevyS,HandJS.Nursingdirectors’perceptionsofthedentalcompo-nentsof theMinimumDataSet(MDS) innursinghomes.SpecCareDentist.2000;20(1):23–27.

25.AdachiM,IshiharaK,AbeS,OkudaK.Professionaloralhealthcarebydentalhygienistsreducedrespi-ratoryinfectionsinelderlypersonsrequiringnursingcare.IntJDentHyg.2007;5(2):69-74.

26.MatearDW,BarbaroJ.Caregiverperspectivesinoralhealthcareinaninstitutionalisedelderlypopulationwithoutaccesstodentalservices:apilotstudy.JRSocPromotHealth.2006;126(1):28-32.

27.WardhI,HallbergLRM,BerggrenU,AnderssonL,SörensenS.Oralhealtheducationfornursingper-sonnel; experiences among specially trained oralcareaides:one-yearfollow-upinterviewswithoralcareaidsatanursingfacility.ScandJCaringSci.2003;17(3):250-256.

28.KullbergE,SjogrenP,ForsellM,etal.Dentalhygieneeducation for nursing staff in a nursinghome forolderpeople.JAdvNurs.2010;66(6):1273-1279.

29.FamilyCaregiverAllianceNationalCenteronCare-giving.Selectedlong-termcarestatistics[Internet].SanFrancisco(CA):FamilyCaregiverAlliance;2015January 31 [cited 2015 July 12]. Available from:http://www.caregiver.org.

30.Lohrentz TD. The Americans with disabilities act[Internet].Bethesda(MD):DepressionandBipolarSupportAlliance;2003November[cited2012Feb-ruary6].2p.Available from:http://dbsanca.org/docs/ADA_Title_1_Employment.1782709.pdf.

31.EttingerR.Oralhealthandtheagingpopulation.JAmDentAssoc.2007;138(Suppl):5S-6S.

32.Brukiene V, Aleksejūnienė J, Gairionyte A. Sali-varyfactorsanddentalplaquelevelsinrelationtothe general health of elderly residents in a long-termcarefacility:apilotstudy.SpecCareDentist.2011;31(1):27-32.

33.GuptaB,MaryaCM,JunejaV,DahiyaV.Rootcaries:anagingproblem.InternetJDentSci.2007;5(1).

34.Chalmers JM, Ettinger RL. Public health issues ingeriatricdentistryintheUnitedStates.DentClinNAm.2008;52(2):423-466.

35.Araujo ACS, Gusmao ES, Batista JEM, Cimões R.Impact of periodontal disease on quality of life.QuintessenceInt.2010;41(6):111-118.

36.CarmonaR.Ageisminhealthcare:areournation’sseniorsreceivingproperoralhealthcare?RemarksbeforethespecialcommitteeonagingUnitedStatesSenate[Internet].Washington(DC):UnitedStatesDepartmentofHealthandHumanServices;2007January 8 [cited 2011 December 31]. Availablefrom: www.surgeongeneral.gov/news/testimony/ageism09222003.htm.

37.MealeyBL,OcampoGL.Diabetesmellitusandperi-odontal disease. Periodontol 2000. 2007;44:127-153.

38.BensingK.Oralcareinelderlypatients[Internet].KingofPrussia(PA):AdvanceHealthcareNetworkfor Nurse Practitioners and Physicians Assistants;2013January18[cited2013October13].Availablefrom: http://nurse-practitioners-and-physician-as-sistants.advanceweb.com/Features/Articles/Oral-Care-in-Elderly-Patients.aspx.

39.National Institute of Dental and Craniofacial Re-search. Oral health in America: a report of theSurgeonGeneral(ExecutiveSummary)[Internet].Bethesda (MD): National Institute of Dental andCraniofacial Research; 2014 March 7 [cited 2011November1].Availablefrom:http://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/execu-tivesummary.htm

40.JablonskiRA,SweckerT,MunroC,GrapMJ,LigonM.Measuring theoralhealthofnursinghomeel-ders.ClinNursRes.2009;18(3):200-217.

41.Budtz-Jorgensen E, Mojon P, Banon-Clement JM,Baehni P. Oral candidiasis in long-term hospitalcare: comparisonof edentulousanddentate sub-jects.OralDis.1996;2(4):285-290.

42.ColemanP.Opportunitiesfornursing-dentalcollabo-ration:addressingoralhealthneedsamongelderly.NursOutlook.2005;53(1):33-39.

43.SuraL,MadhavanA,CarnabyG,CraryMA.Dys-phagiaintheelderly:managementandnutritionalconsiderations.ClinIntervAging.2012;7:287-298.

44.KanehisaY,YoshidaM,TajiT,AkagawaY,NakamuraH. Bodyweight and serum albumin change afterprosthodontictreatmentamonglong-termelderlyinalong-termcaregeriatrichospital.CommunityDentOralEpidemiol.2009;37(6):534-538.


45.Gil-MontoyaJA,SubiráC,RamónJM,Gonzalez-MolesMA.Oralhealth-relatedqualityoflifeandnutritionalstatus.JPublicHealthDent.2008;68(2):88-93.

46.Centers forMedicaidandMedicareServices.MDS3.0fornursinghomesandswingbedproviders[In-ternet].Baltimore(MD):CentersforMedicaidandMedicareServices.2015March6[cited2015July13]. Available from: http://www.cms.gov/Medi-care/Quality-Initiatives-Patient-Assessment-Instru-ments/NursingHomeQualityInits/NHQIMDS30.html.

47.American Dental Association. Medicaid and Medi-care[Internet].Chicago(IL):AmericanDentalAs-sociation.1995-2014.[cited2014April8].Avail-ablefrom:http://www.ada.org/368.aspx.

48.AmericanDentalAssociation.Payingfordentalcare:ahow-toguide(incurredmedicalexpenses)[Inter-net]. Chicago (IL): American Dental Association.[cited2014April8]. Availablefrom:http://www.ada.org/en/member-center/member-benefits/prac-tice-resources/paying-for-dental-care-a-how-to-guide-incurred-med.

49.American Dental Hygienists’ Association. Stateswhichdirectlyreimbursedentalhygienistsforser-vicesundertheMedicaidprogram[Internet].Chi-cago(IL):AmericanDentalHygienists’Association.2010June[cited2014April7].3p.Availablefrom:https://www.adha.org/resources-docs/7519_Di-rect_Reimbursement_Medicaid_by_State.pdf.

50.Howard RM, Sullivan DC. Survey of oral hygieneknowledgeandpracticeamongMississippinursinghomestaff.JMissAcadSci.2011;56-57.

51.National Institute on Aging, U.S. Census Bureau.DramaticchangesinU.S.aginghighlightedinnewcensus,NIHreport[Internet].Bethesda(MD):Na-tionalInstitutesofHealth;2006March9[cited2015July13].Availablefrom:http://www.nih.gov/news/pr/mar2006/nia-09.htm.

52.Kaasalainen S, Ploeg J, McAiney C, et al. Roleof the nurse practitioner in providing palliativecare in long-term care homes. Int J Palliat Nurs.2013;19(10):477-485.

53.KohLC.Studentattitudesandeducationalsupportin caring for older people: a review of literature.NurseEducPract.2012;12(1):16-20.

54.MichaudPL,deGrandmontP,FeineJS,EmamiE.Measuring patient-based outcomes: is treatmentsatisfactionassociatedwithoralhealthrelatedqual-ityoflife?JDent.2012;40(8):624-631.

55.Wyatt CC. A 5-year follow-up of older adults re-sidinginalong-termcarefacilities:utilizationofacomprehensivedentalprogramme.Gerodontology.2009;26(4):282-290.

56.ColemanP.Collaborationof nursinganddentistry[Internet].Milwaukee (WI):GeriatricOralHealth.2015.[cited2015July13].Availablefrom:http://www.geriatricoralhealth.org/topics/topic07/default.aspx.

57.Medicare. U.S. department of health and humanservices[Internet].[cited2012February3].Avail-able at: http://www.medicare.gov/longtermcare/static/home.asp.

58.WårdhI,HallbergLR,BerggrenU,AnderssonL,Sö-rensenS.Oralhealthcare—alowpriorityinnursing.In-depthinterviewswithnursingstaff.ScandJCar-ingSci.2000;14(2):137-142.

59.Health&DrugPlans[Internet].[cited2011Octo-ber 25]. Available at: http://www.medicare.gov/default.aspx.

60.BerensonRA,HorvathJ.Confrontingthebarrierstochronic caremanagement inMedicare.HealthAff(Millwood).2003;SupplWebExclusives:W3-37-53.

61.SynopsesofStatePublicHealthDentalPrograms.SummaryReportforAssociationofStateandTerri-torialDentalDirectors[Internet].2011-2012[cited2013October13].Availablefrom:www.astdd.org/docs/state-synopsis-report-summary.pdf

62.AmericanDentalHygienists’Association.Directac-cessstates[Internet].Chicago(IL):AmericanDen-talHygienistAssociation.2014June[cited2015July13].14p.Availablefrom:www.adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf

63.MarshLA.Dentalhygienistattitudestowardprovid-ingcarefortheunderservedpopulation.JDentHyg.2012;86(4):315-322.

64.BestH.Educationalsystemsandthecontinuumofcarefortheolderadult.JDentEduc.2010;74(1):7-12.

65.DolanTA.AccesstodentalcareforolderAmericans.NYStateDentJ.2010;76(5):34-37.

66.Commission on Dental Accreditation. AmericanDentalAssociation.[Internet].2013.[cited2014April7].Availableat:http://www.ada.org/sections/educationAndCareers/pdfs/dh.pdf

67.FriedJ.Interprofessionalcollaboration:ifnotnow,when?JDentHyg.2013;87(Suppl1):41-43.


Thenegativeeffectsof ionizing radiationonhu-man tissues of both patients and operators havebeenwelldocumented.1,2Asaresult,dentistryhastriedtominimizepatientdosethroughtheuseofpa-tientprotectiveequipment, fasterreceptors,digitalimaging,beamalignmentdevices,longersourcetoenddistancesand collimationof thebeam.1-5Sev-eraldecadesago,beamalignmentparallelinginstru-mentswereintroducedonthecommercialmarkettominimizepatientdoseandimprovediagnosticqual-ity.Originally,thesewereusedwithcircularcollima-tion.Inthe1980s,auniversalrectangularcollimatorwasdevelopedforusewithbeamalignmentdevicestofurtherreducethedosetothepatient.Althoughsuccessfulinreducingdose,studieshaveshownthatrectangular collimation has not been well adoptedby themajority of dental practitioners and its useresultsinmorecollimatorcuterrors.Themostlikelyexplanationforthisoccurrenceisthereducedmar-ginforerror.5-7

TechnicalPerformanceofUniversalandEnhancedIntraoralImagingRectangularCollimatorsK.BrandonJohnson,RDH,MS;SallyMMauriello,RDH,EdD;JohnB.Ludlow,DDS,MS;EnriquePlatin,RT,EdD

AbstractPurpose:Thepurposeofthisstudywastocomparethenumberandtypeoftechnicalerrorsbetween2rectangularcollimators,time/motioneffortandradiographerpreference.Methods:Subjects(n=17)wererecruitedtoexposean18projection fullmouthseries(FMX)usingTru-Align™(enhanced)andRinn®(universal)collimatordevices.BothFMXswereexposedusingphoto-stimulablephosphor(PSP)digitalsensorsonaDXTTRmanikinwithanintraoralx-rayunit.A5-questionsurveyevaluatedeaseofdeviceuse,timerequiredanddevicepreference.Datawereanalyzedusingfrequencies,pairedt-test,ANOVAandleastsquaresmeansusingagenerallinearmodel.Results: AlowermeannumberoftechniqueerrorsperFMXoccurredwiththeenhanceddevice(9.7)comparedtotheuniversaldevice(12.1).Collimatorcenteringerrorsoccurred3-timesmoreoftenwiththeuniversaldevice.ThemeannumbersofdiagnosticallyunacceptableerrorsperFMXweresimilar(Uni-versal=3.2vsEnhanced=2.9).Theleastsquaresmeansadjustedmodelshowedastatisticallysignificantdifferenceoferrorsbetweenthe2devices(p=0.0478)anderrorsbylocationwhencomparingposteriortoanteriorandposteriortobitewing(p<0.0001).Subjects(94%)preferredtheenhanceddeviceandfounditeasiertousecomparedtotheuniversaldevice.SignificantlylesstimewasneededtoexposeanFMX(4min)whenusingtheenhanceddevice(p=0.0001).Conclusion: Theenhanceddevice enabled subjects to exposediagnostically acceptable radiographsmoreefficientlywithfewercollimatorcenteringerrors;however,itdoessowitha35%greaterexposureareaandaconcomitantincreaseinpatientdose.Keywords:intraoralradiographictechniqueerrors,rectangularcollimator,intraoralradiograph,collima-torcut,conecut,tru-alignrectangularcollimatorThisstudysupportstheNDHRApriorityarea,Clinical Dental Hygiene Care: Assesshowdentalhygien-istsareusingemergingsciencethroughoutthedentalhygieneprocessofcare.

research

introDuction

TheAmericanDentalAssociation(ADA),Interna-tional Commission on Radiation Protection (ICRP)and National Commission on Radiation Protection(NCRP) strongly recommend the use of rectangu-lar collimation with intraoral imaging.1-4 A currentguidelineestablishedbytheNCRPstatesthatthex-raybeamshouldnotexceedtheminimumcoveragenecessary,andeachdimensionofthebeamshouldbecollimatedsothatthebeamdoesnotexceedthereceptorbymore than2%of the source-to-imagereceptordistance.Radiographicequipmentiseithermanufacturedtoincorporaterectangularcollimationoruniversaladaptersareavailabletoretrofitexistingcircularly collimated equipment.5,6 Continuing con-cernaboutlong-termandcumulativerisksofcancerdevelopmentfromlowdosesofionizingradiationhasincreased interest inthe implementationofrectan-gularcollimation.1

Morerecently,arectangularcollimatordevicehasbeenmarketedwithenhancementfeaturesthatmay



Thestudypopulationconsistedof33seniordentalhygienestudentsattheUniversityofNorthCarolinaatChapelHillSchoolofDentistry.Criteriaforinclu-sioninthestudyweresuccessfulcompletionofthepreclinicalradiologycourseand2semestersofclini-calradiologyexperiencepriortoenrollingtopartici-pate.Participantswereaskedtoenrollvoluntarilyinthestudyandsignaconsentform.ThisstudywasapprovedbytheUniversityofNorthCarolinaInstitu-tionalReviewBoard.

Twodevice/collimatorcombinationswereusedtotestfortechnicalperformanceanddiagnosticaccept-ability.Bothdevice combinationsweredesigned tobeusedwiththeRinnXCP®receptorholdingdevice,althoughthemethodforalignmentvarieddependingon thedeviceemployed.TheRinn® universal rect-angularcollimatorinsert(RinnCorp,Elgin,Ill)here-after referred toas “Universal”wasfittedover thecircularcollimatorendresultingina33cmsource-

Figure 1a: Universal Collimator Device(DXTTRManikin)

Figure 1b: Enhanced Collimator Device(DXTTRManikin)

Figure 2: Bitewing Bite Blocks, Ring Barswith Color Corresponding Alignment RingsandEnhancedDevices’MagneticRing

Fromlefttoright:TheXCPanterior,posteriorandbitewingbiteblocks;ringbarswithcolorcorrespondingalignmentrings;enhanceddevices’uniquemagnetic ring (replacesthe3XCPalignmentrings)

help minimize the collimator cut technique errorscreatedwitharectangularcollimatedbeam.Adevicecomposedofamagneticalignmentringandaposi-tioning-indicator laserbeamwithavisual lightandaudiblesignalwasdesignedtoeliminatecollimatorcutsand retakes.Anearlystudyevaluated techni-calperformanceusingthedeviceprototypeandtheauthorsrecommendedmodificationstooptimizethediagnosticqualityoftheimage.5Thesemodificationsallowedforretrofittingthedevicetocircularcollima-torsandanincreasedsizeoftherectangularwindow.Thisstudy’sauthorsareunawareofanystudiesthathaveevaluatedhowthesedesignchangesaffectedtheabilitytoproducequalityanddiagnosticintraoralimageswith thisdevice.Therefore, thepurposeofthisstudywastoevaluatethetechnicalperformanceof2rectangularcollimatormodalitiescurrentlyavail-ableonthecommercialmarket.

to-enddistance(Figure1a).Theuniversal collima-torproducedanexposureareaof46mmx36mm(1,652mm2),measuredatadistanceof2.5cmfromthe collimator end.8 The IDI Tru-Align™ intraoralrectangularcollimatingdevice,hereafterreferredtoas“Enhanced,”wasfittedontheopeningofthetubeheadproducinga30cmsource-to-enddistance(Fig-ure1b).Theenhanceddeviceproducedanexposureareaof56mmx45mm(2,524mm2),measuredatadistanceof2.5cmfromthecollimatorend.8Theuniversal device was used with the XCP® receptorholdingdevice(receptorholder/biteblockwithcor-respondingalignmentringandbar).Fortechniquesusedwiththeenhanceddevice, theXCP® ringwasreplacedbyaspecificallydesigned ring (Figure2).Theenhanceddevice’salignmentringwassquareinshapewiththeappropriatelycorrespondingappend-


Figure 3: Displays the Enhanced DeviceAlignmentRingContainingEmbeddedMag-nets

agesforanterior/bitewingandposteriorprojections.Thealignmentringwasaffixedwithmultipleroundflushmountedmagnetstosecurethecollimatortotheaimingdevice(Figure3).

All projections were exposed using DenOptix®(GENDEX,Hatfield,Penn)PhotostimulablePhosphorPlate(PSP)receptorsforeachFMX.Size1receptorswere used for lateral/canine periapical projections(n=4) and Size 2 receptors were used for central(n=2), premolar (n=4), and molar (n=4) periapi-calprojectionsandpremolar(n=2)andmolar(n=2)bitewingprojections.Atotalof18projectionsconsti-tutedanFMXforthetechnicalperformancesegmentofthisstudy.

All exposureswith both universal and enhancedcollimator devices were made using an intraoralPlanmecaProstylex-rayunit(Intra,PlanmecaUSA,Roselle,Ill).TwoDentalX-rayTeachingandTrainingReplicas(DXTTRs)(RinnCorp,Elgin,Ill)wereidenti-fiedforuseinthestudy.EachDXTTRwasdesignedwithnaturalteethandhumanskulls.SelectionoftheDXTTRswasbasedonoptimal,mechanicalandop-erationalconditions.

A5-itempost-participationsurveyinstrumentwasdesigned to solicit information from the subjectsregarding their experienceusing theuniversal andenhanceddevices.All5questionswereopen-endedindesign.Oneaskedforanycomplicationsormal-functionsthatmayhaveoccurredwitheitherdevice.Thesecondasked for thehelpfulnessof theaddedfeatures of the enhanced device (visual, audible,magnetic ring). Two of the questions explored thesubject’s impressionof the imagequality renderedandeaseofuseofbothcollimators.Thelastquestionaskedtheoperatoroverallpreferencefortheirchoiceofdeviceandwhy.

All study subjects chose a block of time to par-ticipate.Nomorethan2subjectscouldparticipateatthesametime.Onceatimeforparticipationwasestablished, each subject was required to consentbyreadingandsigningtheIRBapprovedstudypar-ticipationconsentform.Uponarrival,subjectsweregivenabriefreviewontheproperusageofeachofthe2devicesandtheirtask.Priortoarrival,theprin-cipal investigatorsetupDXTTRmanikins,arrangedsensorswithacorrespondingFMXtemplateandin-stalled both universal and enhanced devices to bereadyforuse.Eachsubjectwasrandomlyassignedtoanoperatory,DXXTRmanikinand1of2studyde-vices.Whenreadytobegin,consentedsubjectsex-posed1FMXusingeithertheuniversaldeviceortheenhanceddevice.Theprincipalinvestigatorrecordedstartandstop times foreachstudysubjectduringtestingofeachdevice.UponcompletionofthefirstFMX with either device, the principal investigatorgatheredexposedsensorsandscannedimagesinto

theTrainingElectronicPatientRecord(TEPR).Allim-ageswerecodedtoblindtheevaluatortothesubjectanddeviceused.Theprincipalinvestigatorremovedthefirstofthe2devicestestedandinstalledthere-maining device for subject use and start and stoptimeswere again recorded. Subjectswere allowedunlimitedtimetocompletethe18projectionseries,butwereencouragedtotreattheradiographicexamas if itwereapatientsimulation.BothFMX’swereexposedusingPSPdigitalsensorsonaDXTTRmani-kin.Attheendoftheirtask,eachsubjectcompletedthepostparticipationsurvey.Eachsurveydocumentwascodedprovidinganonymityforthestudysubjectwhileofferingtheprincipalinvestigatoridentificationofdevice,DXTTRandoperatoryused.

Anexperiencedevaluator(dentalhygieneprofes-sorwith35years’experienceevaluatingradiograph-ictechnicalperformance)assessedtheradiographicimages for technical and diagnostic quality. Intra-raterreliabilitywasdeterminedduringtheevaluationprocessbyrandomlyre-grading10FMX’s(5withtheuniversal collimatorand5with theenhancedcolli-mator).Eachprojectionwasviewedinalowlitroomona22”Lenovomonitorwitharesolutionof1680x 1050 dpi. All projections were evaluated over athreehourtimeframewithperiodic(two10minute)breaks.Datawerecollectedusingadirectdataen-trysystemusinganEXCEL(Microsoft2010Version)statisticalapplication.

All study images were blinded to the evaluatorbasedondevice/collimatorcombinationandradiog-rapher.Theimageswereevaluatedbasedonprede-terminedcriteriaassessingthepresenceandsever-ityofcollimatorcentering(CC),verticalangulation(V),horizontalangulation(H)andpacketplacement(PP) errors. If the error was present but the pro-jectionwasdiagnosticallyacceptable,thentheerrorwascodedasa“minor”error.Iftheerrorwaspres-


reSultS

Atotalof17subjectsenrolledinthestudycom-prisinga51.5%participationrate.Allsubjectscom-pletedthetechnicalcomponentofthestudyandthepost-participationsurvey.Theintra-raterreliabilitywasICC=0.77.

Figures 4 and 5 present the findings of all er-rors by number and error type. Figure 4 displaysthemean number of errors per fullmouth for alltechnique errors (PP, V, H and CC) as a functionof the collimator device (universal vs. enhanced).ThemeannumberoferrorsperFMXfortheuniver-saldevicewas12.1and9.7fortheenhancedde-vice.Astatisticallysignificantdifferencewasseenwhen the data were analyzed using the adjustedmodel (F=4.35, df=1, p=0.048). In Figure 5, thedatawereevaluatedbythemeannumberoferrorsper fullmouth as a function of error type by de-vice,asimilarnumberoferrorsoccurredbydeviceforeacherrortypeexceptforcollimatorcentering.Themeannumberofcollimatorcenteringerrorsperfullmouthseriesoccurred3timesmoreoftenwith

Figure4:Displaysthemeannumberofer-rorsperfullmouthforalltechniqueerrors(PP,V,H,andCC)asafunctionofthecol-limatordevice(universalvs.enhanced)

The mean number of errors per FMX was 12.1 for theuniversaldeviceand9.7fortheenhanceddevice.Asta-tistically significant difference was seen when the datawereanalyzedusingtheadjustedmodel(F=4.35,d.f.=1,p=0.048).

1817161514131211109876543210

DescriptiveMeanNumberforAllErrorsbyDevice

Mean#ofErrorsperFMX

Universal Enhanced

Universal

Enhanced

A similar number of errors occurred by device for eacherrortypeexceptforcollimatorcentering.Themeannum-berofcollimatorcenteringerrorsperfullmouthseriesoc-curred three timesmoreoftenwith theuniversal device(universaldevice=3.6vs.enhanceddevice=1.1)

Figure5:Meannumber and typeof tech-niqueerrorsperFMXasafunctionoferrortypebydevice

7

6

5

4

3

2

1

0

-1

DescriptiveMeansforErrorTypesbyDevice

Mean#ofErrorsperFMX

Packet

Placement

Universal

Enhanced

Horizontal

Vertical

Collimator

Centering

entbutrenderedtheprojectiondiagnosticallyunac-ceptable,thentheerrorwascodeda“major”error.Minorerrorsinvolvingpacketplacement,horizontalangulation, vertical angulation and collimator cen-teringconstitutedadeductionofonepointpererrorwith4pointsbeingthegreatestdeductionperpro-jection.Majorerrors involvinganyof the4criteriaweredeemednon-diagnosticandautomatically re-sultedina4pointdeductionforthatimage.Eachofthe18imagesoftheFMXwasgradedandanoverallscoregivenforthatsetofimages.

