Journal of Dental HygieneVol. 90 • No. 1 • February 2016 The JourNal oF DeNTal hygieNe 3 inSiDe JourNal oF DeNTal hygieNe Vol. 90 • No. 1 • February 2016 featureS eDitorial

Vol. 90 • No. 1 • February 2016 The JourNal oF DeNTal hygieNe 1

•ParallelsbetweentheDevelopmentoftheNursePractitionerandtheAdvancementoftheDentalHygienist

•TheFrequencyofDietaryAdviceProvisioninaDentalHygieneClinic:ARetrospectiveCross-SectionalStudy

•AssociationbetweenEarlyChildhoodCaries,FeedingPracticesandanEstablishedDentalHome

•ReadabilityLevelsofDentalPatientEducationBrochures

•AnalysisofPhoneCallsRegardingFluorideExposuremadetoNewJerseyPoisonControlCenterfrom2010to2012

•EffectofaSimulationExerciseonRestorativeIdentificationSkillsofFirstYearDentalHygieneStudents

•AssessingFacultyDevelopmentNeedsamongFlorida’sAlliedDentalFaculty

•ClinicalPracticeGuidelinesforRecallandMaintenanceofPatientswithTooth-BorneandImplant-BorneDentalRestorations

Journal ofDentalHygiene

The americaN DeNTal hygieNisTs’ associaTioN

February 2016 • Volume 90 • Number 1

2 The JourNal oF DeNTal hygieNe Vol. 90 • No. 1 • February 2016

Journal of Dental Hygiene

CelesteM.Abraham,DDS,MSCynthiaC.Amyot,MSDH,EdDJoannaAsadoorian,AAS,BScD,MSc,PhDCarenM.Barnes,RDH,MSKathrynBell,RDH,MSStephanieBossenberger,RDH,MSLindaD.Boyd,RDH,RD,EdDJennieBrame,RDH,MSKimberlyS.Bray,RDH,MSColleenBrickle,RDH,RF,EdDLorraineBrockmann,RDH,MSPatriciaRegenerCampbell,RDH,MSMarieCollins,EdD,RDHSharonCompton,PhD,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,MedJoanGluch,RDH,PhD

MariaPernoGoldie,MS,RDHEllenB.Grimes,RDH,MA,MPA,EdDTamiGrzesikowski,RDH,MEdJoAnnR.Gurenlian,RDH,PhDAnneGwozdek,RDH,BA,MALindaL.Hanlon,RDH,PhD,BS,MedRachelHenry,RDH,MSLisaF.HarperMallonee,BSDH,MPH,RD/LDHaroldA.Henson,RDH,MEDAliceM.Horowitz,PhDLynneCarolHunt,RDH,MSOlgaA.C.Ibsen,RDH,MSHeatherJared,RDH,MS,BSJanetKinney,RDH,MSSalmeLavigne,RDH,BA,MSDHJessicaY.Lee,DDS,MPH,PhDDeborahLyle,RDH,BS,MSDeborahS.Manne,RDH,RN,MSN,OCNOliviaMarchisioAnnL.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,MSMelanieSimmer-Beck,RDH,PhDDeanneShuman,BSDH,MSPhDJudithSkeleton,RDH,MEd,PhD,BSDHAnnEshenaurSpolarich,RDH,PhDRebeccaStolberg,RDH,BS,MSDHJulieSutton,RDH,MSSherylL.ErnestSyme,RDH,MSTerriTilliss,RDH,PhDLynnTolle,BSDH,MSBethanyValachi,PT,MS,CEASMarshaA.Voelker,CDA,RDH,MSMargaretWalsh,RDH,MS,MA,EdDPatWalters,RDH,BSDH,BSOBDonnaWarren-Morris,RDH,MeDCherylWestphal,RDH,MSKarenB.Williams,RDH,MS,PhDPamelaZarkowski,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 90 • Number 1 • February 2016

aDHA/JDH Staff


inSiDeJourNal oF DeNTal hygieNe

Vol. 90 • No. 1 • February 2016

featureS

eDitorial

reSearcH

06 Parallels between the Development of the Nurse Practitioner and the Advancement of the Dental Hygienist HeatherTaylor,MPH,LDH

12 The Frequency of Dietary Advice Provision in a Dental Hygiene Clinic: A Retrospective Cross-Sectional Study MelanieJ.Hayes,BOH,BHSc(Hons),PhD;JohannaFranki,BOH, BHSc(Hons);JaneA.Taylor,BDS,BScDent(Hons),MScDent,PhD

18 Association between Early Childhood Caries, Feeding Practices and an Established Dental Home ErinA.Kierce,RDH,MS,MPH;LindaD.Boyd,RDH,RD,EdD;Lori Rainchuso,RDH,MS;CaroleA.Palmer,EdD,RD,LDN;AndrewsRothman, MS,EIT

28 Readability Levels of Dental Patient Education Brochures CatherineD.Boles,RDH,MS;YingLiu,PhD;DebraNovember-Rider,RDH, MS

35 Analysis of Phone Calls Regarding Fluoride Exposure made to New Jersey Poison Control Center from 2010 to 2012 SnehaShah,RDH,MPH;SamuelQuek,DMD,MPH;BruceRuck,PharmD

46 Effect of a Simulation Exercise on Restorative Identification Skills of First Year Dental Hygiene Students MargaretLemaster,RDH,MS;JoyceM.Flores,RDH,MS;MargaretS. Blacketer,MPH

52 Assessing Faculty Development Needs among Florida’s Allied Dental Faculty LindaS.Behar-Horenstein,PhD;CyndiW.Garvan,PhD;FrankA. Catalanotto,DMD;YuSu,MEd;XiaoyingFeng,BS

60 Clinical Practice Guidelines for Recall and Maintenance of Patients with Tooth-Borne and Implant-Borne Dental Restorations AvinashS.Bidra,BDS,MS,FACP;DianeM.Daubert,RDH,MS;LilyT. Garcia,DDS,MS,FACP;TimothyF.Kosinski,MS,DDS,MAGD;ConradA. Nenn,DDS;JohnA.Olsen,DDS,MAGD,DICOI;JeffreyA.Platt,DDS,MS; SusanS.Wingrove,RDH,BS;NancyDealChandler,RHIA,CAE,CFRE; DonaldA.Curtis,DMD,FACP

04 The Impact of Leadership and Research on Decision Making: The Power of Knowledge AnnBattrell,MSDH

05 Interprofessional Collaboration between Dental Hygienists and Registered Nurses: The Time is Overdue JacquelineE.Sharpe,RN,MSN,CHES,PhD;MugeAkpinar-Elci,MD,MPH

critical iSSueS in Dental Hygiene

Practice guiDelineS

letter to tHe eDitor


TheImpactofLeadershipandResearchonDecisionMaking:ThePowerofKnowledge

eDiTorial

AnnBattrell,MSDHInmyroleasChiefExecutiveOfficeroftheAmerican

DentalHygienists’Association(ADHA),Ihavehadthehonorandprivilegeofworkingalongsidemanydentalhygieneleadersinavarietyofprofessionalroles.WhatIhaveobservedintheseleadersisthateachhastheirownuniquestyleofleadershipthathasallowedthemtoleavealastingimpressiononourprofessionandonADHA. In thisway, each leader is like a fingerprint,showcasingtheirindividualityandcreativity.