Datawereanalyzedusingfrequencies,ANOVAandleast squaresmeansusingageneral linearmodel.The mean number of errors per full mouth serieswere calculated and then averaged across all fullmouth series. A general linearmodelwas used toanalyzemeannumbersoferrorsbetweenthe2de-vices.ANOVAwasused toassesserrordifferencesduetolocationinthemouth(Anterior,PosteriorandBitewing).Apairedt-testwasusedtoevaluatethemean time/effort between the two devices. Intra-rater reliability was measured using an IntraclassCorrelationCoefficient(ICC).


theuniversaldevice(universaldevice=3.6vs.en-hanceddevice=1.1).

Figure 6 presents the findings based on errorseverity (major or minor) displaying the averagenumberoferrors(PP,V,H,andCC)perFMX.Aner-rorscoredasamajorerrorindicatedthattheimagedidnotofferdiagnosticvalue.Aminorerrorindicat-edthattheerrorwaspresentbutdidnotcompro-misethediagnosticqualityoftheimage.Themeannumber of diagnostically unacceptable errors perfullmouthserieswassimilarbetween thedevices(Universaldevice=3.2vs.Enhanceddevice=2.9).Agreaterdifferencewasseen in the reportedmeannumberofminorerrorsperfullmouthbetweenthetwo devices (Universal device=8.9 vs. Enhanceddevice=6.8).Minor collimator centeringerrorsoc-curred three timesmore often with the Universaldevice (Universal device=3.5 vs. Enhanced de-vice=1.1).

Figure7showstheerrorratesbasedonlocation.Theaveragenumberofallerrorsthatoccurredwasevaluatedbasedonlocationinthemouth(Anterior,Posterior, Bitewing) and by device (Universal vs.Enhanced).Therewasadifference in theaveragenumber of errorswhen comparing posterior (Uni-versaldevice=6.5vs.Enhanceddevice=5.4)toan-teriorlocations(Universaldevice=2.5vs.Enhanceddevice=2.0) and posterior to bitewing locations(Universal device=3.1 vs. Enhanced device=2.3).Themodelshowedastatisticallysignificantdiffer-enceintheaveragenumberoferrorsperFMXwhencomparingposteriortoanterior locationsandpos-teriortobitewinglocations(p<0.0001).Therewasnotasignificantdifferencewhencomparinganteriortobitewinglocations(p>0.38).

TimerequiredtocompleteaFMXbydevicewasevaluated. Average time required to complete aFMXusingtheuniversalandenhanceddevicewas21 minutes and 17 minutes respectively. Signifi-cantlylesstimewasneeded(4minutes)toexposeaFMXwhenusingtheenhanceddevice(p=0.0001)(Figure8).

TableIdisplaysthesubjectresponsestoeachofthefivequestionsofthepost-participationsurvey.Question#1askedthesubjects(n=17)tostateanycomplications/malfunctionsofthedevice/collimatorcombinations that were experiencedwhen expos-ingtheprojections.Regardingtheuniversaldevice,foursubjects(24%)reportedx-rayunittubeheadinstabilityordriftingandonesubject(<1%)report-edexperiencingamalfunctionwith thecollimator.Regardingtheenhanceddevice,8subjects(47%)reportedthattheweightofthedevicewasanissueand6subjects(35%)reportedthatthelightedsig-nalfeatureproducedinaccuracies.

14131211109876543210

DescriptiveMeanNumberforAllErrorsbySeverity

Mean#ofErrorsperFMX

AllMajor AllMinor

Universal

Enhanced

Figure6:Meannumberofallerrors(majorandminor)perFMXbetweenthe2devices

Themean number of diagnostically unacceptable errorsperfullmouthserieswassimilarbetweenthedevices(Uni-versal device=3.2 vs. Enhanced device=2.9). A greaterdifferencewasseeninthereportedmeannumberofminorerrors per fullmouth between the two devices (Univer-saldevice=8.9vs.Enhanceddevice=6.8).Minorcollima-torcenteringerrorsoccurredthreetimesmoreoftenwiththeUniversaldevice(Universaldevice=3.5vs.Enhanceddevice=1.1).

Figure7:Meannumberofallerrors(PP,VA,HA,CC)bydeviceasafunctionofprojec-tionlocation

Therewasastatisticallysignificantdifferenceintheaver-agenumberoferrorsperFMXwhencomparingposteriorto anterior locations and posterior to bitewing locations(p<0.0001).Therewasnotasignificantdifferencewhencomparinganteriortobitewinglocations(p>0.38).

109876543210

DescriptiveMeanNumberforAllErrorLocationbyDevice

Mean#ofErrorsper

FMX

Anterior Posterior Bitewing

Universal

Enhanced


DiScuSSion

Aprimarygoalofradiographyistorenderadiag-nosticimagewhilekeepingthedosetothepatientaslowasreasonablyachievable.Thisstudycomparedthetechnicaloutcomeof2rectangularcollimators:onewithtechniqueenhancementfeaturesthatret-rofittedtothetubeheadandonethatinsertedintoa circular collimator. In addition, subject feedbackwassolicitedontheuseandpreferenceofthecol-limators.

Whenthedeviceswerecomparedbasedontech-nicalperformancetherewasnotaconsistentpatternseenwhereonedeviceoutperformedtheotherwithrespecttopacketplacement,verticalangulationorhorizontalangulationerrors.However,theenhanceddevice produced significantly fewer overall errorswhencomparedtotheuniversaldevice.Thetypeoferrorthatwasprimarilyreducedwiththeenhanceddevicewascollimatorcutting.Thisfindingisincon-trasttothatreportedbyZhangetal.5Zhang’sstudyreportedanincreaseincollimatorcutsandsuggest-edthatthedevicemaybemodifiedtoincreasetheaperture opening in the device.5 Interestingly, thecurrentstudydiscoveredthattherewasminimaldif-ference between the devices in thenumber of er-rorsrequiringaretaketorenderadiagnosticimage.

Figure8:AveragetimerequiredtocompleteaFMXbydevice

Onaverage,theFMXexposureswere4minuteslongerus-ingtheUniversaldevicecomparedtotheEnhanceddevice(p=0.0001).

4035302520151050

TimeEffortComparisonbetweenDevices(n=17)

AverageTime(Min)

toCompleteFMX

Universal Enhanced

Universal

Enhanced

Question #2 asked the subjects (n=17) to listwhich enhancement features (audible and visualsignals,magneticring),ifany,werehelpfultothemastheoperator.Eighty-twopercentchosethevisual(lighted)signal,71%listedthemagneticposition-ingring,and35%listedtheaudiblesignalasbeinghelpfultothemduringexposures.

Questions3and4explored thechoicesofsub-jectsregardingimpactonimagequalityandeaseofuse.ResponsestoQuestion3indicatedthatfifteensubjectsfeltthatusingtheenhanceddevicewouldproducebetter quality images.One subject chosetheuniversaldeviceandonesubjectremainedun-decided.Question4askedthesubjects(n=17) tomakeachoiceastowhichofthetwodevicestheyfound easier to use. Sixteen chose the enhanceddevice while 1 remained undecided. No subjectschosetheuniversaldevice.

Question5askedthesubjects(n=17)tochoosea device basedon their overall preference and toelaborateastowhy.Sixteenresponseswereinfa-voroftheenhanceddevicewhileonesubjectpre-ferredtheuniversaldevice.Explanationsthatsub-jectsprovidedforpreferenceoftheenhanceddevicewerethatitprovidedconfidencetotheoperatorre-gardingexposureofaqualityimage,lesstimeandeaseofuse.Theonesubjectthatpreferredtheuni-versaldevicemadethisdecisionbasedonfamiliar-itywiththedevice.

Thus,most of the collimator centering errors thatweremadedidnot influencethediagnosticqualityoftheimage.Incontrasttothecurrentstudy’sre-sults,ParksetalfoundthatuseoftheRinn®Snap-onrectangularcollimatingdeviceresultedinasta-tisticallyhighernumberofretakeswhencomparedto theotherdevices tested(i.e.snap-a-ray/round,XCP®/BAIparalleling/round,snap-a-ray/rectangular,XCP®/BAIparalleling/rectangular,XCP/BAIparallel-ing/Rinn®Snap-on,andPrecision/rectangular).7Al-thoughParksetaldidnotofferanexplanationforthis finding, the greater number of retakesmightbeattributed to theattachmentof the rectangularRinn®Snap-ondevicetothealignmentring.Inad-dition, Parks et al didnot provideadescriptionoftheapertureopeningforthe16inchFFDrectangularcollimatorusedinhisstudy,whichlimitsacompari-sonof his findings to the current study.7 Althoughnot evaluated in this study, use of the XCP-ORA®mayreducethenumberofcollimatorcutsduetothenotchedaimingring.Thiscouldbetestedinfuturestudies.

Additionally, the current study found that moreerrorsoccurredinposteriorprojectionscomparedtoanteriorandbitewingprojectionsregardlessof thedeviceused.Theauthorsofthisstudybelievethatthisphenomenonislikelyduetothepresenceofan-atomicalobstacles(i.e.tongueandcheeks)result-inginthelesseningofvisualconfirmationofproperplacement regardless of the device used. Parks etalreportedthatfilmplacementerrorswerenotaf-fected regardless of collimation technique used oroperatorskill.6

Oneofthemajorchallengesindentistryregardingadoptionofdosereductiontechniquesiswhetherthe


SurveyQuestion SurveyResponses n(Percent)

1.Stateanycomplications/malfunctionsofthede-vice/collimatorcombinationsthatyouexperiencedwhenexposingtheprojections?

•Weightofenhanceddevice•Inaccuratelightactivation•Tubeheadinstabilitywithuniversaldevice•Universaldevicemalfunction

8(47)6(35)4(24)1(<1)

2.Whichenhancementfeatures(audibleandvisualsignals,magneticring),ifany,werehelpfultotheoperator?

•Visuallight•Magneticring•Audiblebeep

14(82)12(71)6(35)

3.Whichdevicedidyouperceiveprovidedthebestdiagnosticimages?

•Universal•Enhanced•Undecided

1(6)15(88)1(6)

4.Ingeneral,whichdevicedidyoufindtobeeasiertouseastheprovider?

•Universal•Enhanced•Undecided

0(0)16(94)1(6)

5.Pleasetellusyouroveralldevicepreferenceandwhy.

•Universal•Enhanced

1(6)16(94)

TableI:Post-ParticipationSurveyResponses

userfeelsthatthedevicehelpsthemtoachievedi-agnosticimageswithgoodimagequality.Thesurveydataindicatedthatthemajorityofsubjectslikedtheenhancement featuresof theenhanceddeviceandfeltthattheenhanceddevicewouldrenderabetterdiagnosticimage.Subjectswereabletoworkfasterwiththeenhanceddeviceandreportedpreferenceforthisdevice.Zhangetalfoundthatstudentsreportedagreatereaseofusewiththeenhancedrectangulardeviceencompassingamagneticalignmentringasopposed to the freely adjustable universal rectan-gular collimator.5However, contrary to this study’sfindings,ZhangetaldidnotseeareductionintimenecessarytocompleteanFMX.5Thisstudyshowedimprovement in time efficiency (approximately 4mins)aswell asa reductionofoverall errorswiththeenhanceddevice regardlessof the fact that inboth study settings, subjects had no previous ex-periencewiththedevice.ThesubjectsinthisstudydidhavepriorexperienceusingtheXCP-ORA®whichmayhavecontributedtoashortlearningcurveforputtingtheinstrumentstogetherandusingthemforradiographic exposures. Thirty-five percent of thestudysubjectsreportedaninaccurateorfalsecon-firmationofthelightandaudibleenhancementfea-turesof theenhanceddevice(Figure9).Similarly,Zhangetalfoundthatfalsesignalingwascommon.5Asaresult,operatorsshouldbecautionedthatfalsesignalsmayinfluencenegativelyaccuratealignmentofthex-raypositionindicatingdevice(PID).

It appears that the enhanced device’s enhance-mentfeaturescouldhaveplayedapartinthereduc-tion of collimator centering errorswhen comparedto the universal device. This study found that thenewly modified enhanced device produced fewercollimator centering errors than the freely adjust-able universal rectangular device. These findingscontradictthefindingsofZhangetalwhousedthe

originallydesigned(unmodified)enhanceddevice.5Zhang reported that use of the original enhanceddevice produced almost four times the number ofcollimatorcenteringerrorsaswiththeuniversalde-vice.5 The 35% larger beam area of themodifiedenhanceddevicecompared to theoriginally testedprototypemaybethereasonforthisfinding.Whenimagequalitywasassessed, thereappeared tobeslightly fewererrorswith theuseof theenhanceddevicebuttheseerrorsdidnotrenderdiagnosticallyunacceptableradiographs.Thus,thelargercollima-torareaoftheenhanceddevicemayhavereducedthenumberof collimator centeringerrors,but thedatashowedthattheenhanceddevicedidnotpro-ducemorediagnostically acceptable imagesand itmayhavebeenattheexpenseofincreasedpatientexposure.

ItisimportanttonotethattheexposureareaoftheRinn®universaldevicecomplieswiththeNCRPstipulationthatrectangularcollimatedbeamsshouldnotexceedthedimensionoftheimagereceptorbymore than twopercentof the source-to-image-re-ceptordistance(SID)andhasbeenmeasuredasonepercentoftheSID.8TheTru-Align™websitesuggeststhattheenhancedcollimator“reducesthebeamsizetoapatternthatisonlytwopercentlargerthantheacquisition device.”9 But according to a previousstudy,themeasureddimensionswerereportedtobe4%largerthantheSID.8Themanufacturer’sclaimofa50%reductioninexposureareacomparedwitha round collimator appears to be overstated com-paredtothestudybyJohnsonetal.8,9Johnsonetaldeterminedthata18%reductioninexposureareaoccurredwhentheenhanceddevicewascomparedtoa6cmroundcollimator.8Similarly,theclaimofa60%reductioninpatientdoseisnotsubstantiat-edwithactualmeasurements.8Thus,theuseofthedesignation“rectangularcollimation”hasanimplicit


Figure9:Displaystheenhancedcollimatorwithoutalignmentringengagedandthereforenoconfirmationlights(left)vs.flushmagneticattachmentofthealignmentrighttothedeviceresultinginvisuallightconfirmation(right)

expectationofcompliancewiththestandardestab-lishedforit.Asaconsequence,thedescriptionoftheenhanceddeviceasrectangularcollimatorshouldbedescribedas“non-standard”.

When interpreting the results of this study, it isimportant torecognize the limitationsof thestudydesign.First,theimagesfromthetechnicalperfor-mance component of this study were exposed onDXTTR manikins. Tongue movement and patientcooperation, factors thatoften influence imageac-ceptability,werenotabletobefactoredinwhende-terminingthetechnicalperformanceofthecollima-tors.Thus,thenumberandtypesoferrorsseenwithDXTTRsmaybedifferentfromlivepatients.Second,onlyabouthalfofthestudypopulationchosetopar-ticipate in the study. This may have introduced asubjectbias.Thus,acomparisonofnon-participantswithstudyparticipantswouldhavehelpedtodeter-mineifdifferencesingroupsexisted.Althoughcom-parisonsbetweengroupswerenotdone,attemptsweremadetostandardizeaminimumcompetencylevelforallsubjects.Forexample,allsubjectshadpassedtheirpreclinicalcompetencyandparticipatedin2semestersofradiographicclinicalpractice.Third,technicaldifferencesbetweenthe2collimatorswerebasedontheradiographicperformanceskillsofthesubjects. Asmentioned, the subjects hadminimalclinical experienceswith patients. Performance re-sultsofthedevicesmayhavebeendifferentiftheywere used by experienced clinicians. Presumably,experiencedcliniciansaremorelikelytoidentifyandproblemsolve incorrect placement of devices. Theauthors also made the observation that tubeheadinstabilitymay influence the interlockingnatureoftheenhanced rectangulardevicewith itsmagneticring.Enhanceddeviceweight (n=8)and tubeheadinstability(n=4)reportedbythesubjectsmayhaveoccurredduetoweightofthedevices.Weighingofthedevicesrevealedthattheuniversalmethodwas

heavier than the testmethod. Another interpreta-tionmightbethatthesubjectswerereferringtotheweight of themagnetic aiming ring usedwith theenhanceddevicewhichisheavierandbulkier.Inad-dition,thegreatercollimatorlengthoftheuniversalmethodmayhavecontributedtothetubeheaddrift.

Thisstudycomparedtheperformanceoftworect-angular collimated devices that are currently usedindentalpractice.Whiledeviceswithenhancementfeaturesmaybeastepintherightdirection,whatisofutmostimportanceistheproductionofqualityimageswhilelimitingdosetothepatient.

concluSion

Toadhereoptimally to theALARAprinciple, theauthors recommend that radiographers use rect-angular collimation meeting NCRP specificationsforbeamlimitationwhenexposingintraoralradio-graphs.Adherencetobestpracticesofdentalpro-fessionals by the adoption of rectangular collima-tionasastandardofcarehasbeenslowtoevolve.However,growingconcernabout the linkbetweenlow doses of ionizing radiation and the long-termand cumulative risks of cancer ensures this tran-sition to be inevitable. The retailmarket provideschoicestodentalprofessionalswhenupgradingin-traoralimagingequipmentforrectangularcollima-tiontechniques,thusit isagoaloftheauthorstopromoteawarenessthatallrectangularcollimatorsarenotcreatedequally.Therectangularformatofacollimatorisnotbyitselfsufficientcriteriatoensurethatareduction inradiationdosewill resultwhencomparedtocircularcollimation.Itispertinentthatdevicemanufacturersadheretoguidelinessetforthby the NCRP with respect to rectangular collima-tor dimensions. If the radiographer feels that thepresence of enhancement features help them ex-posediagnosticimages,thentheenhancedcollima-


1. Ludlow JB,Davies-LudlowLE,WhiteSC.Patientriskrelatedtocommondentalradiographicexam-inations: the impactof2007InternationalCom-missiononRadiologicalProtection recommenda-tionsregardingdosecalculation.JAmDentAssoc.2008;139(9):1237-1243.

2. The2007RecommendationsoftheInternationalCommissiononRadiologicalProtection.ICRPPub-lication103.AnnICRP.2007;37(2-4):1-332.

3. NCRPReportNo.145,RadiationProtectioninDen-tistry.Bethesda(MD):NationalCouncilonRadia-tionProtection&Measurements;2003.

4. American Dental Association Council on Scien-tific Affairs. The use of dental radiographs: up-date and recommendations. J Am Dent Assoc.2006;137(9):1304-1312.

5. ZhangW,AbramovitchK,ThamesW,etal.Com-parisonoftheefficacyandtechnicalaccuracyofdifferentrectangularcollimatorsforintraoralradi-ography.OralSurgOralMedOralPatholOralRa-diolEndod.2009;108(1):e22-e28

6. HornerK,HirschmannPN.Dosereductioninden-talradiography.JDent.1990;18(4):171-184.

7. ParksET.Errorsgeneratedwiththeuseofrectan-gularcollimation.OralSurgOralMedOralPathol.1991;71(4):509-513.

8. JohnsonKB,LudlowJB,MaurielloSM,PlatinE.Re-ducing the riskof intraoral radiographic imagingwithcollimationandthyroidshielding.GenDent.2014;62(4):34-40.

9. Tru-Align™ Frequently Asked Questions [Inter-net].Marietta(GA):InteractiveDiagnosticImag-ing,LLC;c2011-2015[cited2014May24].Avail-ablefrom:http://www.idixray.com/trualign/faq/

referenceS

acknowleDgmentS

AuthorsofthestudywouldliketothankIDIX-RayforthedonationofaTru-Align™RectangularDeviceforthepurposeofthisstudy.

torevaluatedinthecurrentstudyisabetterchoicethanastandardroundcollimator.

Ultimately,emphasisshouldbeplacedonqualitytrainingandconsistentcontinuingeducationtore-inforcethetechniquesandskillsinvolvedinimagingoptimal intraoral projections. Implementing theserecommendationswillhelpensurethationizingra-diationisusedsafelyindentalpracticeandoptimalimagegenerationisachieved.

K. Brandon Johnson, RDH, MS, is a clinical assis-tant professor in the Department of Diagnostic Sci-

ences, School of Dentistry. Sally M Mauriello, RDH, EdD, is a professor, Department of Dental Ecology. John B. Ludlow, DDS, MS, is a professor. Enrique Platin, RT, EdD, is a clinical professor, Department of Diagnostic Sciences. All are at University of North Carolina at Chapel Hill.


FederallyQualifiedHealthCenters(FQHCs)aredi-rected and governed by theHealth Resources andServicesAdministration(HRSA).1,2SubstantialgrantmoneysreceivedbyHRSAensureFQHCscanmain-tainfinancial sustainability.Additionally, FQHCs re-ceive thesegrantsunderSection330of thePublicHealthServiceAct(PHS)andqualifies themtore-ceiveenhancedreimbursementsfromMedicaidandMedicare.2 FQHCs are required to submit data toHRSA’sUniversalDataSystemonanannualbasis.3Thisdatatrackspatientdemographics,servicespro-vided, staffing, clinical indicators, utilization rates,costsandrevenuesofgranteesatstateandnationallevelsonanannualbasis.ThisdataassistsHRSAinevaluating a program’s effectiveness and interven-tionofservicestoimprovethehealthofvulnerablepopulations.3 Besides the number of dental proce-duresprovided,therearenonationallyacceptedoralhealthperformanceindicatorsrequiredbyHRSAforgranteestoreporttotheuniformdatasystem.3

AnAssessmentModelforEvaluatingOutcomesinFederallyQualifiedHealthCenters’DentalDepartments:Resultsofa5YearStudySharonM.Grisanti,RDH,MCOH;LindaD.Boyd,RDH,RD,EdD;LoriRainchuso,RDH,MS

AbstractPurpose:Thepurposeofthisreportwastoestablishbaselinedataon10oralhealthperformanceindi-catorsover5fiscalyears(2007to2008through2011to2012)foranIowahealthcenter.Thebaselinedataprovidesanassessmentmodelandreportsoutcomesbasedontheuseofthemodel.Performanceindicatorsshowevidenceofproviderperformance,accountabilitytostakeholdersandprovidethebench-marksrequiredfordentalmanagementtodevelopfuturegoalstoimproveoralhealthoutcomesforat-riskpopulations.Methods:Usingdescriptivestatistic,thisreportextrapolateddatafromtheIowaHealthCenter’scomputermanagementsystemssoftware,HealthPro,andCentricityelectronicmedicalrecords,andanalyzedusingIBM®SPSS®19.ThisreportdescribesthechangeinutilizationfornumberandtypeofvisitsforuninsuredandMedicaidpatientsover5fiscalyears(afiscalyearismeasuredfromNovember1throughOctober31).Results: Thenumberofpatientsreceivingatleast1dentalvisitinameasurementyearshowedn=81,673procedureswith21%(17,167)beingunduplicatedpatients.Preventiveaveraged46%,restorative18%,urgentcare22%andotherprocedures14%.Conclusion:Federallyqualifiedhealthcenters(FQHCs)withadentalcomponentservepopulationswiththegreatesthealthdisparities.Thispopulationincludesethnicandracialminorities,uninsured,underin-sured,ruralresidents,MedicaidandMedicare.EstablishingbaselinedataforFQHCsprovidesafounda-tionaltoolthatwillallowdentalmanagementtoanalyzesuccessesaswellasdeficienciesinthegoaltoprovideincreasedutilizationtooralhealthcareforat-riskpopulations.Keywords:oralhealthperformancemeasures,practicemanagementforcommunityoralhealth,FQHCs,baselinedataThisstudysupportstheNDHRApriorityarea,Health Promotion/Disease Prevention: Investigatehowenvironmentalfactors(culture,socioeconomicstatus-SES,education)influenceoralhealthbehaviors.

research

introDuction

This report provides descriptive statistic basedon10indicatorsdevelopedbyHealthyPeople2020,HRSA, Maternal Child Health, National Quality Fo-rum, U.S. Department of Health and Human Ser-vices(DHHS)andCrescentCommunityHealthCen-tersdentalmanagementover5fiscalyears(2007to2008 through2011 to 2012).Dentalmanagementselected indicators from these developers becausetheyareleadersintheoralhealthprofession.2,4,5Oralhealth is a high priority for these organizations astheyhavetakentheleadtodeveloporalhealthmea-suresthatreflecttheneedsofat-riskpopulations.2,6Thiscasestudyoffersamodelforcommunityhealthcenterswithdentaldepartmentstofollow.

FQHCs with a dental component are a primarysafety-net solution for vulnerable populations andhelpdecreasethebarriersandinequitiesat-riskpop-ulations face in accessing and utilizing oral healthcare.7-9ThemissionofFQHCsistoprovideprimarycare to vulnerable populations in underserved ar-


eas.7 TheCenters forDiseaseControl andPreven-tion(CDC)maintaintherearesignificantoralhealthdisparities related to socioeconomic status, racialand ethnic groups, geographic locations, age, andgender.10AccordingtotheCDC,oralhealthdispari-tiescontinuetoprogressintheU.S.10Socioeconomicfactorscontributingtothesedisparitiesincluderace(non-Hispanic Blacks, Hispanics, American IndiansandAlaskan natives), age and education. Childrenages2to4and6to8,whoareBlack,non-HispanicandMexicanAmericanhavetwicetheamountofde-cayaswhiteNon-Hispanics.11Thoseadultswithlessthan a high school education aged 35 to 44 have3-timesthedecayascollege-educatedadults.11Ad-ditionally,thissamegrouphas3-timestheamountofdestructiveperiodontaldisease.11

David Satcher, Surgeon General of the U.S., is-sued theOralHealth inAmerica -AReport of theSurgeonGeneralmorethanadecadeago,whichre-vealedgapsinaccesstooralhealthcare,suggestingthatAmericansdonotbenefitequallyfromimprove-ments inhealthcare.12-14ThegoalsHealthyPeople2020establishedundertheleadershipoftheFederalInteragencyWorkgroupincludeimprovingqualityoflifewhilelivingfreeofpreventablediseases,attain-inghealthequalityforallpopulationsegments,pro-motingenvironmentswhichareconducivetohealth,both social and physical, and encouraging healthybehaviorsthroughallstagesoflife.6Dentaldepart-ments located in FQHCs play a critical role in thesupportofthosegoalsbyreducingbarriersinobtain-ingoralhealthserviceshencecreatingabetterqual-ityoflifeforthoseindividualstheyserve.15,16

FQHCsaredocumentedleadersintreatingchronicdiseasesandreducinghealthdisparitieswhilemain-tainingaffordabilityofcare.8,17Theyarelocal,non-profitcommunityneeds-drivenhealthcareprovidersservinglowincome,medicalanddentalunderservedcommunities.Todate,FQHCshaveservedover20millionpeopleacross thecountrywith theprimarygoal to improveaccess tocare formillionsofpeo-pleregardlessoftheirinsurancestatusorabilitytopay.8Iowaishometo14FQHCs;ofthose,12havea dental component. FQHCs in the state of Iowaservedover180,000individuals,providinginexcessof 130,000 dental services in 2012.8,17 Ninety-fourpercentof Iowahealthcenter’spatientshavefam-ilyincomesatorbelow200%ofthefederalpovertyline.The federalpoverty levelguidelines issuedbytheDHHS,recordedbyyearintheFederalRegister,canbedefinedasthesetminimumamountofgrossincomeafamilyneedsforfood,clothing,transpor-tation, shelter and other necessities and assists indeterminingfinancialeligibilityforfederalprograms,includingdentalclinicsofFQHCs.18Thefederalgov-ernment defined the poverty level in 2007, for afamilyof4,at$20,650-thisnumber increasedto$22,350for2011.18,19

FQHCs provide a substantial safety net for bothprevention and emergent dental care for at-riskpopulations. FQHCs provide a slide-fee price scaleinwhichfeesvarydependingonaperson’sabilitytopay.Abilitytopayisbasedonannualincome,familysizeandU.S.federalpovertyguidelines.2Accesstooralhealthcareisoftenconstrainedbasedonfinan-cial barriers,where one resides, aswell as a per-son’sraceandethnicity.Oralhealthdisparitieswidenbyrestrictingaccesstocareforat-riskpopulations.These restrictions impair quality of life, and inflictunnecessarypainandsufferingoncommunities.20-24ThepresenceofdentalclinicsinFQHCsimprovesac-cess to care for low socioeconomic populations byminimizingthesebarriers.25

Utilizationreferstothedocumentedconfirmationthatpatientsareusingservices,aswellasthefre-quency and types of visits.26 Lack of utilization in-clude:26

1.Oralhealthliteracy2.Providerdistributionandavailability3.Financiallimitations4.Transportation,ruralversusurbanlocation5.Ethnicandculturalpreferences6.Healthrelatedcircumstances

FederallyqualifieddentalclinicsacceptMedicaidpa-tients,offerslide-feediscountsfortheuninsuredandprovidelanguageinterpretersalongwithtransporta-tion.25

Oneof thesehealth centers,which is located inDubuque,Iowa(populationof57,637),servesatri-stateregion includingIllinoisandWisconsinborderstates.27Accordingto internalstatistics,thishealthcenter provided services to over 6,000 patients,3,403 being medical and 3,497 dental. Of those,2,438(23%)wereMedicaid,3,018(42%)wereun-insuredand815werehomelesspopulation.

Thepurposeofthisexploratorystudywastode-scribethechangeinutilizationfornumberandtypeof visits for Medicaid, uninsured and privately in-suredpatientsofCrescentCommunityHealthCen-ter’sdentaldepartmentforthefiscalyearsof2007to2008through2011to2012.Thisreportprovidesdescriptivestatisticsbasedon10oralhealthperfor-manceindicators,developedbyNationalQualityFo-rum,HealthyPeople2020,HRSA,MaternalandChildHealth Bureau, Health Systems Capacity IndicatorandCrescent’sdentalmanagement(TableI).

Objective of Report

Theobjectiveofcompilingretrospectivedatawasto establish benchmarks for internal and externalquality for dental practice management. InternalQualityismeasuredas:


• Identifyoralhealthperformanceindicatorsmostapplicable to Crescent Community Health Cen-ter’sdentaldepartment

• Attainingbaselinemeasures• Developwaystoimproveonclinicaloutcomes• Assess benchmarks for provider performanceandproductivity

• Recognizeareasforqualityimprovement• ExternalQuality

Developer Measure/Goal Numerator Denominator

#1:HealthyPeople2020OH-11,NationalQualityForum

Increasethepercentofpatientswhoreceiveoralhealthservicesinamea-surementyearatFQHCs

Totalnumberofunduplicat-eddentalpatientsreceivingatleastoneD-codeproce-

dure

TotalnumberofallD-codeprocedures

#2:HealthPeople2020:OH-8,OH-14DeltaDentalNationalQualityForum#1334

Increasetheproportionadultsandchildrenwhoreceivepreventiveservicesinameasurementyear

Totalnumberofpreventiveservicesbypatientsaged(0-21)andthenby(22>)

Totalnumberofpreventiveservicesbyallagegroups

#3:HRSAIncreasepercentofseal-antsinameasurementyearbyages(6-21)

Totalnumberof(D1351)sealantsbyages(6-21)

TotalnumberofD-codeproceduresbychildrenage

category(6-21)

#4:MaternalChildHealth,HealthSystemsCapacityIndicator#7b

Increasepercentofdentalproceduresbychildrenage(6-9)insuredbyMedicaidwhoreceivedanydentalserviceinameasurement

year

Totalnumberofdentalproceduresbychildrenage(6-9)insuredbyMedic-aidreceivinganyD-code

procedure

Totalnumberofdentalprocedurebychildrenage(6-9)ofallpayertypesreceivinganyD-codepro-

cedure

#5:HealthyPeople2020OH-1.1,NationalQualityForum

Reducethenumberofchildrenaged(3-5)withrestorativeorextractionprocedurewhileincreasingpreventiveproceduresina

measurementyear

Totalnumberof(3-5)yearoldswhoreceived,preven-tive,orrestoratives,orex-tractions,orotherD-code

procedures

Totalnumberof(3-5)yearoldswhoreceiveanyD-

codeprocedure

#6:HealthResourcesSer-vicesAdministration

Increasepercentofpa-tientsgreaterthanorequalto18yearsofageinthetargetpopulationwho

receivedD0150inamea-surementyear

Totalnumberofpatients18andolderwhohadacom-prehensiveexam(D0150)

Totalnumberofpatientsofallageswhohadacom-prehensiveexam(D0150)

procedure

#7:CrescentCommunityHealthCentermanage-ment

Percentofdentalproce-duresbyprovider

Totalnumberofproceduresbyhygienistordentist

Totalnumberofproceduresbyallproviders

#8:HealthPeople2020OH:7

Increasetheproportionofdentalpatientsages(2-17)thathadapreventivepro-cedureinameasurement

year

Totalnumberofpreventiveproceduresby(2-17)years

oldTotalnumberofpreventiveproceduresbyallages

#9:NationalQualityForum#1388

IncreasethepercentageofMedicaidpatientsaged(2-21)yearswhohadatleastonedentalprocedureinameasurementyear

Numberofdentalproce-duresforchildrenaged(2-21)insuredbyMedicaid

Totalnumberofdentalpro-ceduresforall(2-21)yearoldsforallpayertypes

#10:Crescentdentalman-agementHealthyPeople2020OH:3.2

IncreasePercentageofpreventivevisitswhile

decreasingrestorativeandurgentcareproceduresforpatients65>inamea-

surementyear

Numberofpreventive,restorative,thenurgentproceduresbypatients

aged65>

Totalnumberofproceduresbypatientsaged65>

TableI:OralHealthIndicators

• EnsuretransparencytoHRSA,Medicaidandoth-ergrantors

• Educating Crescent Community Health Centercommunityondentalutilization

• Establishdataforgrantwriting• Demonstrate to stakeholders that health careservicesarebeingutilized


reSultS

Toaddresstheresearchobjective(basedonthe10oralhealthindicatorsshowninTableI),datade-scribes thechange inutilizationofpreventive, re-storativeandurgentcareproceduresforMedicaid,uninsuredandprivatelyinsuredpatientsforspecificage groups at the time of services fromCrescentCommunityHealthCenter’sdentaldepartment for


ThisdescriptiveanalysisusedquantitativeprimarydataobtainedthroughthisIowahealthcenter’sad-ministrative records to capture longitudinal trendsintypeandnumberofpatientsutilizingspecificoralhealthservicesforfiscalyears2007to2008throughfiscal year 2011 to 2012. Change in utilization forspecific typesof visits forMedicaid,uninsuredandprivatelyinsuredpatientsofthisIowahealthcenter’sdentaldepartmentwereexplored.TableIillustratestheoralhealthperformanceindicators,andthede-velopersthisreportwasbasedon.

FiscalyearsforthisIowahealthcenterwerede-finedasNovember1 throughOctober 31 for eachmeasurementyear, (e.g.onefiscalyearbeginNo-vember1,2007andendsOctober312008of thefollowing year). Two electronic medical recordsHealthProandCentricitywere linked tooralhealthprocedures, demographic characteristics, such asrace, gender, payer type, provider, and age at thetimeofservice.DataweretransferredtoMicrosoft™Excel®spreadsheetthentoIBM®SPSS®19,captureddental population characteristics, and oral healthservicedata.TheMassachusettsCollegeofPharma-cyandHealthScienceUniversityInstitutionalReviewBoardapprovedthisstudy.

All records were de-identified to protect patientconfidentiality and uphold HIPAA standards. Thedataincludedthosepatientswhohadatleast1den-tal visit to the Iowahealth center’s dental depart-ment. Categorical variables such as age, providertype, race,gender,payer typeandprocedure typewerecollapsedforanalysisinSPSS.Agerangeswereconstructedbasedonthe10oralhealthperformanceindicatorsmeasured(TableI).Additionalcategoriesincludedpayertype(Medicaid,uninsured,privatelyinsured),providertype(dentalhygienistordentist),gender (male or female) and race (Caucasian, Af-ricanAmerican,Hispanic,morethanonerace,andOther).ProceduralD-codesweredividedinto4maincategories(preventive,restorative,urgentcareandother). Three additional D-code categories weredefined for comprehensive exams, extractions andsealants.TheAmericanDentalAssociation(ADA)de-velopedauniversaldentalcodingsystemfordentalproceduresandnomenclature(CDT)toensureuni-formityandconsistencyintherecordingandbillingfordentalprocedures.28

thefiscal years of 2007 to2008 through2011 to2012(TablesIItoXI).Datawerepluggedintotheformulasandresultsreportedasfollows.

Oral health indicator #1 - National Quality Forum, Healthy People 2020 OH-11 goal: In-crease the proportion of patients who receive atleastonedentalvisit inameasurementyearatafederallyqualifiedhealthcenter.

Overall forfiscal year2007 to2008 to2011 to2012 there were n=81,673 procedures with 21%(n=17,167)beingunduplicatedpatients.Thisshowsanincreaseinunduplicatedpatientsof87%overall(n=1844). Figure 1 shows patient utilization per-centageswithpreventiveservicesaveraging46%,restorative18%,urgentcare22%andotherproce-dures14%.Fromfiscalyear2007to2008tofiscalyear2011to2012,therewasanincreaseof106%for preventive, 87% increase in restorative and a25%increaseinurgentcareservices.

Oral health indicator #2 - Healthy People 2020, Oral Health-14, National Quality Forum #1334 goal: Increase the proportion of adults(aged 22 and older) and children (aged 0 to 21)whoreceivepreventiveinterventionsinameasure-mentyear.

Theproportionofpatientsinbothagegroupswhoreceived preventive procedures remained stableoverthe5-yearmeasurementperiod.Datashowedpreventive procedures more than doubled fromyear1toyear5foragegroup0to21fromn=2,407to n=4,850 and age group 22> from n=2,098 ton=4,415.Theoverall5-yearaverageforages0to21was53%andforages22>was47%ofallser-viceswerepreventiveinnature.

Oral health indicator #3 - Health Resourc-es and Services Administration goal: Increasethepercentofchildrenbetween6and21yearsofagewhoreceivedatleastonesealant(D1351)inameasurementyear.

While results show sealants increased fromn=206 ton=376, theproportionof sealantplace-mentcomparedtoallotherproceduresutilizedre-mainedunchanged,averaging7%overthe5years.These results should encourage the providers ofthishealthcentertoadvocateandeducateparentsonthepreventivebenefitsofsealantsforthisagegroup.

Oral health indicator #4, Health Systems Ca-pacity Indicator #7b goal:Increasethepercentofdentalvisitsbychildren(ages6to9)insuredbyMedicaidreceivinganydentalserviceinameasure-mentyear.


Goal:Toincreasetheproportionofpatientswhoreceiveatleast1dentalvisitinameasurementyearataFQHC

FiscalYear Unduplicatedpatients/totalnumberofallD-codeprocedures

2007 2,137/11,470(19%)2008 2,648/13,360(25%)2009 3,498/18,185(25%)2010 4,903/19,007(20%)2011 3,981/19,651(20%)

TableII:Oralhealthindicator#1

Goal:Increasetheproportionofadultsandchildrenwhoreceivepreventiveinterventionsinameasure-mentyear

FiscalYear Childrenaged0to21*

Adults22andolder**

2007 2,407/4,505(53%)

2,098/4,505(47%)

2008 3,264/5,891(55%)

2,627/5,891(45%)

2009 4,571/9,225(50%)

4,654/9,225(45%)

2010 4,844/9,118(53%)

4,274/9,118(47%)

2011 4,850/9,265(52%)

4,415/9,265(48%)

*Totalnumberofpreventiveservicesbypatientsages0to21/totalnumberofpreventiveservicesbyallagegroups**Numberofpreventiveservicesbypatientsages22>/totalnumberofpreventiveservicesbyallagegroups

TableIII:OralHealthIndicator#2

Goal:Increasethepercentofchildrenages6to21whoreceivedatleast1sealant(D1351)inamea-surementyear

FiscalYear

Totalnumberof(D1351)sealantsbyages(6-21)/TotalnumberofD-codeproceduresbychildren

aged(6-21)2007 206/2,767(7%)2008 317/3,806(8%)2009 360/4,996(7%)2010 413/5,662(7%)2011 376/5,445(7%)

TableIV:OralHealthIndicator#3

Goal:Increasethenumberofdentalvisitsbychildren(ages6to9)insuredbyMedicaid

FiscalYear Medicaid Uninsured PrivatelyInsurance

2007 86% 8% 6%2008 83% 11% 6%2009 84% 9% 7%2010 89% 7% 4%2011 84% 10% 6%

TableV:OralHealthIndicator#4

Medicaidutilization for thisagegroupremainedstable averaging 85%, while the uninsured aver-aged9%andprivately insuredaveraged6%.Thegoaltoincreasethepercentofdentalvisitsbychil-dren (ages 6 to 9) insured by Medicaid receivinganydentalserviceinameasurementyearwasnotmet,showing2%decreaseinMedicaidfrommea-surement year 1 to year 5 and a 2% increase inuninsuredduringthissamemeasurementperiod.

Oral health indicator #5, developed by Na-tional Quality Forum, Healthy People 2020 OH-1.1 goal: Reduceproportionofchildren(ages3 to 5) receiving restorative or extraction proce-dures,whileincreasingpreventiveproceduresinameasurementyear.

Fromfiscalyear2007to2008tofiscalyear2011to 2012, preventive procedures increased fromn=545 to n=865, an upturn of 59%. Restorativeprocedures increased 56%, while extractions de-creased by 40%. Of the n=81,673 procedures ofthetotalpopulation,8%(n=6,269)werefromtheagegroup3 to5.Of those,87%(n=5,479)wereMedicaid,uninsuredat5.5%(n=344),andprivate-lyinsured7%(n=446).

Oral health indicator #6, developed by Health Recourses and Services Administra-tion:Percentandtypeofpatients18yearsofageandolderwho receivedacomprehensive (D0150)examinameasurementyear.

Thisbenchmarkshowedthat,fora5-yearmea-surementperiod,therewasa27%increaseincom-prehensiveexamsfortheagegroup18>.Intotal,there were n=54,348 procedures over the 5-yearmeasurement period for ages 18>. Of those, 6%(n=3,383)werecomprehensiveexams.Payertypebreaksdown into37%(n=1,248)beingMedicaid,57% (n=1,931) uninsured and 6% (n=204) pri-vately insured. For gender, females accounted for59% (n=2,011), and males 41% (n=1,372). Forraces,Caucasianaccountedfor82%(n=2,752),Af-

ricanAmerican8%(n=283),Hispanic6%(n=216),morethanonerace1%(n=30),andcombinedrac-es3%(n=102).


Goal:Reduceproportionofchildren(ages3to5)receivingrestorativeorextractionprocedures,whileincreasingpreventiveproceduresinameasurementyearTotalnumberofpreventive,restorative,extractionorotherD-codeservicesbyages3to5/TotalnumberofD-codeservicesbyages3to5FiscalYear Preventive Restorative Extractions Other2007 545/914(60%) 110/914(12%) 32/914(4%) 227/914(25%)2008 677/1,085(62%) 129/1,085(12%) 17/1,085(2%) 262/1,085(24%)2009 915/1,442(63%) 171/1,442(12%) 28/1,442(2%) 328/1,442(23%)2010 886/1,461(61%) 203/1,461(14%) 22/1,461(2%) 350/1,461(24%)2011 865/1,367(63%) 172/1,367(13%) 19/1,367(1%) 311/1,367(23%)

TableVI:OralHealthIndicator#5

FiscalYearNumberofcomprehensiveexamsforages18>/totalcomprehensive

examsofallages2007 614/958(64%)2008 495/807(61%)2009 835/1,340(62%)2010 662/1,020(65%)2011 777/1,207(64%)

TableVII:OralHealthIndicator#6

Benchmark:Numberofpreventiveservicesforages(2to17)inameasurementyearTotalnumberofpreventiveservicesforages(2to17)/TotalnumberofpreventiveservicesforallagegroupsFiscalYear Preventiveprocedures/totalprocedures2007 2,164/3,321(65%)2008 2,920/4,522(64%)2009 3,926/5,786(68%)2010 4,279/6,590(65%)2011 4,271/6,146(69%)

TableIX:OralHealthIndicator#8

Oral health indicator #7 endorsed Crescent Community Health Centers dental manage-ment:Percentandnumberofdentalservicespro-videdbyprovidertypeinameasurementyear.

For fiscal years 2007 to 2008 through 2011 to2012,thedentalhygienedepartmentprovided39%ofallD-codeservicesand61%byadentistoverthe5-yearmeasurementperiod.

Oral health indicator #8, guided by Healthy People 2020 OH: 7: Number of dental patientsages2to17thathadapreventiveprocedureinameasurementyear.

Results of this benchmark showed preventiveutilization for this age group increased by 97%(n=2,164 to n=4,271 procedures) frommeasure-mentyear1,fiscalyear2007to2008toyear5fis-calyear2011to2012.

Oral health indicator #9 endorsed and de-signed by National Quality Forum #1388:Per-centofMedicaidpatientsages2to21thathadatleast 1 dental procedure during a measurementyearshows.

This benchmark showedMedicaid patients ages2 to21 thathadat least1dentalproceduredur-ingameasurementyearshowed(outofn=30,154procedures), 78%were Medicaid compared to allother payer types,with 16%were uninsured and6% were privately insured. Although the percentof Medicaid patients for this age group remainedstableoverthis5-yearmeasurementperiod,resultsrevealed 16% of patients in this age group wereuninsured.

Oral health indicator #10 refers to Healthy People 2020 OH: 3.2: Number of patients ages65 to 75with untreated coronal caries in amea-surement year. This Iowa’s health center dentalmanagement modified this indicator, to increasepreventiveprocedureswhiledecreasingrestorative

andurgentcareproceduresfortheagegroup(65>)frompreviousmeasurementyears.

Figure2givesoverall5-yeardataforagecatego-ry(65>),showingpreventiveproceduresaveraged39%(n=1,524),restorative20%(n=788),urgentcare25% (n=978), andother15% (n=602). Thegoal to increase preventive procedures while de-creasingrestorativeandurgentcareproceduresforthisagegroupof(65>)frompreviousmeasurementyearsisbeingmet.Ourfindingsshowed,therewasanincreaseofn=216or140%forpreventivepro-cedures,restorativeshowedanincreaseofn=61or56%, while urgent care procedures decreased by


PercentandnumberofservicesbyprovidertypeinameasurementyearTotalnumberofD-codeservicesperformedbyeachprovider/TotalnumberofD-codeservicesFiscalYear DentalHygienist/TotalProcedures Dentist/Totalprocedures2007 2,965/11,470(26%) 8,505/11,470(74%)2008 4,819/13,360(36%) 8,541/13,360(64%)2009 6,608/18,185(36%) 11,577/18,185(64%)2010 8,467/19,007(45%) 10,540/19,007(55%)2011 8,706/19,651(44%) 10,945/19,651(56%)

TableVIII:OralHealthIndicator#7

PercentageofMedicaidpatients(aged2to21)havingatleastonedentalprocedureduringameasurementyear

FiscalYear Medicaidprocedures/totalPro-cedures

Uninsuredprocedures/totalprocedures

PrivateInsuredprocedures/to-talprocedures

2007 3,030/3,827(79%) 679/3,827(18%) 118/3,827(3%)2008 4,049/5,177(78%) 831/5,177(16%) 297/5,177(6%)2009 5,178/6,724(77%) 1,157/6,724(17%) 389/6,724(6%)2010 6,033/7,417(81%) 1,039/7,417(14%) 345/7,417(5%)2011 5,355/7,009(76%) 1,080/7,009(15%) 574/7,009(8%)

TableX:OralHealthIndicator#9

Goal:Increasepreventiveprocedureswhiledecreasingrestorativeandurgentcareproceduresfortheages(65>)frompreviousmeasurementyears

FiscalYearTotalpreventiveservicesforages(65>)/Totalservicesfor

agegroup(65>)

Totalrestorativeservicesforagegroup(65>)/Totalservicesfor

agegroup(65>)

Totalurgentcareservicesforagegroup(65>)/Totalservicesfor

agegroup(65>)2007 154/611(25%) 109/611(18%) 210/611(36%)2008 247/734(33%) 153/734(21%) 219/734(30%)2009 413/895(46%) 163/895(18%) 181/895(20%)2010 340/794(43%) 193/794(24%) 173/794(22%)2011 370/858(43%) 170/858(20%) 195/858(23%)

TableXI:OralHealthIndicator#10

n=15ora7%reduction.Ofthosevisits,81%wereuninsured,17%Medicaidand2%privatelyinsured.