Thinkingaboutleadershipasafingerprinthelpstounderstandwhatittakestobeagreatleader.Inorderforthatuniquenessandcreativitytohavealastingim-pact, leadersneedtopossesscertainskills.Acrucialleadershipskillistheabilitytoinfluenceothers.Influ-encecanoccurthroughhavingexcellentcommunica-tionskills,andtheconfidencetocommunicate ideasandgoalstoothers.Additionally,greatleaderswillof-tenfindother leaderstoemulate, identifying leader-shipbehaviorsthatspeaktothem.Weoftenseedentalhygienestudentsemulatingthe leadershipbehaviorsoftheirfaculty,andmanyofuscanbringtomindafacultymemberearlyoninoureducationthatplantedandnurturedtheseedsofourownleadership.Itisim-portantthatleaderscreateavisionofthepersontheywanttobe,andthattheyhavethementorstodoso.

However,individualityandcommunicationareonlytwopiecestothepuzzle.Leadersareoftencalledupontomakedecisionsonavarietyofmatters,anddentalhygieneleadersarenoexception.Thecomplexitiesoftheissueswefaceanddecisionsthatmustbemadeareconsiderable.Therefore,inordertomakesenseofcomplexissuesandtomakedecisionsinthebestinter-estoftheorganization,today’sleaders(aswellasourfutureleaders)needtopossesscriticalthinkingskillsthatenablesounddecisionmaking.

Severalyearsago,theADHABoardofTrusteesmadeasignificantdecisiontouseaknowledge-baseddeci-sionmakingmodel,providedbyTeckerInternationalConsulting,foralloftheirgoverningresponsibilities.1Theknowledge-baseddecisionmakingmodelasks:

1.Whatdoweknowaboutourstakeholders’needs,wantsandpreferences,thatisrelevanttothisdeci-sion?

2.Whatdoweknowaboutthecurrentrealitiesandevolvingdynamicsofourenvironmentthatisrel-evanttothisdecision?

3.Whatdoweknowaboutthecapacityandstrategic

positionofourorganizationthatisrelevanttothisdecision?

4.Whataretheethicalimplicationsofthisdecision?

Notice that each of these questions beginswith thephrase,“Whatdoweknowabout…?”OurroleasADHAstaffistogathertheevidenceforeachoftheseques-tionsthatwillprovidethe“knowledge”uponwhichtheBoardofTrusteeswilldeliberateanddebatetomaketheirfinaldecisions.Utilizingaknowledge-baseddeci-sionmodelenablestheboardmember’scriticalthink-ingskills,andreducestheincidentsofemotionaldeci-sionmakingoranecdotaldecisionmaking.

No matter which professional role dental hygien-istschooseastheircareerchoice,dailydecisionsneedto bemade. The underpinning of the decisionmak-ingprocessisevidenceandknowledge.Evidenceandknowledge provides the answer to the fundamentalquestionof“WhatdoIknowabout…”Dentalhygienistsinaclinicianrolehavetheresponsibilityforusingthedentalhygieneprocessofcaretoultimatelydeterminea dental hygiene diagnosis and treatment plan, andevaluate theoralhealthoutcomes for theirpatients.Scientificevidence,orknowledge,istheunderpinningupon which oral health care providers should maketheirdecisions.

It isthroughourcommitmenttoresearchandthequesttobuildthedentalhygieneknowledgebasethatour profession grows and our ability to provide evi-dence-basedcaretoourpatients.Simplyaskingour-selves thequestion“Whatdo Iknowabout…” is thestartingpointtosearchingforknowledge,informationandscientificevidenceforthecriticalthinkingneces-saryforleadersinalloftheprofessionalrolesofaden-talhygienist.

Sincerely,

AnnBattrell,MSDHCEO,AmericanDentalHygienists’Association

1. Knowledge-BasedDecisionMaking.TeckerInter-nationalConsulting[Internet].2012[cited2016February 5]. Available from: http://www.tecker.com/wp-content/uploads/2012/10/TIKBDM-Jan12.pdf

referenceS


The recentpublicationofanarticle that is listedasaCriticalIssueintheJournalofDentalHygiene1deservesstrong lettersofendorsement fromnurs-ing professionals.2 It has been twelve years sincetheInstituteofMedicinecalledforinterprofessionaleducationtobeadoptedbythehealthprofessionaleducation community. The increasing numbers ofdentistsindentalprogramsandthedecreasingnum-bersofphysiciansinmedicalprogramslenditselffordentistsandphysicianstobesupportiveofsuchin-terprofessionalcollaborations.Thereissomuchpo-tentialforregisterednursesanddentalhygieniststowork together to improve thehealthof thepublic.Thisrecentpublicationservestorefuelthequestionraised by Jackie Fried in 1987, “InterprofessionalCollaboration:Ifnotnow,when?”3Andadditionally,theEditorialremarksmadebyLisaMalloneein2012,“The Need for Inter-Professional Collaboration.”4The dental hygienists and registered nurses of to-dayneedtodevelopinter-professionalrelationships–now!Thegrowingnumbersofthepopulationandbecauseofpeoplelivinglongerdemandsit.Theedu-cationalpreparationforaregisterednurse,doesde-terminethedegreeofabilitytoprovideoralcaretoapatient,otherthanjusthandingthepersonatooth-brushandsometoothpaste.Forexample,aclinicalmaster’sdegreeinnursingpreparationandthatofadoctoratedegreeinnursingprovidestheknowledgeandskillsforphysicalassessmentskillsfortheentirebodyfordiagnosticpurposes.Buttheneedbeingad-dressedinthisarticlepertainingtoregisterednursesisexaminingoralcomplicationsofxerostemia,dys-phagia,andtrimus.Eveneducatingthenursingstaffonthecareofpatientswithdentureswouldhelpde-creasetheirunnecessarylossesandbreakageswhenhospitalized.Ittakesmorethanatoothbrush,asuc-tion tip, and toothpaste tomeet theneedsof cer-tainkindsofpatientsthatmandatesspecializedoralcare;theexamplesmentionedarejustafewwheretheexpertiseandtheskillsofadentalhygienistcanprovideassistance.Wemustfirstbegininterprofes-sional collaboration by breaking down barriers toeffectivecommunication,misperceptionsofoccupa-tionalroles,andoutoftouchcurriculainthetrain-ing of these two professional groups that still areaddressingthehumanbodyasifitisseparateandnotoneunitthatworkstogether.Programsforcon-