Overall,thiscommunityhealthcenter’sdentalde-partmentprovided50%ofprocedures(n=40,723)toMedicaid,44%(n=36,033)wereuninsuredand6%wereprivatelyinsuredpatientsoverthe5-yearsmeasured.The racialbreakdownshowedanaver-ageof75%Caucasian,13%AfricanAmerican,7%Hispanics,2%morethanoneraceand3%forother.Forgender,femalesreceivedn=44,266procedures,whilemalesutilizedn=37,407.

DiScuSSion

Although there is little consensus among den-tal professionals on which performance measures

shouldbeadopted,theoralhealthindicatorschosenforthisreportexpressedthephilosophyofthedentalmanagementofCrescentCommunityHealthCenter.The10oralhealthindicators,establishedbyHealthyPeople2020,HRSA,MaternalHealth,NationalQual-ity Forum,DHHS,andCrescentCommunityHealthCenter’s management were chosen based on thecommitment these developers have to improvingoralhealthoutcomesforvulnerablepopulations.Theobjectiveofcollectingdataonthe10measuresweretoshowevidenceofproviderperformance,account-abilitytostakeholdersandprovidethebenchmarksforqualityenhancementandultimatelyimproveoralhealthoutcomesforat-riskpopulations.

Thedatashowedtherewasan increase innum-ber of unduplicated patients (86%), aswell as an


Figure1:TypeofDentalProceduresUtilizedforFiscalYear2007to2008ThroughFiscalYear2011to2012

0% 10% 20% 30% 40% 50% 60%

FiscalYear2007

FiscalYear2008

FiscalYear2009

FiscalYear2010

FiscalYear2011

PercentPreventive

PercentRestorative

PercentUrgent

PercentOther

increaseof71%inthenumberofproceduresfromfiscalyear2007to2008tofiscalyear2011to2012.Thedentalhygienedepartmentprovidedsignificantimpactregardingpreventiveservicesfororalhealthperformanceindicators#2,#3,#5,#6,#7,#8and#10. Utilization for preventive procedures showedan overall increase of 106%, restorative increasedby87%andurgentcareby26%.Genderandageat the time of service remained stable in relationtoproceduretype.Forpayertype,Medicaidutiliza-tiondeclinedslightlywhiletheuninsuredpopulationgrew.ThisresultimpliesCrescentCommunityHealthCenterisreachingtheuninsuredpopulationsofthiscommunity as affordability to oral health care in-creasesaccessandreducesbarrierstoservices.

Regarding oral health indicator #3, sealant uti-lization needs to increase. The PewCenter report,Falling Short: Most States Lag on Dental Sealants,providedastrongmessagethatmoststatesareinef-fectivewhenitcomestoprovidingsealantstochil-dren.29Pewdatashowedoutof50states,onlyNorthDakota,Maine,andNewHampshirewheregivenan“A”grade forsealantplacement.Majorityofstatesreceiveda“C”orlower.29Whiledentalhygienistsanddentistsunderstandtheimportanceofsealantplace-ment,ourdatashowedashortfallofsealantutiliza-tionforthiscommunityhealthcenter.Thesefindingssuggestthenecessityforincreasedadvocacy,diag-noses, treatment planning, and educating parentsontheimportanceofthebenefitsoftimelysealantplacement.30 In a recent NewHampshire study by

Chietal,theproportionofsealantplacementcom-paredtoallotherproceduresaveraged12%.31Theresultsof thecurrentstudyshowedonly7%ofallproceduresweresealants,roughlyhalffoundinChi’sstudy.Withapproximately80%ofallchildrenunderthe age of 21 having Medicaid and 10% privatelyinsured,thiscommunityhealthcenterappearstobefallingshortwhenitcomestosealantapplication.

The goal to reduce the proportion of children(ages3to5)receivingrestorativeorextractionpro-cedures, while increasing preventive procedures,showedmeasurablechange.Preventiveproceduresincreased by 59% (n=545 to n=865) and restor-ativeproceduresincreased56%(n=110ton=172).Extractions showed the least amount of change at17%(n=117ton=137)overthe5yearsmeasured.Thesefindingsindicate,byreducingbarriers,accessto preventive utilization for Medicaid childrenmayreplacemoreinvasiveprocedures.32Again,theCres-cent Community Health Center dental hygienists’roleasapreventivespecialistinfluencesthechangefrom extractions to restorative through preventiveintervention.Hygienistsprovideandtrackoralhealtheducation,nutritionalguidance,andfluorideplace-ment,leadingtoimprovedoralhealthoutcomesforthisagegroup(3to5).

Additionalresearchisneededtoassessthenum-berofpatientswhoreceivedacomprehensiveexamcomparedtothenumberofpatientscompletingtheirtreatmentinameasurementyear(oralhealthindica-


Figure2:AgeCategory65andOlderbyProcedureforFiscalYear2007to2008ThroughFiscalYear2011to2012

0% 10% 20% 30% 40% 50% 60%

FiscalYear2007

FiscalYear2008

FiscalYear2009

FiscalYear2010

FiscalYear2011

OtherProcedures

UrgentCare

Restorative

Preventive

tor#6,patientsage18>).Theprevalenceofunmetdentalneedsisanongoingproblemforlow-incomepopulations, placing themat risk of advanced oralhealthconditions.33Thisdentaldepartmentneedstouse this data todevelopagoal to complete treat-mentplansbaseon thenumberof comprehensiveexamsperformed.Developingaplantotrackincom-pletetreatmentplanscanfacilitatebetterhealthout-comesforCrescentCommunityHealthCenterdentalpatients.

Most importantly, results of this study revealedthe contribution dental hygienists make to thishealthcenter,providingcloseto40%ofallservices.Overall, preventive utilization has increased from39%to47%,andurgentcareutilizationshowedaslightdecline from15%to13%.Dentalhygienistsat this FQHC play a critical role in the success ofpatientoralhealthoutcomes.Thedentalhygienist’sroleinoralhealthpromotioninthisclinicencompassamultitudeofservices:oralcancerscreenings,nu-tritionalguidance,bloodpressurescreenings,smok-ingcessation,thedeliveryofperiodontalcare,andcounseling on the connection between oral healthandgeneralhealthforat-riskpopulations.Evidenceshowsthatdentalhygienistsplayanintegralpartinthesuccessinmeetingtheoralhealthgoalssetforthinthisreport.

IdentifyinguninsuredchildrenshouldbeapriorityofCrescentCommunityHealthCenter.EventhoughthepercentMedicaidpatients(ages2to21)receiv-

ingatleast1dentalserviceinameasurementyearremainedstable,therewere16%ofchildreninthisage group who were uninsured. This data shouldencourage this community health center’s dentaladministration to educate and facilitate enrollmentof this uninsured child population to an appropri-atestatechildreninsuranceprogram,asthisshouldtranslate into increased utilization of all proceduretypesforthisagegroup.34

Thecombinationsofbarrierssuchaspoverty,liv-inginaruralcommunity,paucityofproviders,pro-vider acceptance, add to oral health inequities.15,35ThisIowahealthcenterprovidesasafety-netforbothpreventionandurgentdentalcareneedsforpatientsexperiencingutilizationbarriers.Given thenumberof urgent care visits (n=16,936 over a 5-year pe-riod),thisdataprovidesacriticaltooltosupportthepremise this Iowa community health center’s pro-vision of caremay affect local hospital emergencydepartments.36 The goal for Crescent CommunityHealthCentersistoprovidecontinuedaccesstooralcarebyreducingbarriersthatpreventequityinoralhealthforpeopleoflowsocioeconomicstatus,thusreducing the need for emergency department vis-its.36

Limitations

Thelimitationsofthisreportlayinthelackofstan-dardizationoforalhealthmeasuresamongfederallyqualified health centers with a dental component.


concluSion

Providing baseline data is instrumental in ana-lyzing deficiencies as well as successes. Theseoral health indicator measures created a jumpingoff point for this Iowa health center and providedamodel for other dental departments of federallyqualified health centers to adopt. Outcome mea-suresprovidethetoolstocreateandsecuregrantsfordentalprograms;theyshowtrendsandbench-marksforestablishingfuturegoalsthatimproveoralhealthoutcomesforthepatientsweserve.Baselinemeasuresareatool,whichcanpromoteefficiencyinplanningforfutureyears.Theyprovidecriticaldatafor policy change. Measures promote collaboration

acknowleDgmentS

TheauthorsthankJulieWoodyard,ExecutiveDi-rectorofCrescentCommunityHealthCenterforherassistance in choosing the outcomemeasuremostmeaningfultoCrescent’sdentalmanagementandtoMaryBrimeyer,CFOofCrescentCommunityHealthCenterforherassistanceintheextrapolationofdatafromHealthProandCentricityelectronicmedicalre-cords. I would also like to acknowledge all dentalproviderswhoservethepoorfortheyaretruecham-pionsoforalhealthpromotionandequity.

Without integrationoforalhealthmeasuresamonghealthcenters,thereisnomodetocomparediscretemeasureswithotherdentaldepartments.Outcomemeasuresevaluatedherearenotmeanttobegener-alizabletoprivatepracticesettingsbuttobeusedtoimproveIowacommunityhealthcentersdentalpro-grams.Thestrengthofthisdataisthatisprovidesothercenterswiththemodeltocompareanddesignmeasuressignificantandmeaningfultotheirdentalpopulation.

between community health centers and lastly pro-videevidencetoourcommunity,stakeholders,pro-fessionalcolleagues,andlocalbusinessleadersthebenefitsofhavingacommunityhealthcenterwithadentalcomponentintheircommunity.

Sharon Grisanti, RDH, MCOH, is Dental Program Director of Crescent Community Health Center, a FQHC located in Dubuque, Iowa. Linda Boyd, RDH, RD, EdD is Dean and Professor, Forsyth School of Dental Hygiene at MCPHS University. Lori Rainchuso, RDH MS is the Interim Graduate Program Director at Forsyth School of Dental Hygiene, MCPHS University.

1. ResearchcenterADHA.AmericanDentalHygienists’Association[Internet].2014[cited2014March2].Available from: http://www.adha.org/research-cen-ter

2. U.S. Department of Health and Human ServicesHealthResourcesandServicesAdministration[Inter-net].Rockville(MD):HealthResourcesandServicesAdministration;2015[cited2015July14].Availablefrom:http://www.hrsa.gov/index.html.

3. U.S. Department of Health and Human ServicesHealthResourcesandServicesAdministration.Healthcenterdataandreporting[Internet].Rockville(MD):HealthResourcesandServicesAdministration;2015[cited2015July14].Availablefromhttp://bphc.hrsa.gov/datareporting/.

4. U.S.DepartmentofHealthandHumanServicesOf-fice of Disease Prevention and Health Promotion.Healthypeople2020 [Internet].Washington (DC):OfficeofDiseasePreventionandHealthPromotion;2015 [cited2015 July 14].Available from:http://www.healthypeople.gov/2020/default.

5. NationalQualityForum[Internet].Washington(DC):2015 [cited2015 July 14].Available from:http://www.qualityforum.org/Home.aspx.

6. HealthyPeople2020-ImprovingthehealthofAmer-icans.U.S.DepartmentofHealthandHumanSer-vicesOfficeofDiseasePreventionandHealthPromo-tion.2012.

7. GroverJ.Issuesfacedbycommunityhealthcenters.JCalifDentAssoc.2009;37(5):339-343.

8. RiedyCA,LyKA,YbarraV,MilgromP.AnFQHCre-searchnetworkinoralhealth:enhancingthework-force and reducing disparities. Public Health Rep.2007;122(5):592-601.

9. ShiL,LebrunLA,TsaiJ.Assessingtheimpactofthehealthcentergrowthinitiativeonhealthcenterpa-tients.PublicHealthRep.2010;125(2):258-266.

10.CentersforDiseaseControlandPrevention.Promot-ingoralhealth: interventions forpreventingdentalcaries,oralandpharyngealcancers,andsports-relat-edcraniofacialinjuries.areportonrecommendationsofthetaskforceoncommunitypreventiveservices.MMWRRecommRep.2001;50(RR-21):1-13.

11.Centers forDiseaseControlandPrevention(CDC).Dental caries in rural Alaska native children —Alaska, 2008. MMWR Morb Mortal Wkly Rep.2011;60(37):1275-1278.

referenceS


12.U.S.DepartmentofHealthandHumanServices.OralhealthinAmerica:areportofthesurgeongeneral.U.S.DepartmentofHealthandHumanServices,Na-tionalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth.2000.

13.KleinmanDV. The future of the dental profession:PerspectivesfromoralhealthinAmerica:areportofthesurgeongeneral.JAmCollDent.2002;69(3):6-10.

14.OralhealthinAmerica:areportofthesurgeongen-eral.JCalifDentAssoc.2000;28(9):685-695.

15.MacDowellM,GlasserM,FittsM,NielsenK,HunsakerM.AnationalviewofruralhealthworkforceissuesintheUSA.RuralRemoteHealth.2010;10(3):1531.

16.FisherMA,MascarenhasAK.AcomparisonofmedicalanddentaloutcomesforMedicaid-insuredandunin-suredMedicaid-eligiblechildren:aU.S.population-basedstudy.JAmDentAssoc.2009;140(11):1403-1412.

17.Federallyqualifiedhealthcenter(FQHC)resources.RuralAssistantCenter[Internet].2012[cited2012October30].Availablefrom:https://www.raconline.org

18.FamiliesUSA.Thevoiceforhealthcareconsumers[Internet].Washington(DC):2015[cited2015July14].Availablefrom:http://www.familiesusa.org/.

19.U. S. Department of Health and Human Services.2011HHSpovertyguidelines[Internet].Washington(DC):2012February2[cited2012February2].Avail-able from: http://aspe.hhs.gov/poverty/11poverty.shtml.

20.BisgaierJ,CuttsDB,EdelsteinBL,RhodesKV.Dis-paritiesinchildaccesstoemergencycareforacuteoralinjury.Pediatrics.2011;127(6):e1428-1435.

21.BernabéE,HobdellMH.Is incomeinequalityrelat-edtochildhooddentalcariesinrichcountries?JAmDentAssoc.2010;141(2):143-149.

22.Flores G, Tomany-Korman SC. Racial and ethnicdisparities inmedical and dental health, access tocare,anduseofservicesinUSchildren.Pediatrics.2008;121(2):e286-298.

23.DyeBA,BarkerLK,LiX,LewisBG,Beltran-AguilarED. Overview and quality assurance for the oralhealthcomponentofthenationalhealthandnutri-tionexaminationsurvey(NHANES),2005-08.JPub-licHealthDent.2011;71(1):54-61.

24.DyeBA,Thornton-EvansG.Trendsinoralhealthbypovertystatusasmeasuredbyhealthypeople2010objectives.PublicHealthRep.2010;125(6):817-830.

25.GreenbergBJ,KumarJV,StevensonH.Dentalcasemanagement:increasingaccesstooralhealthcareforfamiliesandchildrenwithlowincomes.JAmDentAssoc.2008;139(8):1114-1121.

26.Crall JJ. Access to oral health care: profes-sional and societal considerations. J Dent Educ.2006;70(11):1133-1138.

27.U.S. Census Bureau. FAQs [Internet]. https://ask.census.gov/.Accessed10/27/2012,2012.

28.AmericanDentalAssociation.Home-AmericanDen-tal Association [Internet]. Chicago, (IL): AmericanDentalAssociation;2015[cited2015July17].Avail-ablefrom:http://www.ada.org/.

29.Pew report finds majority of states fail to ensureproperdentalhealthandaccesstocareforchildren.The Pew Charitable Trusts [Internet]. 2013 [cited2013May5].Availablefrom:http://www.pewtrusts.org/news_room_detail.aspx?id=57449

30.TellezM,GraySL,GrayS,LimS, IsmailAI.Seal-antsanddentalcaries:dentists’perspectivesonev-idence-based recommendations. JAmDentAssoc.2011;142(9):1033-1040.

31.ChiD,MilgromP.Preventivedentalserviceutilizationformedicaid-enrolledchildreninNewHampshire:acomparisonofcareprovidedbypediatricdentistsandgeneral dentists. J Health Care Poor Underserved.2009;20(2):458-472.

32.WatsonMR,ManskiRJ,MacekMD.Theimpactofin-comeonchildren’sandadolescents’preventivedentalvisits.JAmDentAssoc.2001;132(11):1580-1587.

33.DavisMM,HiltonTJ,BensonS,etal.Unmetdentalneedsinruralprimarycare:Aclinic-,community-,andpractice-basedresearchnetworkcollaborative.JAmBoardFamMed.2010;23(4):514-522.

34.WangH,NortonEC,RozierRG.EffectsoftheStateChildren’s Health Insurance Program on access todentalcareanduseofdentalservices.HealthServRes.2007;42(4):1544-1563.

35.KuthyRA,McKernanSC,HandJS,JohnsenDC.Den-tistworkforcetrendsinaprimarilyruralstate:Iowa:1997-2007.JAmDentAssoc.2009;140(12):1527-1534.

36.Smith-CampbellB.Emergencydepartmentandcom-munityhealthcentervisitsandcostsinanuninsuredpopulation.JNursScholarsh.2005;37(1):80-86.


Multi-drugresistant(MDR)bacteriasuchasmeth-icillin-resistant Staphylococci aureus (MRSA) haveevolvedfromhospital-acquiredinfectionstocommu-nity-acquired infections. Increasingly,MDR bacterialinfectionshavethepotentialtocrosstheboundariesofhospitalintensive-careunitstothosemostsuscep-tible.1-3Theglobalemergenceandacceleratedevolu-tionofMDRbacteriahasresultedinacallbyresearch-ersformoreeffectiveinfectioncontrolmeasuresinanattempttohalttheirdissemination.2,4

Ithas longbeen recognized that thesinglemosteffectivemeansofpreventingthespreadofdiseaseisproperhandhygienemeasureswhichincludestheuseof protective gloves.5-7 Beginning in 1986, govern-mentalorganizationsuchasCentersforDiseaseCon-trolandPrevention (CDC),andOccupationalSafety&HealthAdministration(OSHA)haverecommendedandmandatedrespectivelytheuseofutilityglovesaspartofdentalhealth-careproviders(DHCP)personalprotectiveequipment(PPE)topreventpercutaneousandchemicalinjuryduringsterilizationanddisinfec-tion procedures.8,9 Unlike disposable examinationgloves,utilityglovesarenotconsideredamedicalde-

EvaluatingUtilityGlovesasaPotentialReservoirforPathogenicBacteriaKathyL.Grant,RDH,BS;E.DonaldNaber,EdD;WilliamA.Halteman,PhD

AbstractPurpose:Thispilotstudysoughttodeterminetherateanddegreetowhichgram-negativeKlebsiellapneu-moniae,EscherichiacoliandPseudomonasaeruginosaandgram-positiveStaphylococcusaureusoccurredontheinsideofutilityglovesusedatUniversityofMaineatAugusta,DentalHealthPrograms’dentalhygieneclinic.Methods:Fivesteamautoclaveutilitygloveswererandomlyselectedtoserveascontrolandaconveniencesampleof10usedutilitygloveswereselectedfromthesterilizationarea.Asamplewascollectedfromapre-determinedsurfaceareafromtheinsideofeachsteamautoclaveutilitygloveandusedutilityglove.EachsamplewasusedtoinoculateaPetriplatecontaining2typesofculturemedia.Sampleswereincubatedat37ºCfor30to36hoursinaerobicconditions.Colonyformingunits(CFU)werecounted.Results: Confidenceintervals(CI)estimatedtherateofcontaminationwithgram-negativeK.pneumoniae,E.coliandP.aeruginosaontheinsideofsteamautoclaveutilityglovestoben=3395%CL[0.000,0.049],usedutilityglovestoben=70,95%CL[0.000,0.0303].Dataestimatedtherateofcontaminationwithgram-positiveS.aureusontheinsideofsteamautoclaveutilityglovestoben=35,95%CL[0.233,0.530],usedutilityglovestoben=70,95%CL[0.2730,0.4975].CulturemediaexpressedawiderangeofCFUfrom0toover200.Conclusion:Theriskofutilityglovecontaminationwithgram-negativebacteriaislikelylow.TheexpressedgrowthofS.aureusfromsteamautoclaveutilityglovescontrolsraisesquestionsabouttheeffectivenessandsafetyofgenerallyacceptedsterilizationstandardsforthegovernmentallymandateduseofutilitygloves.Keywords:pathogenicbacteria,infectioncontrol,utilitygloves,dentalhygieneThisstudysupportstheNDHRApriorityarea,Occupational Health and Safety: Investigatemethodstode-creaseerrors,risksandorhazardsinhealthcareandtheirharmfulimpactonpatients.

research

introDuction

viceandmanufacturingstandardsarenotregulatedbytheU.S.FoodandDrugAdministration.5,8,9UtilityglovesaremeanttoprotectDHCP’sfrompercutane-ous/chemical injuryratherthanameanstopreventcross-contaminationand/orcross-infection.5,8,9Thereisnouniversallyestablishedprotocolforthedonning,use,disinfectionandsterilization;protocolsarelarge-ly designed and implemented by dental hospitals,academic dental clinics andprivate dental practiceswith minimal guidance by those governmental andprofessionalagenciesthatrecommendandmandatetheiruse.

Areviewoftheliteraturedetailedtheevolutionofhandwashing and protective gloves as a means ofinfectioncontrol inhealthcare.Italsoanalyzedtheelements of disease transmission, the role of resi-dentandtransienthandfloraincross-contamination/cross-infection,andthetop5MDRbacteriaasapos-sibleunderestimatedreservoirforpathogenicbacte-ria.Whenutilityglovesareusedtocarryoutdisin-fectionandsterilizationprocedures,theyaredonnedwith bare hands. The written policy, which followsgovernmental guidelines, instructs “Utility gloves


mustbewashedwithantimicrobialsoap,rinsedandsprayedwithadisinfectantaftereachuse”shouldre-peated use be anticipated in the same day.10 Usedutilityglovesaresteamautoclavedattheendofeachdayat250poundspersquareinchfor20minutes.

The“cleanhand”techniqueimplementedfordon-ning and removing utility gloves requires multiplestepsandcanberepeatednumeroustimesduringaclinicalday,increasingtheriskofinfectioncontroler-ror.Asutilityglovesarepulledon,thelengthofutilityglovecuffsextendbeyondthelengthofexamglovecuffstothecontaminatedsleeveoflabcoatsincreas-ing the riskof transferringbacteria to the insideofutilitygloves.Theveryactofwashingutilitygloveswithsoapandwatermayinadvertentlyallowforcon-tamination.Watercouldtravelthelengthoftheglove,transportingbacteria from theoutside to the insidevialooseutilityglovecuffs.Thecontaminatedutilityglovewould then serve as a reservoir for bacteria,causing the recontamination of DHCP’s hands witheachsubsequentuse.Theinsideofutilityglovesmayprovide an underestimated growth medium, giventhe literature’s verification that proliferation of bac-teriaincreasesrapidlyinwarmwetenvironments,11,12combinedwithnumerousother factors,suchastheaccumulationofhandsweat,inadvertentwatercon-taminationduring thedisinfectionprotocol, and thesurvival times of pathogenic bacteria on inanimatesurfaces.13

Itwastheorizedthis“perfectstorm”oflikecondi-tionscoulddiminishthesafetyforwhichtheirdonningwas intended toprevent. It iswell established thatdryordamagedhandscanserveasaportalofentryaswellasincreasetheriskoftransientbacterialcar-riageandsubsequentcross-contaminationbywayofDHCP’shands.5,14

Nostudywasfoundtorefuteorsupportthepres-enceorabsenceofpathogenbacteriaontheinsideofutilitygloves.Fourbacteriathataccountsfor34%ofallreportedhospital-acquiredinfectionswereselectedfor the study.15 Since the environmental survival ofpathogenicbacteriaparallelstheenvironmentalsur-vivalofMDRbacteriaofthesamespecies,thepres-enceofpathogenicfoundinsideutilityglovesservedasanindicationthatenvironmentalconditionsequallyfavored thegrowthofMDRbacteria introduced intothesameenvironment.12Apilotstudywasconductedtolendempiricaldataandtohelpdeterminetheneedfor there-evaluationof theutilitygloveprotocolbyansweringthefollowingquestions:

1.Afteradayofuse,whatfrequencyaregram-posi-tiveS.aureus,K.pneumoniae,E.coliandP.aeru-ginosapresentontheinsideofusedutilitygloves?

2.Towhatdegreeareutilityglovescontaminated?3.Doesthedegreeofcontaminationmatchtheex-pectedoutcome?


Institutional review board approval was granted.The researcher incurred all costs and no financialstakesfromthedesign,conductionoranalysisofthispilotstudyweregained.

EachWednesdayfor6weeks,5steamautoclavedutilityglovesfromthecleanutilityglovestoragecon-tainerwererandomlyselectedtoserveascontrol.Aconveniencesampleof10usedutilityglovesplacedinthesterilizationareaforsterilizationfollowingan8hourclinicdaywereselectedforsampling.Theran-domnessoftheusedutilityglovessampleswasde-finedbytherandomnumberoftimestheglovesareworn,therandomsizerangingfromsmall,medium,largeandextra-large,thevariationinhandwashingtechniquesandthevariationofuniquebacteriafoundonindividualhands.

Utilizingaseptictechnique,theinsideofeachutilityglovewasturnedinsideonafabricatedhandformtoexposetheindexfinger,palmareaandthumb.Utiliz-ingstandardbiologicalswabbingtechnique,asterileswabmoistenedwithsterilesalinewasusedtocollectasamplefromeachoftheutilitygloves.Thesamplingareaoriginatedfromtheindexfinger,continuedfromtheindexfingerintopalmareaandthenextendedtothetipofthethumb.Theswabwasusedtoinoculatethecenterareaof2FisherBrandSterile100mmx15mmPolystyrenePetridishescontainingMannitolSaltagar (Carolina Biological Supply Company, Burling-ton,NC)andMacConkeyagar(BaltimoreBiological,Baltimore,MD).Anewsterile swabmoistenedwithsterilesalinewasusedtouniformlydistributethein-oculumontheMannitolSaltagar(MSA)employingastandardstreakmethod.Asecondsterileswabmoist-enedwithsterilesalinewasusedtodistributethein-oculumontheMacConkeyagaremployingthesamestreakmethod.Additionally,aPetriplateofMannitolSaltandMacConkeyculturemediawereuncoveredatthebeginningofthesamplingsessionandcoveredattheendofthesessiontoserveasanairbornecontrol.

Thesampleswereincubatedat37ºCfor30to36hoursinaerobicconditions.Eachplatewasevaluat-edforCFUs.MSAisselectiveforsalt-lovingbacteriasuchasStaphylococcianddifferentialinthatpatho-genicspeciesofStaphylococcitypicallyproduceyel-lowcolonieswithyellowzones.Initially,S.aureuswasidentifiedbycolonymorphology,gramstainandthemicroscopicexamination.SubsequentidentificationofS.aureuswasidentifiedbydistinctvisualappearanceof colonymorphologyonMannitolSalt agar.Gram-negative K. pneumoniae, E. coli and P. aeruginosawere identifiedbythedistinctvisualappearanceontheselectiveanddifferentialMacConkeycultureme-dia.CFUwerecountedupto200perPetriplate.TheCFUcountswereassignedarangeofvaluestofurtherqualifythedegreeofcontaminationexpressedperPe-triplateasshowninTableI.


CFUperPetriPlate DegreeofContamination<20 light20to100 moderate100to200 heavy>200toonumeroustocount(TNTC) gross

Table I: Designation of CFU to Degree ofContaminationperPetriPlate

SteamAutoclaveUtilityGloves

n=33CL95%(0.000,0.049)

UsedUtilityGloves n=70CL95%(0.000,0.030)

Table II: EstimatedRate ofContaminationwithGram-NegativeK.pneumoniae,E.coliandP.aeruginosa

SteamAutoclaveUtilityGloves

n=33CL95%(0.233,0.530)

UsedUtilityGloves n=70CL95%(0.273,0.498)

TableIII:EstimatedRateofContaminationwithGram-PositiveS.aureus

Week Mean LowerCIlimit

UpperCIlimit

0(pilotweek) 4.10 2.84 5.30

1 2.90 1.91 3.972 997.28 978.18 1016.803 0.20 0.00 0.484 5.90 4.43 7.465 153.47 145.95 161.226 0.10 0.00 0.30

TableIV:EstimatedMeanS.aureusCUFforEachWeekofDataEntries

Analysis and Statistics

Confidence intervals(CI)wereconstructedtoes-timate the rate of contamination. CI’swere viewedastheprobabilitythatanyrandomlyselectedutilityglovewouldexpressCFUcontaminationwitha95%confidence level (CL). Data collected from the pilotweekofthispilotstudywereincludedinthestatisticalanalysisbecausetheresultswereconsistentwiththestudydata.

reSultS

Rate of contamination: gram-negative K. pneumoniae, E. coli and P. aeruginosa: PetriplatesofMacConkeyagarexpressednogrowthforbothsteamautoclaveutilityglovesandusedutilitygloves. Table II summarizes the estimated rate ofcontaminationexpressedinconfidenceintervalsforsteamautoclaveutilityglovecontrolsandusedutil-ityglovesamples.

Degree of used utility gloves contamination: K. pneumoniae, E. coli and P. aeruginosa: NoPetri-plateofMacConkeyagarexpressedgram-neg-ative CFU. Therefore, the degree of contaminationcouldnotbecalculated.

Rate of contamination: gram-positive S. au-reus: Petri plates ofMannitol Salt agar expressedgrowth forbothsteamautoclaveutilityglovesandused utility gloves. Table III summarizes the esti-matedrateofcontaminationexpressedinconfidenceintervals for steam autoclave utility glove controlsandusedutilityglovesamples.

Degree of used utility gloves contamination: gram-positive S. aureus:Thedegreeofusedutil-ityglovescontaminationwasextremelyvariedoverthesevenweeksamplingperiod.Thereforethecon-taminationrateswerecalculatedseparatelyforeachofthesamplingperiods.TheTNTCentriesrequiredanupperlimitvaluetobeincluded.Avalueof1400CFUwasassignedtoTNTC.TableIVpresentsthees-timatedmeanintensityCFUwitha95%CLforeachsamplingperiods.

To further explore the relative intensity of usedutilityglovessamples,thechronologyofweekswerearrangedtoidentifyperhapsthreelevelsofcontami-nation intensity as illustrated on Table V. By com-paringthelowerCIandtheupperCIlimitswiththemean,itisclearthereisawiderangeofcontamina-tion fromweek toweek.Arranged in thisway, theintensity of contamination is at the lowest level inweeks3and6,followedbyweekszero(pilotweek),1,and4,withweeks2and5atthehighestlevelofcontaminationintensity.

DiScuSSion

Frequency of used utility gloves contaminat-ed and expected outcomes:Itwashypothesizedthatgram-negativeculturemediawouldnotexpressgrowthofK.pneumoniae,E. coliorP.aeruginosa.Nopetriplateexpressedgrowthandtherefore,therawdatematchedtheexpectedoutcomeofzero.CIbasedon70samplesanda95%CLestimatedtherateofcontaminationwasnohigherthan3%.

Itwashypothesizedthatgram-positivecultureme-diawouldexpressgrowthofS.aureusbutwouldnotexceedtheupperlimitsoftheaveragecarriagerateof30%foundingeneralpopulationintheU.S.17Therawdatayieldedahigherthanexpectedoutcomeof


Week MeanCFU LowerCIlimit

UpperCIlimit

3 0.20 0.00 0.486 0.10 0.00 0.300(pilotweek) 4.10 2.84 5.301 2.90 1.91 3.974 5.90 4.43 7.462 997.28 978.18 1016.805 153.47 145.95 161.22

TableV:ThreelevelsofUsedUtilityGlovesSam-pleContaminationIntensityGroupedbyWeek

Week

UsedUtil-ityGlovescontamina-tionintensitylowerCI

UsedUtil-ityGlovescontaminationintensityup-perCI

SteamAuto-claveUtilityGlovesrangeofCFUperplate/rawdata

3 0.00 0.48 06 0.00 0.30 <200(pilotweek) 2.84 5.30 <20to>200

1 1.91 3.97 <204 4.43 7.46 <202 978.18 1016.80 100to>2005 145.95 161.22 100to200

TableVI:Comparison:UsedUtilityGlovesLow-erandUpperCIofContaminationIntensitytoSteamAutoclaveUtilityGlovesRawData

MacConkeyculturemedia 95%CI(0.011,0.054)Mannitolsaltculturemedia 95%CI(0.022,0.073)

TableVII:CIEstimatedRateofPetriPlateContamination

38.5%.CI,basedon70samples,anda95%CL,es-timatetherateofcontaminationtobebetween27%and 50%. However, the unexpected growth of S.aureusfromsteamautoclaveutilityglovescontrolsconfoundedtheusedutilityglovesampleresults.

The raw data of steam autoclave utility glovesshowed a contamination rate of 37.1%. CI, basedon35samples,anda95%CL,estimatetherateofcontaminationtobebetween23%and53%.

Degree of contaminated with S. aureus:Theraw data of steam autoclave utility glove controlsandstatisticalanalysisofusedutilityglovesamplesproduced a wide variation of contamination levelsrangingfromunder20CFUstoover200CFUsperPetriplate.Beyondthedegreeofcontamination,CI’ssuggestawidevariationintheintensityofcontami-nation.

Whentheusedutilityglovesamplemeanintensityconfidenceintervalsarepairedwiththecorrespond-ingweekof raw steamautoclaveutility gloveCFUcontrol data, the contamination intensity and therangeof contaminationare closelymatched (TableVI).Thesimilaritiesofsteamautoclaveutilityglovestousedutilityglovessamplessuggestthepossibil-ityofacorrelation.It is reasonabletohypothesizesteamautoclaveutilityglovescontaminationwasacontributingfactortotheS.aureusgrowthexpressedfrom the used utility gloves samples. Additionally,the3levelsofcontaminationshowninTableVsug-gestthere issomemechanismorprocessoreventthatoccurssomeweeksandnotothersthatmightexplainthehighlevelofvariationbetweenweeks.

Steam autoclave utility glove contamination with S. aureus:Weeklybiologicalsporetestswereconductedinthemorningandutilityglovedsamplingwasconductedintheafternoonofthesameday.Thesporetestresultsindicatedallautoclaveswerefunc-tional. It seems unlikely that functional steamau-toclaveswould kill highly resistant spores and notkill the less resistant staphylococci bacteria. Thepossiblemechanism,processoreventthatprecededsteam autoclave utility gloves contamination fromfunctional autoclaves present concerns about thestandard steam autoclave sterilization proceduresand the subsequent handling/ storage of sterilizedutilitygloves.Anumberofpossiblecontributingfac-torsmustbeconsidered:

• Over-loadingautoclave:Overloadingmaynotal-lowforsufficientpenetrationfortheutilitygloveslocatedclosertothemiddleoftheautoclave.

• Lengthoftimeutilitygloveswerestored:Utilitygloveswerestoredinacoveredstoragecontain-eroverthesummer.Itispossiblethattheutilityglovesbecamecontaminatedduetoanextendedperiodofstorage.

• Conditionutilitygloveswerestored:Utilityglovesthatwerestoredwetcouldhavefacilitatedbacte-rialgrowth ifS.aureuswasalreadypresent. Ithasalsobeenshown thatS.aureusandMRSAhave been recovered after periods of desicca-tion.12

• Airborne contamination: Airborne controls ofMannitol salt agar yieldedameanof 2.14CFUperPetriplateforthe7weektrails.

• DamagedUtilityGloves:DamagedutilityglovessuchastearsorcouldprovideandentrypointforenvironmentalS.aureuscontamination.

Alternatively, contamination could explain the ex-pressionofSaureusonculturemediatefromsam-plestakenfromsteamautoclaveutilitygloves.Given


concluSion

Theriskofutilityglovecontaminationwithgram-negativebacteriaislow.TheexpressedgrowthofS.aureusfromsteamautoclaveutilityglovescontrolsraisesquestionsabouttheeffectivenessandsafetyofgenerallyacceptedsterilizationstandardsforgov-ernmentallymandateduseofutilitygloves.Subse-quent researchshouldbeconducted tomore thor-oughlydifferentiate, countandstatisticallyanalyzemicrobialflorafoundontheinsideofutilitygloves.Researchshouldalsobeconducted todetermine ifthere are differences in material quality betweenmanufacturersandtoevaluatetheeffectivenessofsteamautoclavesterilization.Intheeraofevidence-basedpractice,thelackofstudiesrepresentingthemandateduseofutilitygloves,combinedwithnon-standardizedprotocols, increases thepotential riskofdiscrepanciesininfectioncontroloutcomes.

Kathy L. Grant RDH, BS, is a Professional Teach-er for Dental Health Programs at the University of Maine at Augusta, Bangor and is a practicing dental hygienist. E. Donald Naber, EdD, is an Associate Pro-fessor of Biological Sciences and Science Coordinator at the University of Maine at Augusta, Bangor and is an Adjunct Professor of Nursing at the University of Maine. William A. Halteman, PhD, is a Professor of Biostatistics in the Dept. of Mathematics and Statis-tics, at the University of Maine.

acknowleDgmentS

TheauthorsthankDawnBearor,EdD,forherin-sightfuleditsoftheliteraturereviewthatprecededthisbodyofresearch.

the technique sensitivemethod of preparing, han-dlingandinoculationculturemedia,techniqueerrorcannotberuledout.

Study limitations:steamautoclaveutilityglovesas“negative”controls:Thestudyintendedtoevalu-ate thepresenceorabsenceofspecificpathogenicbacteriainsideutilityglovesasaresultoftheproto-colfordonningandremovingthemduringadayofclinical use. The contamination of steamautoclaveutility gloves controls with S. aureus confoundedusedutilityglovessampleresults.

The studydesigndidnot include controls to es-timate the rate of sterile swab and sterile salinecontamination.Culturemediawaspreparedby theresearcherandinspectedforcontaminationpriortouse.Thenumberofcontaminatedculturemediawasrecordedeachweek.Theestimatedrateofcontami-nationofsolidculturemediapreparationwasevalu-atedwithCI(TableVII).

Testingsuchasbloodagar,alpha-hemolysis,co-agulaseactivityandcatalaseshouldhavebeencon-ductedtofurtherdifferentiateofS.AureusCFUontheMannitolSaltagar.Thereisnostandardizedmethodforsamplingenvironmentalsurfaces largelyduetothevastvarietyofsurfaceareaschosentosampleby researchers.UMA,DentalHealthProgramspro-vides4sizesofutilitygloves;small,medium,largeandextra-large.Thesizevariationhelpedtodefinetherandomizationoftheutilityglovessampledbutalsoservedtoweakenthestrengthofthestudyout-comesbecausethesizeofsurfaceareasampledin-side the utility gloves varied corresponding to thesizeoftheutilityglove.

ThesamplesizewassmallforCItobeconstructed.Theconfidenceintervalswouldbenarrowergivenamore precise estimate of the contamination rates.Thearbitraryassignmentof1,400CFUtoanyvaluebeyondtheCFUcountof200forthepurposeofmea-suring the intensity/degree to which utility gloveswere contaminated does not accurately representthetruelevelofcontaminationandtherefore,limitsinterpretationofthedatarepresentedonTablesI,VandVI.

TheemergenceanddisseminationofMDRbacteriabegsaconcertedeffortbyallhealth-careproviderstoreviewand,ifnecessary,revisecurrentinfectioncontrol policies and procedures. The small samplesizeofthispilotstudylimitstheconclusionsthatcanbedrawn.However,confidenceintervalsindicatetheriskofutilityglovecontaminationwithgram-nega-tive bacteria to be low. The findings of this studysupport current literature suggesting a low risk oftransmission and/or infection with gram-negativebacteriaindentistry.16

Study design limitations and study design flawsnotwithstanding, the unexpected contamination ofsteamautoclavedutilityglovesilluminateapotentialgapininfectioncontrol.TheramificationsofDHCP’sdonningutilityglovescontaminatedwithS.aureusareunclear.However,steamautoclaveutilitygloves’scontaminatedwithS.aureusmayputDHCP’satriskforinfectionandincreasetheriskofbecominghandcarriersofpathogenicbacteria.7,17

Utility gloves, considered a non-medical device,arenotregulatedbytheFDA.Therefore,thequal-ityofutilityglovesvariesbymanufacturerspecifica-tions.Thisresearcherfoundnostudiesinthelitera-tureevaluatingtheefficacyofutilityglovesfortheirintendedpurposeofprotectingDHCP’sfromchemi-calandpunctureinjurynorwereanystudiesfoundevaluating steam autoclave effects and/or efficacyonutilityglovematerial.Thedatacollectedfromthispilotstudycanserveasanimpetusforamorescien-tificandcontrolledstudy.


1. DePaolaL,FriedJ.Microbialresistanceandhealthcare-associated infections:combatingthisglobalthreatpart1.Access.2011;25(8):10-12.

2. DePaolaL,FriedJ.Microbialresistanceandhealthcare-associated infections:combatingthisglobalthreatpart2.Access.2011;25(10):22-24.

3. Ben-AmiR,Rodríguez-BañoJ,ArslanH,etal.Mul-tinationalsurveyofriskfactorsforinfectionwithextended-spectrum β-lactamase-producing en-terobacteriaceaeinnonhospitalizedpatients.ClinInfectDis.2009;49(5):682-690.

4. Pitout JD, Laupland KB. Extended-spectrum be-ta-lactamase-producing enterobacteriaceae: anemergingpublic-healthconcernLancetInfectDis.2008;8(3):159-166.

5. KohnWG,CollinsAS,ClevelandJL,etal.Guidelinesfor Infection Control in Dental Health-Care Set-tings---2003.MMWRRecommRep.2003;52(RR-17):1-61.

6. OlsenRJ,LynchP,CoyleMB,etal.Examinationglovesasbarrierstohandcontaminationinclini-calpractice.JAmMedAssoc.1993;270(3):350-353.

7. Boyce JM, Pittet D. Guideline for hand hygieneinhealth-caresettings: recommendationsof thehealthcare infection control practices advisorycommittee and the HICPAC/SHEA/APIC/IDSAhandhygienetaskforce.InfectControlHospEpi-demiol.2002;23(12Suppl):S3-40.

8. Model plans and programs for theOSHAblood-borne pathogens and hazard communicationsStandards [Internet]. Washington (DC): Occu-pationalSafetyandHealthAdministration;2003[cited 2014 April 23]; OSHA 3186-06R. Avail-able from: https://www.osha.gov/Publications/osha3186.pdf

9. Infectioncontrolindentalsettings.FAQ.personalprotective equipment [Internet]. Atlanta (GA):Centers forDisease Control and Prevention.Di-vision of Oral Health. 2013 July 10 [cited 2014April 23]. Available from: http://www.cdc.gov/OralHealth/infectioncontrol/faq/protective_equip-ment.htm

10.University of Maine at Augusta-Bangor. DentalHealthPrograms.ClinicManual:Section III: In-fectioncontrol.2013.3p.

11.GouldD,ChamberlainA.Gram-negativebacteria.Thechallengeofpreventingcross-infectioninhos-pitalwards:areviewoftheliterature.JClinNurs.1994;3(6):339-345.

12.CimolaiN.MRSAand theenvironment: implica-tionsforcomprehensivecontrolmeasures.EurJClinMicrobiolInfectDis.2008;27:481-493.

13.KramerA,SchwebkeI,KampfG.Howlongdonos-ocomialpathogenspersistoninanimatesurfaces?asystematicreview.BMCInfectDis.2006;6:130.

14.GouldD.Skinflora:implicationsfornursing.NursStand.2012;26(33):48-56.

15.Hidron A, Edwards JR, Patel J, et al. NHSN an-nual update: antimicrobial-resistant pathogensassociatedwithhealthcare-associated infections:annualsummaryofdatareportedtotheNationalHealthcareSafetyNetworkattheCentersforDis-easeControlandPrevention,2006–2007. InfectControlHospEpidemiol.2008;29(11):996-1011.

16.LaheijAMGA,KistlerJO,BelibasakisGN.Health-care-associated viral and bacterial infections indentistry.JOralMicrobiol.2012;4.

17.LarsonEL,HughesCA,PyrekJD.Changesinbac-terialfloraassociatedwithskindamageonhandsof health care personnel. Am J Infect Control.1998;26(5):513-521.

referenceS


In dental hygiene education, clinical instructorswith varying experience, backgrounds and educa-tionunitewith thecommongoalofcreatingcom-petent graduates prepared to care for the public.Thisuniqueexpertiseprovidesawealthofknowl-edgenotfoundintextbooks.However,thisdiversitymight also interfere with providing quality dentalhygieneeducation.1

Whiletheeducationalgoalmightbeunified,theteachingmethodsandclinicaltechniquesofinstruc-torsmightbeconflicted.Facultyvariationdistractsthestudentsfromfocusingonpatientcareandre-directs them to satisfying the evaluating instruc-tor.2Dentalhygienestudentsdevelopcompetencethrough didactic instruction, evaluation of clini-cal careandperformancemodeledby instructors.Thereareoftenmultiplewaystoperformefficaciousskills. Novice students learning to think criticallyandproblem-solvemightexperiencedifficultysort-ingthroughinstructorinconsistencies.

ASurveyofClinicalFacultyCalibrationinDentalHygieneProgramsNicholeL.Dicke,RDH,MDSH;KathleenO.Hodges,RDH,MS;EllenJ.Rogo,RDH,PhD;BeverlyJ.Hewett,RN,PhD

AbstractPurpose:Thisstudyinvestigatedthecalibrationeffortsofentry-leveldentalhygieneprogramsintheU.S.Fouraspectswereexplored,includingattitudes,characteristics,qualityandsatisfaction,toevaluatecur-rentcalibrationpractices.Methods:Adescriptivecomparativesurveydesignwasused.Directorsofaccrediteddentalhygienepro-grams(n=345)wereaskedtoforwardanelectronicsurveyinvitationtoclinicalfaculty.Eighty-fivedirec-tors forwarded thesurvey to847 faculty;45.3%(n=384)participated.The37-itemsurveycontainedmultiple-choiceandLikertscalequestionsandwasavailablefor3weeks.Descriptivestatisticswereusedtoanalyzedemographicdataandresearchquestions.TheKruskal-Wallis,SpearmanCorrelationCoefficientandMann-WhitneyUtestswereemployedtoanalyzehypotheses(p=0.05).Results: Thedemographicprofile forparticipants revealed thatmostworked for institutionsawardingassociateentry-leveldegrees,had1to10years’experience,taughtclinicallyanddidactically,andheldamaster’sdegree.Clinicalinstructorsvaluedcalibration,believeditreducedvariationandwantedmorecalibration.Somewerenotofferedqualitycalibration.Therewasadifferencebetweentheentry-levelde-greeawardedandtheprogram’sevaluationofclinicalskillfacultyreliability,asanalyzedusingtheKruskal-Wallistest(p=0.008).Additionally,full-timeversuspart-timeeducatorsreportedmoreobservedstudentfrustrationwithfacultyvariance,asevaluatedusingtheMann-WhitneyUtest(p=0.001,bfp=0.004).Conclusion:Facultymembersvaluecalibration’spotentialbenefitsandwantenhancedcalibrationefforts.Calibrationeffortsneedtobeimprovedtoincludestandardsformeasuringintra-andinter-raterreliabilityandplansforresolvinginconsistencies.Moreresearchisneededtodetermineeffectivecalibrationmethodsandtheirimpactonstudentlearning.Keywords:dentalhygiene,faculty,clinicalskills,reliability,validity,calibration,educationThisstudysupportstheNDHRApriorityarea,Professional Education and Development: Investigatetheextenttowhichnewresearchfindingsareincorporatedintothedentalhygienecurriculum.

research

introDuctionStudents begin their careers with education as

their sole foundation. Reducing variation to bet-termeettheStandardsforClinicalDentalHygienePracticeandaccreditationstandardswillhelppro-gramsaccomplishstudentcompetenciesinpatientcare,ultimatelybenefitingthepublic.3Asprogramsimproveinstructionandassessmentmethods,grad-uateswillbebetterpreparedforever-changingpa-tientdemands.Investigatingcurrenteffortsshouldaid in planning and implementing effective futurecalibrationofferings.