InterprofessionalCollaborationbetweenDentalHygienistsandRegisteredNurses:TheTimeisOverdueJacquelineE.Sharpe,RN,MSN,CHES,PhD;MugeAkpinar-Elci,MD,MPH

leTTer To The eDiTor

tinuingeducationforregisterednursesmustrealizethat there are gaps in the educational preparationofnursesduetoprogramvariations forknowledgeandskillsrequired.Diverseeducationalpreparationcanleadtodifferencesinskilltrainingthatcanlaterbeobtainedthroughcontinuingprofessionaleduca-tion.Opportunitiestoclosethisgaptoenhancecareformeeting theoralneedsofpatients canbemetbydentalhygieniststhroughcontinuingprofessionaleducation as well as interprofessional educationalinitiatives between students of dental hygiene andBachelorofScienceinnursingdegreestudents.5Re-centresearchconductedbythedentalhygieneanddental professionals have consistently shown thatthereisneedforinterprofessionalismamongothergroupsandnotjustwithnursing.However,resultsofsuchresearchmustalsobewidelypublishedincom-munitiesotherthanjustthedentalmedium.

Jacqueline E. Sharpe, RN, MSN, CHES, PhD; Muge Akpinar-Elci, MD, MPH. College of Health Sciences, Old Dominion University.

1. PerryAD,IidaH,PattonLL,WilderRS.Knowledge,PerceivedAbilityandPracticeBehaviorsRegardingOralHealthamongPediatricHematologyandOn-cologyNurses.J Dent Hyg.2015;89(4):219-228.

2. Fried J. Interprofessional Collaboration: If NotNow,When?J Dent Hyg.1987;87(Suppl):41-43.

3. MalloneeLF.TheNeed for InterprofessionalCol-laboration.J Dent Hyg.2012;86(2):56-57.

4. PalattaA,CookBJ,AndersonEL,ValachovicRW.20yearsbeyondthecrossroads:thepathtointer-professionaleducationatusdentalschools.J Dent Educ.2015;79(8):982-996.

5. GrantL,MckayLK,RodgersLG,WiesenthalsLS,CherneySL,BettsLA.Aninterprofessionaleduca-tioninitiativebetweenstudentsofdentalhygieneand bachelor of science in nursing.Can J Dent Hyg.2011;45(1):36-44.

referenceS


Dental hygienists have often been describedas the registerednurses (RN)of thedentalfield.Today there are many more advanced nursingrolesbeyondthatoftheRN.Forexample,nurseshaveexpandedtheireducationandcareeroptionsthroughtheintroductionofthenursepractitioner.1Thepolitical,socialandeducationalenvironmentsthat existed when nurse practitioners were firstintroduced to the U.S. health care system havestrikingsimilaritiestotheenvironmentthatdentalhygienistsfind themselves in todayas theyworktowardadvancingtheirprofession.Althoughthereisconstantchangeinhealthcare,thepublichealthissues driving changes have remained the sameover the last50yearsandacrossall healthpro-fessions (e.g., access to care, lack of affordablecare, provider shortages).2 Political, educationaland social issues were key in the developmentof the nurse practitioner and will continue to beparamount in theadvancementof thedental hy-gienist.1Understandinghowthenursingprofessionaddressed public health issues, expanded theireducation,andconfrontedpoliticalandsocialchal-lengesthroughtheintroductionofthenurseprac-titioner will help dental hygienists gain perspec-tiveabouttheirroleinhealthcare.1-3Recognizingthepathwaysofprogressandthehistoricalback-ground of the nurse practitionermay allow den-talhygieniststobetterdirecttheirownexpandedroles in therapeutic health care. This critical is-suespaperevaluatessimilaritiesbetweenthepro-fessions as related to historic and current public

ParallelsbetweentheDevelopmentoftheNursePractitionerandtheAdvancementoftheDentalHygienistHeatherTaylor,MPH,LDH

AbstractPurpose:Dentalhygienistshaveoftenbeendescribedastheregisterednursesofthedentalfield.Simi-larparallelsalsoexistbetweenthedevelopmentofthenursepractitionerfromthenursingprofessionandtheevolutionofthedentalhygienepracticeandprofession.Thisarticleexplores3majorsimilaritiesbetweentheprofessionsofnursepractitioneranddentalhygienist.Publichealthissues,educationalcon-structs,andthesocialandpoliticalenvironmentsshapingeachprofessionarediscussedtoinformdentalhygienistsoftheirpotentialcareeroptionsforfutureexpandedtherapeuticcareroles.Keywords:dentalhygiene,nursepractitioners,mid-levelprovider,publichealthThisstudysupportstheNDHRApriorityarea,Professional Education and Development: Investigatehowotherhealthprofessionshaveestablishedthemastersanddoctorallevelsofeducationastheirentrylevelintopractice.

criTical issues iN DeNTal hygieNe

introDuction

health issues,theeducationalconstructsforbothhealthcareproviders,andthesocialandpoliticalenvironment that continues shaping both profes-sions.1-37 Growth potential for the dental hygieneprofessioncanbefurtherexamined.

Public Health Issues

Nurse practitioners were introduced into theU.S.healthsysteminthe1960sinresponsetothepublic’s concernoverphysician shortagesaswellasthedemandforaffordableprimaryhealthcareservicestounderservedpopulationsandgroups.1-4Atthetime,thenumberofprimarycareproviderswas insufficient tosupport thedemandandneedformedical care.Physicianspecializationcontrib-utedtoadecreaseinthenumberofprimarycareproviders.2Vulnerablepopulations,includingruralandpoorurbanpopulations,women,children,andthe elderly had the greatest difficulty accessingmedicalcare.2Arealpublichealthneedforanewworkforcemodelemergedasaresultofaccessis-sues.Theevolutionoftheindependentnurseprac-titioner fromexisting nursing educationalmodelswastheresult.1

Justasinthe1960swhenmedicalcareconcernsfocused on physician shortage and rising costs,dentistry faces similar issues. According to theU.S. Department of Health and Human Services,thenumberoftraditionaldentalhealthprofession-alshortageareashastripledinthelast25years.5


Currently,about5,000areasintheU.S.aredes-ignatedasdentalhealthprofessionalshortagear-eas(aratioof5,000ormorepeopleto1dentistin thearea).Reportedly, itwouldrequireroughly7,300more dentists to eliminate the designationof these shortage areas.6 Approximately 5,200studentsgraduatedfromdentalschoolsacrosstheU.S. in2013,but3,500dentistsretired lastyearandthatnumberisexpectedtorisewiththeagingworkforcepopulation.7,8TheHealthResourcesandServicesAdministration(HRSA) releaseda reportinFebruaryof2015concludingthatall50statesintheU.S.willexperienceashortageofdentistsby2025.9Theshortageofprimarydentalcareprovid-ersisclearlyevidentinepidemiologicdata.5-9

Dentalhealthshortageareastypicallyarepopu-latedbysomeofthemostvulnerablepopulations.6Disproportionately distributed dentists, coupledwith the lownumbersofdentistswhoparticipateinMedicaid,equatestomillionsoflow-incomechil-drenwithinadequatedentalcare.10ThePEWChar-itableTrustsreportedthatin2011,lessthanhalfof the Medicaid-enrolled children received dentalcarein22states.10Thesefactsaresignificantsincelower income children are twice as likely to de-velopcavitiesastheiraffluentcounterparts.10Lowprovidernumbersandunmetneedsoftheunder-servedare2substantialparallelsbetweenthede-velopment of nurse practitioners and the futureexpansion of the dental hygienist’s roles.1-6,9 Lownumbersofdirectaccessdentalcareprovidersandunderserved populations are now also promptingdiscussions about expanding roles for dental hy-gienists, educatingmoremid-level providers andmaking legislative changes to treat underservedpopulations.9

Risingdentalcostsalsoparalleltherisinghealthcare costs that occurred during the introductionofthenursepractitioner.11-13DuringWorldWarII,health careexpendituresaccounted for0.38%ofthe nation’s Gross Domestic Product (GDP).11 By1961,ithadrisento1%,andresultedinconcernover the lack of affordable care for the elderly,childrenandwomen.11Thisencouragedthedevel-opmentofadifferentworkforcemodelinprimarycare, thenursepractitioner.11Economiccostsaresignificantly higher today. In 2012, health careexpenditures accounted for 17.2% of the GDP,meaning that, on average $8,915 is spent perperson for health care.12 Cost of dental servicesreached $110.9 billion in 2012 and continues toincrease.13 Ultimately much like the introductionof thenursepractitioner, the introductionofnewdentalhygiene-basedworkforcemodelsacrossthenationarebeingdrivenbysimilarpublichealthis-sues(e.g., insufficientdentalcareproviders, lackofdentalcareforvulnerablepopulationsandrisingdentalcarecosts).9,10,13

Constructs of Education

Registerednursesmustobtainamaster’sordoc-toraldegreeandthenseekadditionallicensureinordertobecomeanursepractitioner.14Today,thereareover350academicnursepractitionerprogramsintheU.S.15TheseprogramsstartedwhennursingpioneersLorettaFordandHenrySilverrespondedtodemandsformorehealthcareaccess.2FordandSilverrecognizedtheneedfornursestohavead-ditional education and training to allow formorepatient responsibility in expanded roles of care.2Thenewprogramwouldpreparenursestoassumemoreresponsibilityintreatingunderservedpopu-lations.2,3 To fulfill such roles, thesepioneersun-derstood that education of the nurse practitionerneededtogobeyondabachelor’sdegree.16

Statelicensingboardsfornursesrecognizeboththe associate and baccalaureate entry points.1The same is true of dental hygiene, thus addingtoeducationalinconsistencyamongpracticingpro-fessionals. Such inconsistency can adversely in-fluencegraduate education for advanced-practicedentalhygienistsbecausetherecanbe“noexpec-tations for a student’s consistent knowledge andskill levelonadmissionorafterprogramcomple-tion.”1TheAmericanDentalEducationAssociation(ADEA)recognizedtheimplicationsofvaryingen-try-levelprogramsindentalhygienebackin2011.AbriefentitledBracingforTheFuture:OpeningUpPathwaystotheBachelor’sDegreeforDentalHy-gienistsstressedthevalueofabachelor’sdegreesothatdentalhygienistscouldentermaster’s-levelprograms to ensure safe provision of services inexpandedroles.17

Economically,itismostfeasibletotrainmid-lev-eloradvancedprovidersbysupplementingtheed-ucationoflicenseddentalhygienistsjustasnursesdid with the nurse practitioner model. Advanceddentalhygieneroleswouldrequiremoreeducation,andconsequentlytheAmericanDentalHygieneAs-sociation(ADHA)anddentalhygieneeducatorsareestablishingaccreditationstandards foradvancedpracticedentalhygieneeducationalprogramsandnewworkforcemodels.TheCommissiononDentalAccreditation(CODA)assignedataskforcetorec-ommendstandardsforeducatingdentaltherapists,that is, mid-level providers. Initially, however, itdidnotseemthatthestandardsrecommendedbythetaskforceinDecemberof2013wereinclusiveof dental hygiene-track advanced providers. Theresponse,whichwasprovidedbythedentalcom-munity,ADHAandtheFederalTradeCommission,encouragedrevisionstotheserecommendations.18As of February 2015, CODA approved standardsthatallowforaccreditationofdentalhygiene-trackadvanced providers.19 Just like pioneers in nurs-ingrespondedin1965withtheintroductionofthe


nursepractitionermodel,sotootoday,ADHAanddentalhygieneeducatorsaresupportingnewwork-forcemodelsandaccreditationstandardsaddress-ingtheshortageofdentalprovidersandconcernsover risingdental carecosts.4,16,20Withexpandedrolesfordentalhygienists,educationalpathsandspecializedgraduatedegreeprogramsmustbees-tablished.16