Previousmedicaleducationresearchinvestigatedstudent perceptions of faculty variation, variationcauses, calibration attempts and faculty develop-ment. Several studies demonstrated considerablevariation in assessment and clinical judgmentamonghealthcareeducationfaculty.4-10Dentaled-ucation faculty exhibited variation in periodontitisdiagnosisandtreatmentplanning,7cavityprepara-tionassessment,9calculusdetection,4radiographic


interpretation,8 periodontal probing11 and studentperformanceassessment.10

Qualitative research has described faculty andstudent frustration with instructor inconsisten-cy.2,12-14Onestudyreportedonly53%ofdentalstu-dentsweresatisfiedwiththeconsistencyofclinicalinstruction and assessment.12 Common concernsreportedweredifferentstandardsandfrequentdis-agreementsamonginstructors.12Studentsreportedalteringclinicalperformancetosatisfyinstructors.12Twenty percent of perceived programweaknessesrevolvedaroundfacultyinconsistency.12

In investigatingpossiblevariationcauses,someresearchers indicated faculty status as a culprit,10whileotherssuspectedvaryingeducationaland/orprofessionalbackgrounds,1,11,14personalpreferencedifferences,andagingfacultypopulationscouldberesponsible.1Forexample,gradesforstudentper-formancewereassigneddifferentlybyfull-timefac-ulty,residentsandpart-timeclinical faculty.10Thisvariation was possibly due to differing calibrationrequirements of faculty groups; part-time facultywere calibrated yearly, whereas full-time facultywere only calibrated upon hiring.10 Variation wasalsolinkedtoyearsofclinicalexperience.Onestudyinvolvingperiodontalprobingaccuracyshowedthehighestagreementamongfacultywithmoreexperi-ence.11

Calibrationmethodologystudiesrevealedvaried,but promising, results.4,6,8 While calibrating facul-ty inexplorercalculusdetection, researcherscon-cluded calibration became increasingly difficult ascalculusdetectionbecamemorecomplex.4Studieshavedemonstratedshort-and long-termpotentialforcalibrationeffortstoreduceradiographic inter-pretationvariation8andcavityassessmentprepara-tions.6Similarly,thecollectiveliteratureonfacultydevelopment isoptimistic, revealinghigh levelsoffacultyappreciationanddesireformoreprofession-aldevelopmentopportunities.15-18Facultymembershavereportedalteringtheirteachingand/orassess-mentmethods following calibrationexercises,andtheyperceiveun-calibratedcolleaguesasresistanttochangingteachingmethodology.16Anoperationaldefinitionofcalibrateis“tostandardizeasamea-suring instrument by determining the deviationfromastandardsoastoascertainthepropercor-rection factors ... tomeasureprecisely;especiallytomeasureagainstastandard.”19

Available literature on clinical faculty variationandcalibrationmightseemample;however,dentalhygiene is clearly underrepresented.4 The major-ityofstudieshavebeenconductedinmedicalanddentaleducationalprograms.Thelevelofvariationandconsequencescannotbeassumedtobesimilaramongdifferenttypesofhealthcareprograms.Ad-

ditionally, little research is devoted to faculty de-velopmentforteachinginclinical(versusdidactic)settings.16

Basedonliteraturereviewed,researchquestionsand hypotheses were developed to answer ques-tions regarding calibration efforts for entry-leveldentalhygieneclinicalfacultymembers.Theques-tionswere:

1.Whatwerethefacultyattitudesregardingcali-bration?

2.Whatwerethecharacteristicsandqualityofthecurrentcalibrationefforts?

3.Were faculty satisfaction with their program’scalibrationefforts?


The voluntary electronic survey involvedminimalriskandwasapprovedasexemptfromreviewbytheHumanSubjectsCommittee(#3706)atIdahoStateUniversity.Instructorswhotaughtinaccreditedden-talhygieneclinicalprogramsduringthe2011to2012academicyearwereinvitedtoparticipate,regardlessofemploymentstatus,yearsofexperienceorrespon-sibilities.Acensusoftheentirepopulationwasusedtoincludeasmanyclinicalinstructorsaspossibleandobtainalargesample.Supervisingdentistswereex-cluded.

The self-designed 37-question surveywas devel-opedbyreviewingtheliteraturerelatedtocalibration.This reviewsteered thequestiondevelopment.Par-ticipants’ demographics were collected by including7 closed and open-ended questions. Attitude aboutcalibrationattheinstitutionwasassessedusing8Lik-ert typequestionsona scale ranging from1being“strongly agree” to 5 for “strongly disagree.” Char-acteristicsofcalibrationwereevaluatedincorporating5 closed and open-ended questions. Quality of thecalibrationwasexaminedusing7itemsandsatisfac-tionofcalibrationeffortswith10itemsthatwerecon-structedusingthe5-pointLikerttypescale.

The37-itemquestionnairewasassessed forcon-tentvaliditybyperformingaContentValidity Index(CVI).20 Experts were asked to rank each surveyitem for relevancy to researchquestions.Questionsrankedas“notrelevant”or“somewhatrelevant”wererevisedorexcluded.AminimumCVIscoreof0.75,indicating at least 75%of experts viewed the itemas“relevant”or“quiterelevant,”wasrequiredforin-clusion. Reliability was analyzed using a test-retestformat. An agreement of 75%or greater among 8participantsindicatedacceptablereliability.Itemsbe-low75%wererevisedforincreasedclarity.Thepilotstudydetermined92.6%reliabilitybetweenthetestandretestresponses.


reSultS

Eighty-five program directors (24.6% of thosecontacted) forwarded the survey invitation to theirclinicalfaculty(n=847).While393facultymembersconsentedtoandopenedthesurvey,384(45.3%ofthose invited)completed it.Onehundredandthree(26.8%)respondentswerenotabletoanswerques-tionsregardingthecharacteristicsof,qualityofandsatisfactionwithcalibrationefforts,becausetheywerenotofferedcalibrationduringthe2011to2012aca-demicyear;thus,only281responseswerepossiblefortheanalysisofthesequestions.Additionally,someparticipants chosenot toanswer specificquestions,resulting in differing numbers of responses (254 to384)fortheremainingsurveyitems.

The final survey was constructed using Survey-Monkey® to reduce cost while enhancing efficiencyand convenience. Participant consent was obtainedinthesurveyintroduction.Surveyaccesswasdeniedto non-consenting participants. To ensure anonym-ityandconfidentiality,SurveyMonkey®didnotstorepersonalidentifiers.Participantscoulddiscontinuethesurveyatanytimepriortosubmittingtheirrespons-es.Dataweredownloadedforstatisticalanalysisandreportedinaggregateform.

Dentalhygieneprogramdirectors’emailswereob-tainedfromtheAmericanDentalHygienists’Associa-tionandfromtheprograms’websites.21Anemailwassenttodirectorsofall345programsintheU.S.,ask-ingthemto forwardasurvey invitational letterandUniformResourceLocater(URL)toallclinicalinstruc-tors.Directorswereaskedtoindicateparticipationbyresponding to the email and providing the numberofclinical facultyreceivingthesurvey invitation.Anincentive drawing for one prepaid $100 Visa® cardencourageddirectorparticipation.Oneweek later,asecondemailwassent tonon-respondingdirectors,andareminderemailwassenttothosewhoindicatedparticipation,askingthemtoforwardareminderlet-ter to clinical faculty. This follow-up procedurewasrepeated1weeklater;thesurveywasavailablefor3weeks.

Research questionswere analyzed using descrip-tivestatistics.Mean,minimumandmaximumvalueswere calculated for Likert-style questions. Frequen-cies and percentages were calculated for multiple-choice items.Hypotheses involvedordinal dataandweretestedwithnon-parametricinferentialstatistics.TheKruskal-Wallistestwasusedtodetectdifferenceswithinvariablegroups,theSpearmanCorrelationCo-efficientwas used to identify relationships betweenordinalvariablesandtheMann-WhitneyUtestdeter-mineddifferencesonordinalscalesbetween2vari-ables(p=0.05).TheBonferronicorrectionwasutilizedtocontrolTypeIstatisticalerrorsencounteredwhenmultipleanalyseswereperformed.

Thedemographic information for thesamplewasevenlydistributedfromeachgeographicarea(TableI).Themajorityofrespondentswerefacultymemberswho taught both clinically and didactically (55.7%,n=214) in programs awarding entry-level associatedegrees(47.9%,n=178).One-third(38.2%,n=147)workedonlyintheclinicalsetting.Halfoftherespon-dents held amaster’s degree (50.8%, n=193) andworkedfull-time(53.0%,n=196).

Table II conveys the results of survey items thatinvestigatedattitudetowardcalibrationbasedontheLikertscaleof1=stronglyagree,2=agree,3=unde-cided, 4=disagree and 5=strongly disagree. Partici-pantsindicatedastrongmeanagreement(1.1)andno disagreementwith viewing faculty calibration asanimportantaspectofeducatingstudents.Respons-esalsorevealedanoverallwillingnesstoattendnon-mandatory calibration exercises. Clinical instructorsperceived students were more satisfied with theirclinicalexperienceswheninstructorswerecalibrated,andfrustratedwheninstructorswerenotcalibrated.Therewasagreement (2.1)with students changingtheirperformancedependingontheirevaluator,andagreementwithinstructorstatusandvaryingprofes-sional judgment presenting difficulties in calibratingfaculty.

Thecharacteristicsofcalibrationquestionsrevealedthatfull-timeandpart-timeeducatorswererequiredtoparticipate(69.0%,n=189)(TableIII).Nearlyone-fourth of the participants reported attendance wasnotrequiredforclinicalfaculty.Participantscouldalsoselecttheanswerchoiceof“other”andprovidewrit-ten responses,which included reportsof calibrationbeingrequired,yetnotattended,orcalibrationonlyimplicating specific facultymembers, suchas thoseinvolvedwithparticularskillsorclinics.

Whenaskedaboutcalibration frequency, thema-jority of participants (74.6%, n=200) were offeredcalibrationeveryyear, semesterorquarter.A smallportion (7.1%, n=19) was offered calibration onlyonceevery2to4years.Two-thirds(66.5%,n=169)reportedtheirinstitutionsofferedcalibrationonarou-tinebasis,althoughmanyindicatedcalibrationwasof-feredwheneverdeemednecessary(41.7%,n=106),suchaswhenaproblemaroseor anew techniquewas introduced. “Accreditation” and “new faculty”were not significant reasons for calibrating clinicalfaculty.Participantswhoselected“other”andprovid-edwritten responses (1.6%,n=4) included calibra-tionbeingofferedinfrequently,whenneeded,orwhenexternalcontinuingeducationclasseswereavailableas ameans of calibration. Other written responsesmentionedthatgettingtheentirefacultytogetherforparticipationwaschallenging.

Calibrationcompensationwasincludedincontract-edsalary/payforaboutone-third(35.0%,n=95)of


DemographicCharacter-istics Participants Percent n

Geographicregioninwhichprogramislocated(n=371)

Northeast 20.8 77Midwest 27.8 103South 30.7 114West 20.8 77

Entry-leveldegreefordentalhygieneaward-edbytheinstitution(n=372)

Certification/AssociateofAppliedScience 25.8 96

AssociateofScience,Arts,orAlliedHealth 47.9 178

BachelorofScience 26.3 98

Yearsemployedasclinicinstructor(n=369)

1to5 31.4 1166to10 23.3 8611to15 16.8 6216to20 10.6 3921ormore 17.9 66

Employmentstatus(n=370)

Part-time 47.0 174Full-time 53.0 196

Facultyresponsibilities(n=384)

Clinicalinstructoronly 26.0 100Clinicadministrationonly 0.5 2Bothclinicalinstructorandclinicadministration 11.7 45

Bothclinicalinstructoranddidacticinstructor 55.7 214

Programadministrator 2.6 10Othercombinationofinstructionand/orad-

ministration3.4 13

Facultymember’shigh-estdegree(n=380)

AssociateofAppliedSci-ence 2.1 8

AssociateofScience,Arts,orAlliedHealth 6.1 23

BachelorofScienceorArts 36.1 137

MasterofScienceorArts 50.8 193Doctoral 5.0 19

TableI:DemographicVariablesofRespondents(n=384)

the respondents,while another38.5% (n=106) re-ceivednocompensation.One-fifth(19.6%,n=54)oftheparticipantswerecompensatedonanhourlybasis.Written responses (6.5%,n=18) revealed some in-stitutionspaidpart-time,butnotfull-timeeducators,asitwasconsideredapartofcontractedduties,andotherprogramscompensatedonecalibrationsessionper semester. Receiving continuing education creditforcalibrationparticipationwasanotherformofcom-pensation,andsomealsoreceivedreimbursementfortravelexpenses.Schedulingcalibrationduringregularworkinghourspreventedsomeinstitutionsfrompay-ingadditionalwages.

Allclinicalskillsquestionedinthesurveywerein-cludedincalibrationexercises.Powerinstrumentationwascalibratedthe least(54.6%,n=142).Periodon-talassessment/classificationwasthemostcommonlycalibrated skill (85.4%, n=222). Written responsesindicated that local anesthesia, computer training,grading and professional documentation also werecalibrated.

Therespondentsweredividedaboutthequalityoftheirinstitutions’calibration(TableIV).Mostpartici-pantsindicatedthatcalibrationwasheldinaclinicalsetting (2.4) butwereundecided if calibration con-sistedofdiscussionratherthanskillcalibration(2.5).


Statement M Min. Max.Clinicalfacultycalibrationisanimportantaspectofedu-catingdentalhygienestudents.(n=384) 1.1 1 3

Evenifnotrequiredbymyinstitution,Iamwillingtoat-tendcalibrationexercises.(n=382) 1.4 1 4

Studentsaremoresatisfiedwiththeirclinicaleducationwhenfacultymembersarecalibrated.(n=379) 1.5 1 5

Studentshaveindicatedfrustrationwithorconcernaboutthelackofclinicalfacultycalibration.(n=383) 1.8 1 5

IamfrustratedorstrugglewithmyroleasaneducatorwhenIamNOTcalibrated.(n=378) 1.9 1 5

Studentschangetheirperformancebasedonwhoevalu-atesthemintheclinicalsetting.(n=381) 2.1 1 5

Differinginstructorstatus(e.g.part-timeversusfull-time,assistantprofessorversusfullprofessor,etc.)pres-entsachallengeincalibratingfaculty.(n=379)

2.4 1 5

Itisdifficulttocalibrateclinicalfacultyduetodifferingprofessionaljudgment.(n=382) 2.4 1 5

TableII:SummaryofAttitudesTowardCalibration(n=384)

Key:1=Stronglyagree;2=Agree;3=Undecided;4=Disagree;5=Stronglydisagree

Respondentshadvariedattitudeswhenaskedifcali-brationassessedclinicalperformance(3.3),aprede-terminedlevelofperformancewasrequired(2.5)orifcalibrationassessedreliability(3.1)andconsistency(3.3).Facultydisagreed(3.8)thatcalibrationeffortsincludedapre-testtodeterminepre-calibrationper-formance.

TableVsummarizesthesurveyquestionspertain-ing to calibration satisfaction. Participants felt thatcalibrationreducedvariationandthattheypreferredmorecalibration(2.1).Themeanvalueswerebetween“agree” and “indecision” that calibration adequatelyaddressedvariationbetweenmembers(2.6),calibra-tion quality satisfaction (2.6) and individual facultyinconsistencybeingadequatelyaddressed(2.7).Theresultswereinconclusive(range2.8to3.0)iffacultyhadbeencalibratedineachspecifiedclinicalskill.

TheKruskal-Wallistest(p=0.008)revealedadiffer-encebetweentheentry-leveldegreeawardedandtheprogram’sevaluationofclinicalskillfacultyreliability.FurtheranalysisofthisfindingwiththeMann-WhitneyUtestrevealedadifferencebetweenbachelorandas-sociateentry-levelprograms(p=0.003,bfp=0.009).Inaddition,comparingcertificatetobachelorentry-level programs was also suggestive of a difference(p=0.021, bfp=0.063). It was also found that full-timeversuspart-timefacultymembersreportedmoreobservedstudentfrustrationwithfacultyvariance,asevaluatedusingtheMann-WhitneyUtest(p=0.001,bfp=0.004).

DiScuSSion

Research shows instructors with less experiencehavegreaterlevelsofvariation.11One-halfofrespon-dentsworkedpart-timeandhad10orfeweryearsofexperienceasclinicalfaculty.Ifthissampleisrep-resentativeofthedentalhygienefacultypopulation,one-halfofclinicalinstructorshavenotyetreachedthe level of expert. It is accepted among variousfields of study that reaching expertise requires 10yearsofexperience.22Expertsview,processandre-act to situations differently than novices and haveenhancedjudgmentanddecision-makingskills.23

Forthemajorityofparticipants,allfacultymem-berswere required to attend calibration; however,participantsdescribeddifficultiesingettingpart-timeemployeestoattend,duetocommitmentstootherjobs.One-halfofrespondentshadmaster’sdegreesandweremore likely tohave completedadvancededucational methodology coursework. More thanone-third of the participants worked only in clinic(eitherinstructorsand/oradministration)andmightnothavethesameopportunitiesasinstructorswork-inginboththeclinicandclassroomforhearingstu-dent frustrations, discovering gaps between class-roomtheoryandclinicalpractice,orbenefitingfromnetworkingwithotherdidacticcolleagues.

Theoverallattitudeofclinicalfacultytowardcali-brationwaspositive.Participantsviewedcalibrationasveryimportantandwerewillingtovoluntarilypar-ticipate.Thesefindingsarecongruentwithprevious


Question Response Percent n

Selectthestatementthatbestdescribesclinicalfac-ultyparticipationinplannedcalibrationexercise.(n=274)

Allclinicalfacultywererequiredtoattend. 69.0 189

Onlyfull-timefacultywererequiredtoattend. 5.8 16

Onlypart-timefacultywererequiredtoattend. 0.7 2

Calibrationwasprovidedbutnotrequired. 23.4 64

Other 1.1 3

Myinstitutionofferedclinicalskillscalibrationexercises(e.g.exploring,radiographicinterpretation,treatmentplanning,etc.):(n=268)

oncepermonthormore. 14.2 38oncepersemesteror

quarter. 41.4 111

onceperacademicyear. 33.2 89onceevery2to4years. 7.1 19

Other 4.1 11

Myinstitutionofferedcalibration(checkallthatapply):(n=254)

onaregular,scheduledbasis. 66.5 169

whennewclinicalfacultywerehired. 5.2 13

whencalibrationisdeemednecessary(evidenceofaproblem,newinstrumentortechnique,etc).

41.7 106

whenaccreditationwasap-proaching. 3.5 9

Other 1.6 4

Compensationforfacultycalibrationexercises:(n=275)

wasbuiltintomycontract-edsalary/pay. 35.0 95

waspaidonanhourlybasisfortimespentincalibra-

tion.19.6 54

wasapre-determinedamountpercalibrationses-

sion.0.7 2

wasnotoffered. 38.5 106Other 6.5 18

Calibrationworkshopsatmyinstitutionhavecoveredtopicsincluding(checkallthatapply):(n=269)

poweredinstrumentation. 54.6 142hand-activatedinstrumen-

tation. 73.1 190

radiographictechniquesand/orInterpretation. 64.6 168

periodontalassessment/classification. 85.4 222

treatmentplanning. 66.2 172Other 4.2 11

TableIII:SummaryofCharacteristicsofCalibrationExercises(n=281)

research.16,17,24 Clinical faculty also felt calibrationimproves student satisfactionwith their education-al experiences, while variance frustrates students.There was agreement that students change theirperformance tomatch theevaluating instructor,as

reportedinpreviousstudies.2Itispossibleforsuchalterationstogounnoticedbyfaculty;surveyingstu-dentsmighthelpdeterminetheeffectsofvarianceontheireducation.Participantsweredividedintheirattitudetowardtheeffectsofprofessionaljudgment


Statement M Min. Max.Calibrationwasconductedinaclinicalsetting.(n=269) 2.4 1 5

Calibrationeffortsmustresultinarequireddeter-minedlevelofperformancebeingachievedfortheclinicalfacultymembertobeconsideredcalibrated.(n=267)

2.5 1 5

Calibrationeffortsconsistedofdiscussionratherthancalibrationofactualclinicalperformance.(n=270) 2.6 1 5

Duringcalibration,myperformancewascomparedtotheperformanceofotherclinicalfaculty.(n=267) 3.1 1 5

Duringcalibration,theskillwasevaluatedmorethanonceinordertoassessmyconsistency.(n=268) 3.3 1 5

Calibrationincludedanevaluationofmyclinicalperfor-mance.(n=267) 3.3 1 5

Calibrationeffortsoftenutilizedapre-testtodeter-minemypre-calibrationperformance.(n=267) 3.8 1 5


TableIV:SummaryofQualityofCalibration(n=281)

Statement M Min. Max.Clinicalfacultycalibrationeffortsreducedfacultyvaria-tion.(n=267) 2.1 1 5

Iwouldliketohavebeenofferedmoreclinicalfacultycalibrationopportunities.(n=267) 2.1 1 5

Clinicalfacultycalibrationeffortsadequatelyaddressedvariationbetweenfacultymembers.(n=266) 2.6 1 5

Iwassatisfiedwiththequalityofclinicalfacultycali-brationefforts.(n=267) 2.6 1 5

Clinicalcalibrationeffortsadequatelyaddressedincon-sistentclinicalperformanceofindividualfacultymem-bers.(n=266)

2.7 1 5

Theclinicalfacultywascalibratedincalculusdetectionusinganexplorer.(n=263) 2.8 1 5

Theclinicalfacultywascalibratedinradiographicinter-pretation.(n=264) 2.9 1 5

Theclinicalfacultywascalibratedinpoweredinstru-mentationtechniques.(n=263) 3.0 1 5

Theclinicalfacultywascalibratedinhandactivatedinstrumentationtechniques.(n=262) 3.0 1 5

Theclinicalfacultywascalibratedinradiographicex-posuretechniques.(n=262) 3.1 1 5

TableV:SummaryofSatisfactionwithCalibrationEfforts(n=281)


andinstructorstatusoncalibration.Whilesomefeltthesefactorsmakecalibrationmoredifficult,othersdidnot.Furtherresearchtorevealsourcesofdiffi-cultywouldbebeneficial.

Attendanceforcalibrationeffortswasmandatory

for themajority of full- and part-time employees,yetsomefacultydidnotattend,orattendancewasonlyrequiredfortheeducatorsinvolvedinteaching/evaluatingtheskillbeingcalibrated.Truecalibrationevaluatesthereliabilityof faculty;thiscanonlybeachievedifeveryclinicalfacultymemberparticipates


fosteringasenseofteamworkastheyworktowardcommongoals.

More than one-third of the respondents report-edcalibrationoccurredwhena specificproblemorneed arose. Calibration should be preventive andisnecessarywellbeforeneedisevident.Establish-ingascheduleforfrequencyandwhatistobecali-bratedwouldensureeachclinicalskill isaddressedandmaintainedonaregularbasis.Manyprogramsacquirenewpart-timeclinicalfacultyasoftenasev-eryyearorsemester.Newerfacultymightbeheavilyinfluencedbytheirclinicalexperiencesandfindcali-brationeffortspersonallythreatening.14Experienceddental educators viewexpert technical skills as anessential element for clinical faculty,1 yetmightberesistanttochangeorunabletoseetheneedforit.16Program directors indicated that calibration is oneof their biggest challenges; allotting ample oppor-tunities for clinical calibration sessions, inpositive,non-threateningmanners,would help increase thelikelihoodofachievingfacultyreliability.

Thedesiretoimprovereliability,consistency,andeffective teachingmightoftenbeenough incentiveforparticipation.However,manypart-time instruc-torsalsoworkinprivatepracticeandfull-timefac-ultyworkmanyhourstofulfilltheirresponsibilities.Compensating faculty for time in calibration exer-ciseswouldincreaseitsappealandhelpencourageattendance.Morethanone-thirdofrespondentsdidnotreceivecompensation,perhapsbecauseofbud-getrestraints.Therelationshipbetweencompensa-tion,mandatoryparticipationandattendanceshouldbeinvestigatedtodetermineifremuneratingfacultyorotherfactorsmightenhanceparticipation.

Formany,calibrationopportunitieswerenotusedto improve reliability and consistency of clinicalskills.Thisconceptidentifiestheneedforprogramsto decipher between true calibration (including anevaluationandcomparisonofperformance),teach-er in-services,educationalmethodologyworkshopsandfacultymeetings.Somerespondentswerequitepositiveabouttheirexperiences,whileotherswerenot.Facultymembersneedperceivedbenefitsfromcalibration including measurable goals for facultycalibration.

Most respondents thought that calibration oc-curredinclinicalsettings,yetmostalsoagreedthatcalibrationconsistedofdiscussionratherthanactualcalibrationofskillsperformance.Gatheringallclini-calfacultymembersmightposeanidealtimetodis-cussclinicalissues;however,suchactivitydoesnotnecessarilyreduceperformancevariability.Mostcali-brationsessionsdidnotincludeanymeasurementofinter-rater (consistency between facultymembers)orintra-rater(consistencyofeachindividualfacultymember)reliability.Utilizingastandardtowhichev-

eryonewillbecomparedisoptimalforcalibratingandstreamlinestheprocessofevaluatinginter-raterandintra-raterreliability.4,6Dentalhygieneprogramsandlicensureexamsusestandardstomeasurestudentperformanceandclinical instructorsshouldbeheldtothesameexpectations,ifnotgreater.Ifeveryoneis compared to the samestandard,all participantswhoagreewith the standardalsoagreewitheachother,andmeasuringeachparticipantmultipletimeswould determine intra-rater reliability. After gath-eringreliabilitydata,programsneedaplan for re-solving inconsistenciesand re-evaluatingoutcomestoensure reliabilitywasestablished.Discoveringaproblem is onlybeneficial if aneffective resolutionplanhasbeenconstructed.

Previous literature suggested a connection be-tween faculty status/years of experience and atti-tudes toward faculty development.15,16,24 However,thisstudydidnot.Full-timeemployeesdidvoiceastronger agreement with faculty variance causingstudentfrustrationthatisinagreementwithprevi-ousresearch.2,12,13Thiseffectcouldbebecausefull-time faculty members have more opportunities towitnessfrustration.Also,facultywhoworkedforin-stitutionsawardinganentrylevelbachelor’sdegree(asopposedtoanassociate’sdegreeorcertificate)had significantly lower agreement with instructorsbeingassessedmultipletimestoevaluateintra-raterreliability.Thisfinding couldbeattributed to theseuniversitiesemployingfacultyoradministratorswithadvanceddegreesandstrongresearchbackgrounds,heightening the need for reliability and their pro-grams’possibleshortcomings.

Respondentswereundecidedabouttheirsatisfac-tion with calibration. If the efforts do not actuallycalibrate participants, the sessions are not a wiseuse of resources. Therefore, recommendations foradministrators for improvement include establish-ing guidelines about attendance and remunerationandincludingthisinformationinthefacultywrittendepartmentpolicies.Also,thedepartmentmightin-volvetheentirefacultyincreatingacalibrationphi-losophyandpublishitforexistingandnewfaculty.Aplanshouldbecreatedforcalibratingnewfaculty.Ifexistingfacultyarecalibrated,amentorcouldbeassigned to work alongside a new instructor untilcalibration is achieved,asevidencedbyevaluatingstudentssimultaneouslytoestablishinter-raterreli-ability.Calibrationeffortscanbeenhancedbyimple-menting student evaluationmechanisms, by usingpatients during the exercises and by incorporatingastandardformeasuringperformance.Thecalibra-tionexperiencewouldalsoberecreatedforanyab-sence,therefore,attendancecouldimproveknowingthatadditionaltimeisinvolvedinmake-upsessionsfor the calibration presenter aswell as for faculty.The individualsresponsibleforplanningand imple-mentingcalibrationmusthaveamplescheduledtime


1. HandJS.Identificationofcompetenciesforeffec-tivedentalfaculty.JDentEduc.2006;70(9):937-946.

2. HendricsonWD, Anderson E, Andrieu SC, et al..Doesfacultydevelopmentenhanceteachingeffec-tiveness?JDentEduc.2007;71:1513-1533.

3. AmericanDentalHygienists’Association.Standardsofclinicaldentalhygienepractice[Internet].Chi-cago(IL):AmericanDentalHygienists’Association.2008Mar10[cited2015July14].16p.Availablefrom http://www.adha.org/resources-docs/7261_Standards_Clinical_Practice.pdf.

4. GarlandKV,NewellKJ.Dentalhygienefacultycal-ibration in theevaluationof calculusdetection. JDentEduc.2009;73(3):383-389.

5. HrynchakPK,SpaffordMM,YinP,IrvingEL.Fac-tors affecting the reliability of ratings of optom-etry students’ clinical skills. Optometric Educ.2005;30(3):80-84.

6. Haj-AliR,FeilP.Raterreliability:short-andlong-term effects of calibration training. J Dent Educ.2006;70(4):428-433.

referenceS

concluSion

acknowleDgmentS

Demographicdatafoundequaldistributionofre-spondentsfromthe4regionsoftheU.S.Calibrationcharacteristics,attitudes,qualityandsatisfactionasmeasured by this survey research would seem tobegeneralizable tomostdentalhygieneprograms.

TheauthorsthankReneeThompson,Administra-tiveAssistant,forherassistanceinconstructingandmanagingtheelectronicsurvey,theprogramdirec-torsfortheirparticipation,andtherespondentsfortheir contributions. Much appreciation is also ex-tended toTeri Peterson,M.S.,Statistician,DivisionofHealthSciences,forherstatisticalanalysesguid-ance.

toensurecalibrationisquality-oriented,meetsout-come measures and merits the participants’ timeandtheprogram’sresources.

Additionally, calibration efforts need to be safeandnon-threateningforparticipants,which includemaintainingconfidentialityofresults.Facultymem-bersshouldnotfeelthreatenedaboutjobsecurityorthatthecalibrationexercisemightbeduetoalackofperformance.Theemphasisneedstobeplacedonimprovingteachingskillstoenhancestudentlearn-ing.

This study design posed several limitations. Thesamplingmethod depended on the programdirec-tors’ cooperation foreligible clinical instructor invi-tation. Self-selection bias presents a limitation inwhichsubjectsdecideforthemselvesiftheywanttoparticipate.25Directors and facultymembersmighthavedecidedwhetherornottoparticipateasare-sultoftheirpersonalattitudes,experiencesorsatis-factionwiththeirinstitution’scalibration.Inaddition,whenwritingmultiple-choicequestions,itisdifficulttoincludeeverypossibleanswerchoice,thussolicit-ingforcedanswers.26Iftherewasdoubtthateveryreasonableresponsewasincluded,an“Other(pleasespecify)” answer choice was added. Email invita-tionsmighthavebeendisregardedbypotentialpar-ticipants.27 Therefore, sending multiple invitationshelpedincreasethenumberoffacultymemberswhoreadthemessage.

Dentalhygieneprogramsareencouragedtostrate-gicallyplanfrequentcalibrationeventsthataddresseachclinicalskilltaughtandassessed.Suchcalibra-tion sessionsneed toutilize a standardmeasuringclinicalfaculty’sperformanceandaplanforreducingunreliability.

This study’s findings support past research indi-catingmixed yet promising results that calibrationreduces variation, and thatmore research specificto dental hygiene is necessary, suchas identifyingcalibration methods that effectively reduce clinicalfaculty inconsistencies.4,6,8 The effect of calibrationonthestudents’ learninghasnotyetbeen investi-gated.Determining effective calibration techniquesthatenhancestudentlearningshouldbeafocusoffutureresearch.

Nichole L. Dicke, RDH, MDSH, Department of Den-tal Education, Indiana University-Purdue University Fort Wayne. Kathleen O. Hodges, RDH, MS, Profes-sor Emerita, Department of Dental Hygiene, Office of Medical and Oral Health; Ellen J. Rogo, RDH, PhD, Associate Professor, Department of Dental Hygiene, Office of Medical and Oral Health; Beverly J. Hewett, RN, PhD, Clinical Assistant Professor, School of Nurs-ing. All from Idaho State University.


7. LanningSK, PelokSD,WilliamsBC, et al. Varia-tion inperiodontaldiagnosisandtreatmentplan-ning among clinical instructors. J Dent Educ.2005;69(3):325-337.

8. LanningSK,BestAM,TempleHJ,etal.Accuracyand consistency of radiographic interpretationamong clinical instructors in conjunction with atraining program. J Dent Educ. 2006;70(5):545-557.

9. SharafAA,AbdelAzizAM,ElMeligyOA.Intra-andinter-examiner variability in evaluatingpreclinicalpediatric dentistry operative procedures. J DentEduc.2007;71(4):540-544.

10.SeabraRC,CostaFO,CostaJE,VanDykeT,SoaresRV.Impactofclinicalexperienceontheaccuracyofprobingdepthmeasurements.QuintessenceInt.2008;39(7):559-565.

11.ParkRD,SusarlaSM,HowellTH,KarimbuxNY.Dif-ferencesinclinicalgradingassociatedwithinstruc-torstatus.EurJDentEduc.2009;13(1):31-38.

12.HenziD,DavisE,JasineviciusR,HendricsonW.Inthestudents’ownwords:whatarethestrengthsandweaknessesofthedentalschoolcurriculum?JDentEduc.2007;71(5):632-645.

13.LicariFW,KnightGW,GuenzelPJ.Designingevalu-ation forms to facilitate student learning. J DentEduc.2008;72(1):48-58.

14.MasellaRS,ThompsonTJ.Dentaleducationandev-idence-basededucationalbestpractices:bridgingthegreatdivide.JDentEduc.2004;68(12):1266-1271.

15.HolyfieldLJ,BerryCW.Designinganorientationpro-gramfornewfaculty.JDentEduc.2008;72:1531-1543.

16.WallaceJS,Infante,TD.Outcomesassessmentofdentalhygieneclinicalteachingworkshops.JDentEduc.2008;72(10):1169-1176.

17.Shephard KR, Nihill P, Botto RW, McCarthy MW.Factorsinfluencingpursuitandsatisfactionofaca-demicdentistrycareers:perceptionsfornewden-taleducators.JDentEduc.2001;65(9):841-848.

18.HadenNK,HendricsonW,RanneyRR,etal.Thequality of dental faculty work-life: report on the2007dentalschoolfacultyworkenvironmentsur-vey.JDentEduc.2008;72(5):514-531.

19.Calibrate–definition.Merriam-Webster[Internet].2013[cited2013Jan20].Available fromhttp://www.merriam-webster.com/dictionary/calibrate.

20.PolitDF,BeckCT.Thecontentvalidity index:areyou sure you know what’s being reported? cri-tique and recommendations. Res Nurs Health.2006;29(5):489-497.

21.AmericanDentalHygienists’Association.Entry-lev-eldentalhygieneprograms.2012June12[cited2013 Jan 20]. Available from: http://www.adha.org/resources-docs/71612_Degree_Completion_Programs.pdf.

22.ChiMTH,GlaserR,FarrMJ.Thenatureofexpertise.Hillsdale(NJ):LawrenceErlbaumPublishers;1988.

23.ChiMTH,GlaserR,ReesE.Expertise inproblemsolving.In:SternbergRS,ed.Advancesinthepsy-chologyofhumanintelligence.Hillsdale(NJ):Law-renceErlbaumPublishers;1982.Vol.1,pp.1-75.

24.O’SullivanEM.AnationalstudyontheattitudesofIrish dental facultymembers to faculty develop-ment.EurJDentEduc.2010;14(1):43-49.

25.OlsenR.Self-selectionbias.In:LavrakasPJ.Ency-clopediaofsurveyresearch.ThousandOaks(CA):SagePublications;2008.

26.HeckmanJE,HeckmanMV.Evaluatingsurveysasassessmenttools:theory,methods,andmechan-icsofonlinesurveys.MarineBiologicalLaboratory/Woods Hole Oceanographic Institute [Internet].2011April11[cited2013Jan20].Availablefrom:https://darchive.mblwhoilibrary.org/bitstream/handle/1912/4597/Heckman_ iamslic2010.pdf?sequence=1.

27.LefeverS,DalM,MatthiasdottirA.Onlinedatacol-lectioninacademicresearchadvantagesandlimi-tations.BrJEducTechnol.2007;38(4):574-582.


Delayeddentalcareisasignificantpublichealthconcernwhichcouldbeaddressed inpublichealthoutreachprograms.Delayeddentalcareisfrequent-lymorecomplex,costlyandurgent.1Delayeddentalcareoftenresultsindentalvisitstotheemergencydepartmentofhospitals,andsuchvisitsstressthehealthcaresystem.2Manyhospitalsdonothavetheequipment or staff for dental care;3,4 and 90% ofdentallyrelatedemergencydepartmentvisitsdonotresult in definitive dental treatment.2 In the U.S.,therewere1.1milliondentally relatedemergencydepartmentvisitsin2000,and2.1millionin2010.4Overall,approximately4.3%ofemergencyvisitsintheU.S.aredentallyrelated.2Theaveragecostofdentally related emergency department care from2008to2010was$760(adjustedto2010dollars).2More importantly than the financial burden is theprogressionofdentaldisease tocomplexand life-threateninglevels.From2008to2010,therewere101dentally relateddeaths in theemergencyde-partmentintheU.S.(56caries-related,43relatedtoapulp/periapicallesion,18relatedtoperiodontaldiseasesand24relatedtocellulitis/abscess).2

Onedeterminantfordelayeddentalcareiscost.Reedetal indicatedthatcostofcarewasafactor

DentalFearandDelayedDentalCareinAppalachia-WestVirginiaR.ConstanceWiener,DMD,PhD

AbstractPurpose: The people of Appalachia-West Virginia are culturally unique and are known to have oralhealthdisparities.Thepurposeofthisstudywastoevaluatedentalfearinrelationtodelayeddentalcareasafactorinfluencingoralhealthbehaviorswithinthisculture.Methods:Acrosssectionalstudydesignwasused.Participantswereurgentcarepatientsinauniver-sitydentalclinic.Thesampleincluded140adultsoverage18years.TheDentalFearSurveywasusedtodeterminedentalfearlevel.Self-reportofdelayeddentalcarewasprovidedbytheparticipants.TheDentalFearSurveywasdichotomizedatscore33,withhigherscoresindicatingdentalfear.Results: Theprevalenceofdentalfearwas47.1%(n=66).Therewasasignificantassociationofdentalfearanddentaldelay.Theunadjustedoddsratiowas2.87(95%CI:1.17,7.04;p=0.021).Theadjustedoddsratiowas3.83(95%CI:1.14,12.82;p=0.030),controllingfortobaccouse,perceivedoralhealthstatus,pain,andlastdentalvisit.Adifferenceindentaldelaybetweenmenandwomenwasnotpresentinthissample.Theonlysignificantvariableindelayeddentalcarewasdentalfear.Conclusion:InAppalachia-WestVirginia,thereremainsahighlevelofdentalfear,despiteadvancesindentalcare,techniques,andprocedures.Keywords:Unmetneed;delayeddentalcare;dentalfear;dentalanxietyThisstudysupportstheNDHRApriorityarea,Health Promotion/Disease Prevention: Identify,de-scribeandexplainmechanismsthatpromoteaccesstooralhealthcare,e.g.,financial,physical,trans-portation.

research

introDuction

for9%ofparticipants.5Singhaletalstudiedunmetdental need during pregnancy and found women,whose annual incomes were less than $40,000,weremorelikelytohaveunmetdentalneeds.6

Riley et al indicated the sensory and temporalcharacteristicsofpainwerefactorsindelayedden-tal care.7 It was later suggested dental attitudesmore accurately explained oral health behaviors,includingdelayeddentalcare.8Rileyetalusedthecategoriesof:8

1.Individuals with favorable attitudes to dentalcare

2.Frustratedbelieversindentalcare3.Individualswithnegativeattitudesandcostcon-

cerns4.Individualspessimisticaboutpersonalandpro-fessionaloralcare

Dentalanxietyanddentalfearmayalsohavearolein explaining dental health behaviors such as de-layeddentalcare.Dentalanxietyisdefinedastheemotionalstateofunpleasantcognitionsand feel-ings,andthephysiologicalandbehavioralrespons-es relative to a dental experiencewhich precedes


thedentalencounter.1,9,10Dental fear isdefinedastheemotionalstate involvingtheactualencounteroften associated with fear of dental pain, fear ofdamage/catastrophe, fear of specific stimuli, gen-eralizedanxiety,lackofpower/control,feelingem-barrassedorshame,and/ordistrustofdentalper-sonnel.1,9,10Dentalphobiasaredefinedasclinicallydiagnosedmentaldisorderswithexcessiveanxietiesandfears.1,9,10Theprevalenceofdentalfearisdif-ficulttoestablishasvariousscalesandcriteriaexisttomeasuredental fear,andresearchersandclini-cians often use similar language interchangeably.Forexample,someresearchersreport“dentalfear”prevalencewithadefinitionofmoderatetoseverelevelsoffear,whileotherresearchersdonotincludemoderate levels in theirdefinitionof “dental fear.”Cregoetal,11inareviewofliteratureofdentalfearprevalence, found prevalences reported at 16%,1224%13and5to7%.14Asaconsequenceofthere-porteddatafromthevariousstudies,thereisalackofpreciseprevalenceestimatesfordentalfear.11

Dentalfear,dentalanxiety,anddentalpainaffectoralhealthcare.15Aviciouscycledynamic is sug-gestedasamechanismwherefearaffectsdelayeddentalcareorirregulardentalvisits,whichaffectsthe severity of dental conditions, and reinforcestreatment-relatedfearandanxietyasthetreatmentneedsbecomemorecomplex.11Individualswhode-laydentalcareoftenforegopreventivecarewhichislessintensive,expensiveandsevere.11

Appalachia-West Virginia is a culturally uniqueregionoftheU.S.Ithasapopulationof1.85mil-lion, of which 94% is non-Hispanic white.16 Themedian income is $40,043 (the national medianis $53,046), and 17.9% of the population is be-lowthe federalpoverty level (thenationalmedianis 15.4%).16 West Virginia is 42% rural. Its loca-tionhasbeendescribedasbeing in theSouth, intheMid-AtlanticregionandbeingintheAppalachiaregion—features adding to its unique characteris-tics.Theruggedmountainshave isolatedmuchofthepopulationwhichhasresultedinstrongareasofsharedcultureandculturalpride.Appalachia-WestVirginia’spopulationisdescribedasbeingcenteredonreligion,family,food,outdooractivitiesandbe-ing independent. Inaprevious studyof27adultsoverage18yearsinAppalachia-WestVirginia,themeanscoreontheDentalFearSurvey(whichhasvaluesfrom20to100)was65.7(standarddevia-tion=23).17

The people in Appalachia-West Virginia havegreater dental disparities as compared with therestofthenation.Appalachia-WestVirginiahasthehighestnationalprevalenceofolderadultswhoareedentulous(36%inAppalachia-WestVirginiacom-paredto17%nationally).18Fewerpeople inAppa-lachia-WestVirginiahavevisitedthedentistwithin

thepastyearthanthepeopleinthenation(61%inAppalachia-WestVirginiacomparedto70%nation-ally).18

Thepurposeofthisstudywastoevaluatedentalfearasafactorfordelayeddentalcare intheAp-palachia-WestVirginiaculture.Therationaleforthisstudy is that it is important todetermine the riskfactorsfordelayeddentalcareinapopulationwithsignificant oral health disparities. The theoreticalframeworkfortheresearchistheAndersenModelofHealthServicesUse.IntheAndersenModel,serviceuseoutcomes(alsocalled realizedaccess tocare,or actual utilization) are influenced by predispos-ingcharacteristics,enabling resourcesandneed.19The enabling resources include finances/insuranceforcare,thepresenceofasiteforcareinthecom-munity, support from family/friends to seek care,etc.19Needisbothaperceptionfromtheperspec-tiveof the individual andanevaluationof a clini-cianthataserviceshouldbeperformed.Themodelwasdevelopedtohaveascientificmeansbywhichtoevaluateaccesstohealthserviceutilization.20Itis an effectivemodel for use in this study in thathealthservicesinvolvemorethanstateindicators,theyinvolveinterrelationshipsofmanyfactors,andtheAndersenmodelhelpsinexplainingtherelation-ships.21


This studywasapprovedby theAppalachia-WestVirginiaUniversityInstitutionalReviewBoardandwasin compliancewith the Declaration of Helsinki. Thestudy design was cross-sectional. Participants wererecruited fromcommunity-dwellingpatients seekingcareataWestVirginiaUniversitydentalschoolurgentcareclinicduringtheirwaitinthereceptionarea.Theinclusioncriteria for theparticipantswere that theywereage18yearsandabove,andthattheyprovidedverbalconsent.Theresearchersposedthequestionstotheparticipants.Exclusioncriteriaincludedanageoflessthan18years,refusaltoprovideconsentandaninabilitytounderstandtheposedquestions.Con-sentwasobtainedfromallparticipants.Participantsdidnotreceiveanincentivetoparticipateinthesur-vey. The sample included 140 individuals, ages 18yearsandabove.

Thestudyoutcomewasdelayeddentalcare.Theparticipantswereasked“Howlonghaveyouhadto-day’s symptoms?”Thepotential responsesweredi-chotomizedto1to3daysvs.morethan3days.Thecut-point for this study was based upon the 2009consensusdefinitionoforalneglectfor institutional-izedelderlyinwhichthecriteriaforneglectforcaries,abscesses, moderate pain and periodontal disease(amongotherlistedoralconditions)fromdetectiontodiagnosiswas3days.22Thecut-pointwasalsodeter-minedasthecriteriaasabscesses,andcellulitisfrom


reSultS

odontogenicinfectionsmaydevelopveryquicklyfromtheonsetofsymptomsandbecomeseriousriskstohealthandlife.23,24

The 20-question, publicly available Dental FearSurveywasusedtoevaluatetheprimaryvariableofinterest,dentalfear.Thescalewasvalidatedacross4demographicallyandgeographicallydiversegroups.25Infactoranalysis,factorscorevariableshadcorrela-tionsoncomparablefactorsof0.93,0.96and0.97.25Thesurveyhasahighinternalconsistencyandahightest-retestreliability(r=0.74).25-27Ithasbeentrans-lated in many languages and is a research surveyusedworldwide.17,29-32

ThequestionsintheDentalfearsurveyhaveLikert-styleresponsesetsof:1=Notafraidatall,2=Alittleafraid, 3=Somewhat afraid, 4=Pretty much afraidand5=Veryafraid.32,33Thesurveywasdichotomizedatascoreof33basedupontheoperationalizedvalueformoderatefearinpreviousresearch.28,34-36Forthisstudy,scores33andaboveindicateddentalfear.Inthecollecteddata,therewere9missingvaluesfromthepotential1,800values(0.5%),andthesewerere-placedwiththeimputedneutralresponsevalueof3.