Social and Political Environments

The introduction of the new nurse practitionerworkforcemodel toprimarymedical caredidnotcome without substantial battles. As the profes-siongrew,nursepractitionersfacedrestrictionsonpractice, resources and reimbursement.1,14 Theselegal and political barriers were often driven byphysicians’territorialism,needsforstatusandcul-ture.1,2Organizedmedicine viewed this new typeofworkforcemodelwithsuspicion,andexpressedconcernsaboutnursespracticingwithoutdirectsu-pervisionofaphysician.2

Despite opposition, nurse practitioners docu-mented expertise in disease prevention, publichealthpromotion,theabilitytoincreaseaccesstocareandpatientsatisfaction.1Substantialliteratureexistsdocumentingthatprimarycareoutcomesdonotdifferbetweenthedeliveryofcareofferedbya nurse practitioner and a physician.21-25 Despitethis, nurse practitioners are hindered by “incon-sistentstatelaws,insurancereimbursementprac-ticesandamedicalcommunitythatclingstoout-moded notions of a physician-nurse hierarchy.”14Continuedresearchinareasofpatientsatisfactionandcaredocumentingfurtherbeneficialoutcomesmayassistnursestomoveforwardinpracticeandacceptance.2

Similartothenursepractitioner,theexpansionof roles and education for dental hygienists hasreceived resistance. Since regulations and scopeofpracticedefinitions fallunderstate laws, thereareavarietyofdifferences regardinghowdentalhygienistscanpracticewithineachstate.26Forin-stance, in Colorado dental hygienists are legallyable to perform several dental preventive proce-dures independently,withoutthesupervisionofadentist.27Theseproceduresincludedentalprophy-laxis,exposureofradiographs,topicalanesthesia,fluoride application, sealants, anddental hygienediagnosis and treatment planning. In contrast,Indiana isastatewheredentalhygienistscannotperformasimplenon-invasiveproceduresuchasplacingacaries-preventivesealantonapatient’stoothwithoutthedirectsupervisionorwrittenau-thorizationofadentist.26,28Despitetheevidenceofpatient safety and satisfactionwith direct accessdental hygiene care, there aremany states withrestrictivepracticeacts.29-32

DiScuSSion

Table I provides additional parallels betweentheprofessionaladvancementofnursesandden-tal hygienists. These key advancements in boththenursinganddental hygieneprofessionsallowhealth care providers to see similarities and thebenefits of strategically moving the professionforward in education, political, social and publichealtharenas.

Notably, however, it is crucial for the profes-sionofdentalhygienetorecognizethatunlikethenursingprofession,whichisself-regulated,dentalhygienistsareprimarilyregulatedbytheiremploy-ers, dentists.33 Nursing first established self-reg-ulation in1903and lateroutlined thepracticeofregistered nurses between the 1930s and 1950sthroughstateNursePracticeActs(NPAs).34TheseNPAs define nursing practice as independent ofphysicians, and allow state boards controlled bynurses to determine licensure requirements andcodesofethicsfortheprofession.34

Unlikenurses,theprofessionofdentalhygienedoesnothaveautonomy,whichallows state leg-islatorsanddentalboards tosuppressdentalhy-gienists from practicing to the fullest extent oftheirtraining.Wancheksuggestedthatbyexpand-ing educational opportunities and reducing scopeofpracticerestrictionsondentalhygienists,statescould reduce oral disparities and increase accesstodentalcare.33Aswithotherhealthprofessionalswhoareself-regulated,“dentalhygienistspossesstheknowledge,skillandjudgmenttobestregulatethe profession.”35 Therefore, self-regulation willbe importantfortheprofessionofdentalhygieneto obtain to further develop advanced workforcemodelsandgreaterscopeofpracticenationwide.Conducting and publishing additional researchdocumenting quality of care and patient safety,alongwithdentalcostsavings,shouldalsoencour-agenewregulationstandardsandadvancedprac-tice models in dental hygiene, as has happenedin nursing.26,36 The development of advanced ed-ucational models is currently moving forward sothat the profession is adequately educated andcapable of delivering care in expanded practicesettingstreatingunderservedpopulations.16,19Ad-

As the profession of dental hygiene advancesinto the future, researchwill beneeded todocu-mentqualitycareandsatisfactionachievedundernewdentalhygieneworkforcemodels.Suchdatacouldvalidate thecontinueddevelopmentofneworal health care deliverymodels. Just as equiva-lencyofmanyoutcomeshasbeendocumentedbe-tweennursepractitionersandphysicians,outcomeassessments will compare the care provided bydentistsanddentalhygienists.


concluSion

Dental hygiene is facing a paradigm shift forchanging and advancing professional educationandpractice.Theprofessioncanlearnfromstudy-ingthehistoryofthenursepractitioner,includingthe fact that although nurses faced opposition,theywereabletoestablishhighereducationallev-

Advancement Year NursingProfession Year DentalHygieneProfession

Education 1873Firstnursingeducationalprogramopens-BellevueSchoolofNursing,

NewYork1913

Firstschoolfordentalhygieneopens-FonesSchoolofDentalHygiene,

Connecticut

PoliticalandSocial 1896

FormationofprofessionalassociationrepresentingnursesknowntodayastheAmericanNursesAssociation

(ANA)

1923 FormationoftheAmericanDentalHygienists’Association(ADHA)

Education 1900 Publicationofthejournal,AmericanJournalofNursing–1900 1927 Firstpublicationofwhatisknown

todayasJournalofDentalHygiene

PoliticalandSocial 1938 NewYorkbecomesthefirststatetorequirelicensurefornursingpractice 1920 Sixstateshaveestablishedlicensure

fordentalhygienists

Education 1965 Firstnursepractitionerprogramcre-atedattheUniversityofColorado 1947

AmericanDentalAssociation(ADA)andADHAsetaccreditationstan-dardsfordentalhygieneeducational

programs

Education 1973 ANApublishedaccreditationstan-dardsfornursingeducation 1951

ADACouncilonDentalEducationestablishesaccreditationstandardsfordentalhygieneeducation

PoliticalandSocial/PublicHealth

1977to1983

Multiplestudiespublishedcompar-ingnursepractitionercaretothatof

physicians

InstituteofMedicinedocumentscostreductionsandeconomicfeasibilityofcareprovidedbynursepractitio-

ners

1996to1997

Studiespublishedonindependentlypracticingdentalhygienistsshowsafetyandhighqualityofcare

1992

YaleJournalofRegulationpublishesjournalissueoncost-effectiveandhighqualitycareofnursepractitio-ners–acallismadetoeliminate

regulatoryrestrictions

2014

NationalGovernorsAssociationpublishesarticleonincreasedaccesstocarebydentalhygienists–acallismadetoallowdentalhygieniststobereimbursedbyMedicaidandtodecreasepracticeandsupervision

restrictions

TableI:KeyAdvancementswithintheNursingandDentalHygieneProfessionsoftheU.S.2,25,26,36-41

vanceddentalcarepractitionerscanhelpaddressthecomplexdentalpublichealthproblems in theU.S.,justasnursepractitionershavedoneforthenursingprofession.26,36

els within nursing to educate nurse practitionersadequately for expanded roles.1 The progress ofthenursingprofessionviathedevelopmentofthenursepractitionerwithinpublichealth,education,and social and political environments illustratesthepotentialgrowthofthedentalhygieneprofes-sion by way of advanced education and practicemodels.