Other Variables

BivariateanalysesincludedvariablesconsideredinpreviousstudiesandimportantintheAndersenModelofHealthServicesUse.19Thepredisposingvariablesinthestudywere:sex(malevs.female),race/eth-nicity(minorityvs.white-dichotomizedduetothehigh non-Hispanic White population in Appalachia),age(25to44years;45to59years,60andabovevs.18to24years),andhighesteducationofamemberof the family in the household (high school or lessthanhighschoolvs.morethanhighschool).Theen-ablingresourcesevaluatedinthestudywere:house-hold income category (less than $15,000, $15,000to$49,000vs.$50,000andgreater),difficultyinar-rangingaridetoadentalappointment(yesvs.no),difficulty inmanaging a dental bill or dental copaybalanceof($51to$100,morethan$100vs.$50orless),anddifficultywithtakingtimefromwork(yes,Idonothaveemploymentvs.no).

Thelastdentalvisit(1tolessthan3years,3yearsandabovevs.0to1years)wasthe“healthserviceusage” in themodel.Perceivedneedwasevaluatedwithpain level(6to10vs.0to5)andself-report-edoralhealthstatus(verygood,neutral,somewhatpoor,verypoorvs.excellent).Personalhealthprac-ticeswereevaluatedwithsmokingstatus(currentlysmoking(yesvs.no)).

Statistical Analysis

IBMSPSSStatistics21(Armonk,NY)wasusedtoanalyzethedata.Thestatisticalsignificancelevelwas

determinedas0.05priortothestudy.Descriptivesta-tisticswereanalyzed.ThevariablesofinterestwerecomparedwithdelayeddentalcareusingChisquareexactanalyses.Thedatawereanalyzedwithlogisticregressionondentaldelay.

Thedescriptivestatisticsofthestudysamplearepresented in Table I. Therewere 140 participants,57.1%ofwhomweremen,46.4%ofwhomwere25to44yearsand96.4%ofwhomwerenon-Hispanicwhite. The racial characteristic of the survey sam-ple is representative of Appalachia-West Virginia.Amajority of the participants (83.6%)had a highschool education or above. There were 42.9% ofparticipantswhoreportedanincomeof$25,000to$50,000.Morethanhalfoftheparticipants(53.6%)reportedcurrentsmoking.Therewere46.4%ofpar-ticipantswhoreportedasomewhatpoororverypoororalhealthstatus,and17.1%whoreportedapainlevelof10ona0to10scale.Intermsofdentalfear,therewere47.1%withmoderatetohighdentalfearscoreson theDental FearSurvey. In termsof theoutcome variable, delayed dental care, the preva-lenceofdelayeddentalcareover3dayswas78.6%(110participants).

Inbivariateanalysiswithdelayeddentalcare(Ta-ble II), therewere several significant relationshipsbetweendelayeddentalcareandtheothervariablespresented in the study. In the primary analysis ofinterest,therelationshipofdelayeddentalcareanddentalfear,theassociationwassignificant(p=0.014).Significant relationships emerged between delayeddental careand thepain scale (p=0.021),delayeddentalcareandlastdentalvisit(p=0.009),delayeddentalcareandcurrenttobaccouse(p=0.033),de-layeddentalcareandself-reportedoralhealthsta-tus(p=0.014),anddelayeddentalcareandincome(p=0.026).Thep-valuescorresponded toanexactChisquare,one-sidedtestforthesevariables.

Table III provides the logistic regression on de-layeddentalcareanddentalfear.Intheunadjustedanalysis,theoddsratiois2.87(95%CI:1.17,7.04;p=0.021). In the parsimonious adjusted analysis,whichincludedthesignificantvariablesfromthebi-variate analysis (dental fear, current tobacco use,income,perceivedhealthstatus,painandlastden-talvisit),theassociationofdelayeddentalcareanddentalfearwas3.83(1.14,12.82;p=0.030).Noneoftheothervariablesweresignificantlyrelatedwithdelayeddentalcare intheadjusted logisticregres-sion.Inananalysiswhichadditionallyincludedsex,race/ethnicity,ageandeducation,theassociationofdelayeddentalcareanddentalanxiety/fearhadanoddsratioof4.83(95%CI:1.30,17.86;p=0.019).Dental fearwas theonlysignificantvariable in themodels.


DiScuSSion

This study of Appalachia-WestVirginia attendeestoauniversityurgentcareclinicexaminedthepat-ternsofdelayeddental careassociatedwithdentalfear.Theparticipantshadahigh(47.1%)prevalenceof dental fearwhichwasassociatedwith increased

All n(140) Percent(100)SexMale 80 57.1Female 59 42.1

Age18to24 23 16.425to44 65 46.445to59 38 27.160andabove 14 10.0

Race/EthnicityNon-HispanicWhites 135 96.4

Non-HispanicBlacks suppressed suppressed

Non-Hispanic,Other suppressed suppressed

Durationoforalsymptomsbeforeseekingcare1day 7 5.02to3days 22 15.7Morethan3days,butlessthan1month

70 50.0

Over1month 40 28.6Painlevelona0to10scale

0 16 11.41 8 5.72 5 3.63 10 7.14 2 1.45 17 12.16 11 7.97 17 12.18 24 17.19 6 4.310 24 17.1

Lastdentalvisit0to1year 64 45.71tolessthan3years 43 30.7

3yearsandabove 32 22.9

TableI:SampleDescription

All n(140) Percent(100)Difficultyinarrangingaridetoadentalappoint-ment

Yes 13 9.3No 125 89.3

Difficultyinmanagingbillorcopaybalanceof:$50orless 33 23.6$51to$100 36 25.7Morethan$100 68 48.6

DifficultywithtakingtimefromworkYes 41 29.3No 63 45.0Idonothaveem-ployment 34 24.3

EducationLessthanhighschool 22 15.7

Highschoolgradu-ationandabove 117 83.6

CurrenttobaccouseYes 75 53.6No 62 44.3

Self-reportedoralhealthstatusExcellent suppressed suppressedVerygood 23 16.4Neutral 48 34.3Somewhatpoor 45 32.1Verypoor 20 14.3

IncomeMorethan$50,000 14 10.0

$25,000to$50,000 60 42.9

Lessthan$25,000 50 35.7DentalFearSurveyScoresLessthan33 74 52.933andabove 66 47.1

TableI:SampleDescription(continued)

MeanDFSscore:41.6;SD=23.7MeanAvoidance/AnticipatoryFearscore:15.2;SD=9.8MeanFearofSpecificDentalStimuliscore:14.0;SD=8.4MeanPhysiologicalArousalscore:10.1;SD=6.4

odds of delayed dental care. This study describesdentalfearassociatedwithdelayeddentalcareinaregionofknownhealthdisparitiescomparedwiththerestoftheU.S.


Lessthan3days

Over3daydelay p-value

Sex0.294Male 14(17.5%) 6682.5%)

Female 15(25.4%) 44(74.6%)Age

0.47518-24 5(21.7%) 18(78.3%)25-44 13(20.0%) 52(80.0%)45-59 6(15.8%) 32(84.2%)60andabove 5(35.7%) 9(64.3%)

Race/Ethnicity

-

Non-HispanicWhites 28(20.7%) 107(79.3%)

Non-HispanicBlacks 0 suppressed

Non-Hispanic,Other suppressed 0

Painlevelona0-10scale

0.021

0 6(37.5%) 10(62.5%)1 2(25%) 6(75.0%)2 1(20.0%) 4(80.0%)3 0 10(100%)4 0 2(100%)5 6(35.3%) 11(64.7%)6 4(36.4%) 7(63.6%)7 4(23.5%) 13(76.5%)8 5(20.8%) 19(79.2%)9 1(16.7%) 5(83.3%)10 0 24(100%)

Lastdentalvisit

0.009

0-1year 19(29.7%) 45(70.3%)1tolessthan3years 7(16.3%) 36(83.7%)

3yearsandabove 3(9.4%) 29(90.6%)

Difficultyinarrangingaridetoadentalap-pointment

0.542Yes 3(23.1%) 10(76.9%)No 26(20.8%) 99(79.2%)

TableII:SampleDescriptionbyDentalDe-lay(n=140)

Exact2-sidedPearsonChisquareusedforthevariables:sex,age,andrace/ethnicity.Exact1-sidedPearsonChisquareusedfortheothervari-ables.

Lessthan3days

Over3daydelay p-value

Difficultyinmanagingbillorcopaybalanceof:

0.114$50orless 3(9.1%) 30(90.9)$51-$100 9(25.0%) 27(75.0%)Morethan$100 15(22.1%) 53(77.9%)

Difficultywithtakingtimefromwork

0.080Yes 6(14.6%) 35(85.4%)No 13(20.6%) 50(79.4%)Idonothaveemployment 10(21.0%) 24(70.6%)

Education

0.459

Lessthanhighschool 4(18.2%) 18(81.8%)

Highschoolgraduationandabove

25(21.4%) 92(78.6%)

Currenttobaccouse0.033Yes 11(14.7%) 64(85.3%)

No 18(29.0%) 44(71.0%)Self-reportedoralhealthstatus

0.014

Excellent 2(50.0%) 2(50.0%)Verygood 8(34/8%) 15(65.2%)Neutral 9(18.8%) 39(81.3%)Somewhatpoor 8(17.8%) 37(82.2%)

Verypoor 2(10.0%) 18(90.0%)Income

0.026

Morethan$50,000 6(42.9%) 8(57.1%)

$25,000-$50,000 12(20.0%) 48(80.0%)

Lessthan$25,000 7(14.0%) 43(86.0%)

DentalFearSurveyScores0.014Lessthan33 21(28.4%) 53(71.6%)

33andabove 8(12.1%) 58(87.9%)

TableII:SampleDescriptionbyDentalDe-lay(n=140)(continued)

This study indicates that dental fear is an addi-tionalconsiderationinthedentalattitudesassociatedwithoralhealthdisparitiesinadults.8Previousstud-ieshaveaddresseddentalavoidance;however, fewstudieshaveinvestigateddentalcarewhenaperson

issymptomatic.Rileyetalstatednopreviouspubli-cationhadexaminedsociodemographicpredictorsofdelayeddentalcareinrelationtowhenapersonwassymptomatic, prior to their study.7 They indicatedthatminoritystatusindividualsandwomenwereat


TableIII:OddsRatiosand95%ConfidenceIntervalsfromLogisticRegressiononDelayedDentalVisits(n=131)

Oddsratio[CI] p-value -2LogLikelihood modelp-valueUnadjustedHighvs.Lowfear 2.87[1.17,7.04] 0.021 137.033 0.016Adjustedmodel1Highvs.Lowfear 3.83[1.14,12.82] 0.030 99.964 0.016Adjustedmodel2Highvs.Lowfear 4.83[1.30,17.86] 0.019 94.070 0.058

Model1isparsimoniousmodeladjustedforthesignificantvariablesfromthebivariateanalyses(dentalfear,tobaccouse,income,perceivedoralhealthstatus,pain,andlastdentalvisit).Model2additionallyincludessex,race,age,andeducation.

greater risk of delayed dental care longer than 48hours after onset of pain thannon-Hispanicwhitesandmen,respectively.7ThiscurrentstudyofAppa-lachia-WestVirginiaparticipantsdidnotsupporttheresultsrelatedtogender;theonlyvariablewhichwassignificantinthisstudy’sadjustedmodelswasdentalanxiety/fear.Thisresultwasalsoreportedinastudythatexamineddentalfearandfoundgreaterdentalfearwasrelatedtonon-symptomaticdelayeddentalcareoravoidanceofdentalvisitsforanyreason.37

TheattitudesandbehaviorsofAppalachiaresidentshavebeendescribedasreflectingauniqueculture.38OneofthecommonculturalbehaviorsofAppalachiadescribed in themedical literature is “present timeorientation”inwhichpatientsseektoaddressneed-edhealthcareservicesonthedaythattheproblemmanifests,particularlythroughtherequestforanti-bioticsandthebeliefinthecureofantibioticsevenfor non-bacterial diagnoses.37 This time orientationwasnotevidentinthedentalsettingofthepresentstudy,norwas itpresent inastudyofAppalachia-Virginia inwhich residentsdelayedhealthcaredueto cultural beliefs described as “self-reliance,” and“fatalism” (controlled for health insurance).39 Andalthough health perceptions were associated withgeneral health behaviors in the Appalachia-Virginiastudy,that association was not significant for oralhealthperceptionsintheadjustedlogisticregressionondentaldelayinthisstudy.39Inafocus-groupstudyinSouthernAppalachia-WestVirginia,findingsindi-catedthatnotallculturalcharacteristicshistoricallyascribedtoAppalachiansareevidentinAppalachia-WestVirginia,includingthebeliefinfatalism.40Lim-itedhealth-seekingbehaviorwasattributedtolackofknowledgeratherthanfate/religiousfaith.40Culturehasbeenpreviouslyassociatedwithhealthbehavior,and needs to be considered as a factor in delayeddentalcareaswell,butlackofknowledgeanddentalfearareimportantaswell.40

This study has limitations. It was conducted us-ingacross-sectionaldesign,which isaveryuseful

epidemiologicdesign,but,bynature,cannotbeusedtoestablishacausal relationshipor temporal infer-ences.Participantswereaskedtorecallthelengthoftimefromsymptomonset.Thesedatamaybesub-jecttonon-differentialmisclassificationsduetorecallbias.Generally,recallbiastendstoweakenanasso-ciation.Theparticipantsmayhavebeenembarrassedorashamedtoadmitalongdelay.Therefore,asocialdesirabilitybiasmayexist in thedatawhichwouldtend to increase the number of responses of shortdelayreports.Suchabiaswouldtendtoweakenanassociation of delayed dental care and dental fear.Thedatawerecollectedoverseveralmonthsinonedentalschoolclinic’surgentcarearea,therefore,theparticipantsmaynothaverepresentedalldentalpa-tients.Also, thecultureofAppalachia-WestVirginiamay have a unique qualitymaking the results notgeneralizabletootherculturalorgeographicregions.However, the study design allowed for the presentevaluationofdental fear inadentalsetting, ratherthanaretrospectiverecalloffear.Thelogisticregres-sionsandtheresultantoddsratiosansweredthere-search question as to if there were an associationofdentaldelayandfearintheAppalachia-WestVir-ginia population. The studywould be strengthenedifitwereconductedinpractice-basedresearchnet-worksacrossAppalachia-WestVirginiaundersimilarcircumstances.

concluSion

Evidence from this cross-sectional study in apopulation located inAppalachia-WestVirginiawithhigherthannormaldentaldisparitiesindicatesaroleofdentalfearindelayeddentalcare.Datafromthisstudyaddtotheavailableliteratureevidencefurthersupporting a need to address dental fearwith thepublicinregardtotheimpactofdelayeddentalcareondentaltreatment.

Thesedatamaybeutilizedbydentalhygienists,particularlypublichealthdentalhygienistswhoareresponsibleforoutreachprogramsandroutinelyed-


1. GuayAH.Thedifferencesbetweendentalandmedi-calcare:Implicationsfordentalbenefitplandesign.JAmDentAssoc.2006;137(6):801-806.

2. AllareddyV,RampaS,LeeMK,AllareddyV,NalliahRP.Hospital-basedemergencydepartmentvisitsin-volvingdentalconditions:profileandpredictorsofpooroutcomesandresourceutilization.JAmDentAssoc.2014;145(4):331-337.

3. Cohen LA, Bonito AJ, Akin DR, et al. Toothachepain: a comparison of visits to physicians, emer-gencydepartments,anddentists.JAmDentAssoc.2008;139:1205-1216.

4. AstonG.EasingthebiteontheED.HospitalHealthNetw.2013;87:44-46.

5. ReedDB,RayensMK,WinterK,ZhangM.Healthcaredelayoffarmers50yearsandolderinKentuckyandSouthCarolina. JAgromedicine.2008;13:71-79.

6. SinghalA,ChattopadhyayA,GarciaAI,AdamsAB,ChengD.Disparitiesinunmetdentalneedandden-talcarereceivedbypregnantwomeninMaryland.MaternChildHealthJ.2014;18(7):1658-1666.

7. RileyJL,GilbertGH,HeftMW.Orofacialpain:patientsatisfactionanddelayofurgentcare.PublicHealthRep.2005;120(2):140-149.

8. Riley JL, Gilbert GH, Heft MW. Dental attitudes:proximalbasisfororalhealthdisparities inadults.CommunityDentOralEpidemiol.2006;34(4):289-298.

9. Meng X, Heft MW, Bradley MM, Lang PJ. Effectof fear on dental utilization behaviors and oralhealthoutcome.CommunityDentOralEpidemiol.2007;35(4):292-301.

10.LindsaySJ,HumphrisG,BarnbyGJ.Expectationsand preferences for routine dentistry in anxiousadultpatients.BrDentJ.1987;163(4):120-124.

11.CregoA,Carrillo-DiazM,ArmfieldJM,RomeroM.Frompublicmentalhealthtocommunityoralhealth:theimpactofdentalanxietyandfearondentalsta-tus.FrontPublicHealth.2014;2:16.

12.ArmfieldJM,SpencerAJ,StewartJF.DentalfearinAustralia:who’safraidofthedentist?Aust Dent J.2006;51(1):78–85.

13.OosterinkFM,deJonghA,HoogstratenJ.Prevalenceofdentalfearandphobiarelativetootherfearandphobiasubtypes.Eur J Oral Sci.2009;117(2):135–431.

14.SchullerAA,WillumsenT,HolstD.Aretherediffer-ences in oral health andoral health behavior be-tween individuals with high and low dental fear?Community Dent Oral Epidemiol.2003:31(2):116–211.

15.WilsonTD,McNeilDW,KyleBN,WeaverBD,GravesRW.Effectsofconscioussedationonpatientrecallofanxietyandpainafteroralsurgery.OralSurgOralMedOralPatholOralRadiol..2014;117(3):277-282.

16.UnitedStatesCensusBureau.State&CountyQuick-Facts [Internet]. Washington (DC): United StatesCensusBureau;2015May28[cited2015July13].Available from: http://quickfacts.census.gov/qfd/states/54000.html.

referenceS

acknowleDgmentS

DiScloSure

TheauthorthanksAshleyMarzolf,NatalieNelson,MaurielleStacy,AshtonStauntonfordatacollectionforthismanuscript.

Research reported in this publication was sup-portedbytheNationalInstituteOfGeneralMedicalSciencesof theNational InstitutesofHealthunderAwardNumberU54GM104942.Thecontentissolelythe responsibility of the author and does not nec-essarily represent theofficialviewsof theNationalInstitutesofHealth.Thefundershadnoroleinstudydesign,datacollectionandanalysis,decisiontopub-lish,orpreparationofthemanuscript.

ucate the public about oral health conditions. Dis-cussingdelayeddentalcareisrelevantandmayhelptoprovidebetter care if thepublic canbeencour-agedtoseekpreventive,routineandearlyinterven-tion.Theeducationprogramsshould includeadis-cussionondentalfear,andeducatorsshouldstressthatthetechnologicaladvancesindentalcarehavemadedentalproceduresmorecomfortable;andthetechnologicaladvancesinprevention/controlhelptoreducetheneedforurgentcare.

R. Constance Wiener, DMD, PhD is an assistant professor in the Department of Dental Practice and Rural Health in the School of Dentistry, and the De-partment of Epidemiology in the School of Public Health at West Virginia University, Morgantown, WV.


17.FrereCL,CroutR,YortyJ,McNeilDW.Effectsofau-diovisualdistractionduringdentalprophylaxis.JAmDentAssoc.2001;132(7):1031-1038.

18.OralHealthResourcesCDCBehavioralRiskFactorSurveillance System. Centers for Disease ControlandPrevention.2015.

19.AndersenRM.Revisitingthebehavioralmodelandaccesstomedicalcare:doesitmatter?JHealthSocBehav.1995;36(1):1-10.

20.WillisR,GlaserK,PriceD.ApplyingtheAndersenbehaviouralmodeltoinformalsupportamongBrit-ain’sethnicminorities[Internet].York(UK):BritishSocietyofGerontology.2010July[cited2015July13].Availablefrom:http://www.britishgerontology.org/DB/gr-editions-2/generations-review/applying-the-andersen-behavioural-model-to-informa.html.

21.AndersonJG.Causalmodelofahealthservicessys-tem.HealthServRes.1972;7(1):23-42.

22.KatzRV,SmithBJ,BerkeyDB,GusetA,O’ConnorMP.Definingoralneglectininstitutionalizedelderly.JAmDentAssoc.2010;141(4):433-440.

23.UluibauIC,JaunayT,GossAN.Severeodontogenicinfections.AustDentJ.2005;50(4Suppl2):S74-S81.

24.YlijokiS,SuuronenR,Jousimies-SomerH,MeurmanJH,LindqvistC.Differencesbetweenpatientswithorwithout theneed for intensivecaredue tose-vereodontogenicinfections.JOralMaxillofacSurg.2001;59(8):867-872.

25.KleinknechtRA, ThorndikeRM,McGlynn FD,Har-kavyJ.Factoranalysisofthedentalfearsurveywithcross-validation.JAmDentAssoc.1984;108(1):59-61.

26.McGlynnFD,McNeilDW,GallagherSL,VranaS.Fac-tor structure, stability,and internal consistencyoftheDentalFearSurvey.BehavAssess.1987;9:57-66.

27.JohanssonP,BerggrenU.Assessmentofdentalfear:a comparison of two psychometeric instruments.ActaOdontolScand.1992;50(1):43-49.

28.López-Jornet P, Camacho-Alonso F, Sanchez-SilesM. Assessment of general pre and postopera-tive anxiety in patients undergoing tooth extrac-tion:aprospectivestudy.BrJOralMaxillofacSurg.2014;52(1):18-23.

29.RandallCL,ShulmanGP,CroutRJ,McNeilDW.Gag-ging and its associations with dental care-relatedfear,fearofpainandbeliefsabouttreatment.JAmDentAssoc.2014;145(5):452-458.

30.EsaR,OngAL,HumphrisG,FreemanR.Therela-tionshipofdentalcariesanddentalfearinMalaysianadolescents:a latentvariableapproach.BMCOralHealth.2014;14:19.

31.SirinY,YucelB,FiratD,Husseinova-SenS.Assess-mentofdentalfearandanxietylevelsineatingdis-orderpatientsundergoingminororalsurgery.JOralMaxillofacSurg.2011;69(8):2078-2085.

32.JaakkolaS,RautavaP,AlanenP,etal.Dentalfear:onesingleclinicalquestionformeasurement.OpenDentJ.2009;3:161-166.

33.KleinknechtRA,KlepacRK,AlexanderLD.Originsandcharacteristicsoffearofdentistry.JAmDentAssoc.1973;86(4):842-848.

34.HamissiJ,HamissiH,GhoudosiA,GhholamiS.Fac-torsaffectingdentalanxietyandbeliefs inanIra-nianpopulation.IntJCollabResInternMedPublicHealth.2012;4(5):585-593.

35.Al-MadiEM,AbdelLatifH.Assessmentofdentalfearandanxietyamongadolescent females inRiyadh,SaudiArabia.SaudiDentJ.2002;14(2):77-81.

36.HilbertK.FearProcessinginDentalPhobiaduringCrossmodalSymptomProvocation:AnfMRSStudy.Psychiatryresearch.2014;202:1-9.

37.ArmfieldJM.Whatgoesaroundcomesaround:re-visitingthehypothesizedviciouscycleofdentalfearand avoidance. Community Dent Oral Epidemiol.2013;41(3):279-287.

38.Presley C. Cultural awareness: enhancing clini-cal experiences in rural Appalachia. Nurs Educ.2013;38(5):223-226.

39.McGarveyEL,Leon-VerdinM,KillosLF,GuterbockT,CohnWF.HealthdisparitiesbetweenAppalachianand non-Appalachiaan counties in Virginia USA. JCommunityHealth.2011;36(3):348-356.

40.Coyne CA, Demian-Popescu C, Friend D. Socialandcultural factors influencinghealth insouthernWestVirginia:aqualitativestudy.PrevChronicDis.2006;3(4):A124.

journal of dental hygiene · 204 the journal of dental hygiene vol. 89 • no. 4 • august 2015...

Documents