Heather Taylor, MPH, LDH, is a Visiting Clini-cal Assistant Professor at the Indiana University School of Dentistry in the Department of Cardiol-ogy, Operative Dentistry and Dental Public Health.


1. Sullivan-Marx EM, McGivern DO, Fairman JA,GreenbergSA.NursePractitioners:TheEvolutionandFutureofAdvancedPractice.5thed.SpringerPublishingCompany,LLC;2010.432p.

2. O’BrienJM.Hownursepractitionersobtainedpro-viderstatus:lessonsforpharmacists.Am J Health Syst Pharm.2003;60(22):2301-2307.

3. SavrinC.Growthanddevelopmentof thenursepractitionerrolearoundtheglobe.J Pediatr Health Care.2009;23(5):310-314.

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9. National and State-Level Projections of DentistsandDentalHygienistsintheU.S.,2012-2025.Na-tionalCenterforHealthWorkforceAnalysis.2015.

10.InSearch ofDental Care: TwoTypes ofDentistShortagesLimitChildren’sAccesstoCare.ThePEWCharitableTrusts[Internet].2013[cited2014July31]. Available from: http://www.pewtrusts.org/en/research-and-analysis/reports/2013/06/23/in-search-of-dental-care

11.ChantrillC.USHealthCareSpendingHistoryfrom1900. usgovernmentspending.com [Internet].2014[cited2014July30].Availablefrom:http://www.usgovernmentspending.com/healthcare_spending

12.National Health Expenditure Data. Centers forMedicareandMedicaidServices.2014.

13.National Health Expenditures 2012 Highlights.CentersforMedicareandMedicaidServices.2014.

14.Hansen-TurtonT,WareJ,McClellanF.NursePrac-titioners in Primary Care. Temple Law Review.2010;82:1236-1262.

15.Education. American Association of Nurse Prac-titioners [Internet]. 2013 [cited 2014 August25]. Available from: http://www.aanp.org/education/61-education/faq-np-prep/306-how-many-np-programs-are-there

16.DarbyML.TheAdvancedDentalHygienePractitio-nerattheMaster’s-DegreeLevel:IsitNecessary?J Dent Hyg.2009;83(2):92-95.

17.Bracing for The Future: Opening Up Pathwaysto the Bachelor’s Degree for Dental Hygienists.AmericanDentalEducationAssociation[Internet].2011[cited2014July31].Availablefrom:http://www.adea.org/policy_advocacy/workforce_is-sues/Documents/IHEP2011.pdf

18.Bowers D. Making an Impact. Access.2014;28(3):5.

19.Accreditation News. Commission on Dental Ac-creditation. American Dental Association [Inter-net].2015[cited2015March30].Availablefrom:http://www.ada.org/en/coda/accreditation/ac-creditation-news

20.StolbergRL,BrickleCM,DarbyMM.Developmentandstatusoftheadvanceddentalhygienepracti-tioner.J Dent Hyg.2011;85(2):83-91.

21.LambingAY,AdamsDL,FoxDH,DivineG.Nursepractitioners’ and physicians’ care activities andclinicaloutcomeswithaninpatientgeriatricpopu-lation.J Am Acad Nurse Pract.2004;16(8):343-352.

22.SoxHC,Jr.Qualityofpatientcarebynursepracti-tionersandphysician’sassistants:aten-yearper-spective.Ann Intern Med.1979;91(3):459-468.

23.MundingerMO,KaneRL,LenzER,etal.Primarycareoutcomesinpatientstreatedbynurseprac-titionersorphysicians:arandomizedtrial.J Am Med Assoc.2000;283(1):59-68.

24.LenzER,MundingerMO,KaneRL,HopkinsSC,LinSX.Primarycareoutcomesinpatientstreatedbynursepractitionersorphysicians:two-yearfollow-up.Med Care Res Rev.2004;61(3):332-351.

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26.TheRoleofDentalHygienistsinProvidingAccesstoOralHealthCare.NationalGovernorsAssocia-tion[Internet].2014[cited2014July1].Availablefrom: http://www.nga.org/files/live/sites/NGA/files/pdf/2014/1401DentalHealthCare.pdf

27.DirectAccessStates.AmericanDentalHygienists’Association[Internet].2014[cited2014July31].Availablefrom:https://www.adha.org/resources-docs/7513_Direct_Access_to_Care_from_DH.pdf

28.DentalHygienePracticeActOverview:PermittedFunctionsandSupervisionLevelsbyState.Amer-ican Dental Hygienists’ Association [Internet].2013[cited2015April2].Availablefrom:http://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf

29.Astroth DB, Cross-Poline GN. Pilot study of sixColoradodentalhygieneindependentpractices.J Dent Hyg.1998;72(1):13-22.

30.BattrellAM,Gadbury-AmyotCC,OvermanPR.Aqualitativestudyoflimitedaccesspermitdentalhy-gienistsinOregon.J Dent Educ.2008;72(3):329-343.

31.Perry DA, Freed JR, Kushman JE. Characteris-tics of patients seeking care from independentdental hygienist practices. J Public Health Dent.1997;57(2):76-81.

32.Kushman JE, PerryDA, Freed JR. Practice char-acteristics of dental hygienists operating inde-pendently of dentist supervision. J Dent Hyg.1996;70(5):194-205.

33.Wanchek T. Dental Hygiene Regulation and Ac-cess to Oral Healthcare: Assessing the Varia-tionacrosstheUSStates.British J Indust Relat.2010;48(4):706-725.

34.Hartigan C. APRN regulation: the licensure-certification interface. AACN Adv Crit Care.2011;22(1):50-65.

35.JohnsonPM.Dentalhygieneregulation:aglobalperspective.Int J Dent Hyg.2008;6(3):221-228.

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37.InstituteofMedicineDivisionofHealthCareSer-vices. Nursing and Nursing Education: PublicPolicies andPrivateActions.NationalAcademiesPress.1983.

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The close relationship between diet and oralhealth iswell-established,withawealthof infor-mationdemonstratingtheimpactthatdiethasondentaldiseases,inparticulardentalcariesandero-sion.1-3Dental cariesoccurswhenbacteria in theoral cavitymetabolize fermentable carbohydratesand organic acids are produced, causing demin-eralization of hard tooth structure.1 This processdependsonthepresenceoffermentablecarbohy-drates, thus being directly associated with diet.Whiledentalcaries incidence inAustraliahasde-creased significantly over the last 30 years, thistrend seems to have reached a plateau, and thecariesincidenceinmanypopulationsubgroupsre-mainsunacceptablyhigh.4EarlyChildhoodCaries(ECC) is particularly concerning as it is charac-terizedby severe, rampant caries in the teethofyoung children and is closely associatedwith in-fant feedingpractices.5Dentalerosion is the lossofhardtoothstructureduetoaciddestruction,themost common cause being dietary acids.1 Dentalerosionappears tobeagrowing issueand ithasbeen hypothesized that this rise in prevalence isduetoanincreasedconsumptionofacidicdrinks.6Aswellascontributingtothedevelopmentoforal

TheFrequencyofDietaryAdviceProvisioninaDentalHygieneClinic:ARetrospectiveCross-SectionalStudyMelanieJ.Hayes,BOH,BHSc(Hons),PhD;JohannaFranki,BOH,BHSc(Hons);JaneA.Taylor,BDS,BScDent(Hons),MScDent,PhD

AbstractPurpose:Theaimofthisretrospective,cross-sectionalstudywastoassessthefrequencyofdietaryadviceprovisionbydentalhygienestudents.Methods:Datawasobtainedfromclinicalrecordsofthird-yearBachelorofOralHealthstudentsattheUniversityofNewcastle.Frequencyofdietaryadvicewasrecordedbystudentsovera12-monthperiod.Thestudyinvestigatedassociationsbetweendemographics,treatmentprovidedandfrequencyofdietaryadvice.Results: The results indicateddietaryadvicewasprovided infrequentlybydentalhygienestudents,withonly6.48%ofallpatientsseenduringthe12-monthperiodreceivingdietaryadvice.Astatisticallysignificantcorrelationwasobservedbetweendietaryadviceandage,withchildrenundertheageof18being2.5timesmorelikelythanadultstoreceivedietaryadvice.Additionally,patientswhoreceivedoralhygieneinstructionwere2.5timesaslikelytoreceivedietaryadvice.Strongcorrelationswerealsoobservedbetweentopicalandconcentratedfluorideapplicationanddietaryadvice.Conclusion:Thefindingsindicatedietaryadviceisprovidedinfrequentlybydentalhygienestudents.Furtherresearchisrequiredtostrengthenthefindingsandtoinvestigatebarrierstodietaryadviceprovi-sion,aswellasperceptionsofdentalpractitionersregardingdietaryadvice.Keywords:dentalhygienist,dietaryadvice,studentsThisstudysupportstheNDHRApriorityarea,Clinical Dental Hygiene Care: Investigatehowdentalhygienistsuseemergingsciencetoreduceriskinsusceptiblepatients(riskreductionstrategies).

research

introDuction

health problems, diet also has a direct effect ongeneralhealth.Poordiethasbeenshowntocon-tribute tosystemichealthproblemssuchasobe-sity,diabetesandcardiovasculardisease.7Withanincreasingbodyofevidence linkingoralhealthtogeneralhealththeissueofdietandoralhealthisamajorconcernfordentalprofessionalsandshouldbecomeamajorfocusinthetreatmentofpatients.8

Wattetalsuggestthatdietaryadviceislikelytobemoreeffectiveifateamapproachisadopted.9Dental hygienists traditionally have a preventiveroleinthedentalteamandmaybeideallysuitedtoprovidingdietaryadvice.Whiledentistsoftenfacetimeconstraints,dentalhygienistscommonlyseepatients for longer appointments on a somewhatregularbasis,whichputstheminanidealpositionto assess patients’ dietary habits and to provideappropriate advice.10 A recent study examiningthe attitudes of dental hygienists in North Caro-linaestablishedthat95%ofrespondentsbelievedthatdentalhygienistsshouldplayaroleinhelpingpatientsmake dietary changes.11 Interestingly, astudyinvestigatingtheself-reporteddietarycoun-selling practices of Oregon dental hygienists ob-


servedthatonly53%ofdentalhygienistsprovidedanydietaryadvicetopatients.10Theseresultswerereiterated by a more recent survey of Marylanddentalhygienistswhichestablishedthatnutritionalcounsellingwasonlyprovidedby65%ofrespon-dentsinthepreventionofECC.12Theseresultsareconcerning, considering the crucial role that dietplaysinthedevelopmentofECC.13Itappearsthatwhilethemajorityofdentalhygienistsagreethattheyshouldhavearoleinprovidingdietaryeduca-tionitisimplementedinfrequentlyinpractice.

Despitethebeliefthattheyshouldbeprovidingdietaryadvice,theinfrequentprovisionofdietaryadvicebydentalhygienists leads to the specula-tionthatbarriersexisttodietaryadviceprovision.Research demonstrates that there is a correla-tionbetweentheperceivedextentoftraininganddental hygienists’ confidence in providing dietaryadvice.10,11 Therefore, itwould be valuable to re-viewthecontentandapplicationofdentalhygienecurricula toensurethatdentalhygienistsaread-equatelytrainedandexperiencedindietarycoun-selling.Barrierstotheprovisionofdietaryadviceidentifiedbydentalhygienistsincludeminimalob-servedfinancialgain,dietaryadvicenotfittingintoroutinepatientschedulingandlackoffinancialre-imbursementsfromhealthinsurancecompanies.10Inadditiontopracticebarriers,patientfactorsmayalsolimitthefrequencywithwhichdietaryadviceis provided.Sarmadi et al reported that girls re-ceiveddietaryadviceslightlymorefrequentlythanboys; however, this relationship was not signifi-cant.14 Minimal research has examined whetherprovisionofdietaryadvicebydentalhygienistsisinfluencedbydifferentpatientfactorssuchasageandgender.

ArecentCochraneReviewwhichinvestigatedtheeffectiveness of one-to-one dietary interventionsfoundthatasignificantchangeindietarybehaviorwasobservedinparticipantsin4ofthe5studiesreviewed.15 However, due to the limited researchavailable,strongevidenceislacking.WhiletheCo-chrane review provides a useful overview of theeffectivenessofdietaryinterventions,thequestionoffrequencyofdietaryadviceprovisionbydentalhygienistsseemstobeasomewhatoverlookedis-sue.

Dental hygiene students are a useful group toresearchastheyareagroupwhoarecloselysu-pervised by clinical faculty and are required tofollow strict guidelines about the treatment theyprovide. It can be assumed dental hygiene stu-dents’ treatment follows the current body of re-search and, therefore, that students frequentlyincorporatedietaryadvice into theirpractices. InAustralia, where this study was conducted, theAustralian Dental Council requires newly gradu-

ateddental hygienists tobeable to “identify theimpactofenvironmentaland lifestyle factorsandthedeterminantsofhealthonoralhealthandim-plementstrategiestopositivelyinfluencethesein-teractions”asper theProfessionalAttributesandCompetencies.16 Thus, the aim of this studywastoassessthefrequencyofdietaryadviceprovisionbydentalhygienestudentsandtoinvestigatefac-tors influencingthefrequencythatdietaryadviceisprovided.

metHoDS anD materialS

Study Design

This studyused a retrospective cross-sectionaldesigntoexaminethefrequencythatdietaryad-vicewasprovidedby students in their thirdyearof a Bachelor of Oral Health at the University ofNewcastle. In addition, the study also examinedwhether different patient factorswere associatedwiththefrequencyofdietaryadviceprovision.Eth-ics approvalwas obtained from theUniversity ofNewcastleEthicsCommitteein2013.

Setting

Individuals wishing to register as a dental hy-gienistinAustraliamustcompletea3-yearBach-elorofOralHealthdegreeor2-yearAdvanceDi-ploma.TheOralHealthprogramattheUniversityofNewcastleisbasedattheOurimbahcampusontheNewSouthWales(NSW)CentralCoastandin-volves an integration of oral health sciences andclinical placements, with a focus on populationhealth.

Participants

Participantsincludedinthestudywereallthirdyear Bachelor of Oral Health students who werecurrentlyenrolledattheOurimbahcampusoftheUniversityofNewcastle,aswellasallpatientsseenbythiscohortattheUniversityclinicin2012.Noexclusioncriteriawereappliedto theselectionofstudentsorpatientstoreduceselectionbias.

Withinthecurriculum,allparticipantshadcom-pletedsessionsondietandnutrition,and its im-pactonoralhealth,andwereencouragedduringclinicalsessionstoexploretheroleofdietandoraldiseasewith theirpatients.Alldatawasde-iden-tifiedbya thirdparty,withpatientnames, timesandidentifiabledetailsremovedfromtheextracteddatabeforeanalysis.Asthedatawasde-identifiednoinformationaboutanyoftheparticipantsorpa-tientswasaccessibleandtherefore,noparticipantswereidentifiableintheresults.Studentswerenotadvantagedordisadvantagedbythestudy,asthey


reSultS

werenotidentifiableinthedataandwerenotdi-rectlyinvolvedinthestudy.

Data Collection

Thestudyusedde-identifieddataretrievedfromDental4Windows, an electronic dental programused in the university dental clinic. Dental4Win-dows is a popular dental program which allowsdental practitioners to enter clinical notes, itemnumbersandmakeappointmentbookingsforpa-tients.Thisstudywasinterestedinexaminingtheageandgenderofpatients,andthetreatmenttheyreceivedoneachvisittotheclinic.

Thedependentvariablewasthefrequencyoftheuseoftheitemnumber131(representingdietaryadvice,whereatleast15minutesofdietaryadviceisprovided).ThiswasmeasuredbyassessinghowfrequentlytheitemnumberwasenteredintoDen-tal4Windowsbythirdyeardentalhygienestudentsover the study period. Dental item numbers areusedinAustraliaasauniformsystemofrecordingservicesprovidedbydental practitioners andareutilisedbyprivatehealthinsurancecompanies,aswell asMedicare, to allow efficient processing ofdentalclaims.

The independent variables measured includedother services provided at that appointment (intheformofitemnumbers),aswellastheageandgenderofpatients.Thereasonforrecordingthesevariables is to get an understanding of which, ifany,patientfactorsinfluencedwhetherornotdif-ferentpatientsreceivedietaryadviceandhowfre-quently.

Data Analysis

Dataanalysiswascompletedusingthestatisticsprogram STATA® version 12 (Statcorp, Chicago,Ill). Frequencies were displayed as percentages.Morecomplexanalysisofdatawascompletedusingregressionanalysis.Regressionanalysiswasusedto describe the relationship between dietary ad-viceandvariablesincludingage,genderandothertreatmentprovided;logisticregressionallowsthedependant variable to be defined and correlatingpredictionstobemade.17

Patient Demographics

DatawasextractedfromDental4WindowsinAu-gust, 2013. The data comprised information aboutallpatientsseenbythirdyearOralHealthstudentsduring 2012. The extracted data consisted of de-identified patient information, including year-of-birth,genderandtreatmentprovided,intheformof

itemnumbers.Atotalof1,189patientswereseenbythirdyearoralhealthstudentsoverthe12-monthstudyperiod.Ofthese,722patientswerefemaleand467weremale.TableIdescribesthegenderdistri-butionofpatientsseenoverthe12-monthstudype-riod.Theagesofpatientsseenwerecategorizedinto3ageranges;lessthan18yearsold,18to65yearsoldandgreaterthan65yearsold(TableI).Thelarg-estproportionofpatientsseenduringthe12monthswere adults aged 18 to 65 (n=723, 60.81%). Ap-proximately one-quarter of patients who attendedthe university clinic were aged over 65 (n=304,25.57%). Patients seen least frequentlywere chil-dren or adolescents under the age of 18 (n=162,13.62%).

Treatments Provided to Patients

Thetreatmentprovidedmostoftenbydentalhy-gienestudentswasoralhygieneinstruction(n=754,63.41%), with the least frequent treatment pro-vided being saliva testing (n=11, 0.93%). Dietaryadvicewasprovidedto77patients,only6.48%ofallpatientappointments.Comparably,oralhygieneinstructionwasprovidedtoalmost10timesasmanypatients (n=754, 63.41%). The frequency of eachofthetreatmentsprovidedbythirdyearoralhealthstudentsoverthe12monthsislistedinTableII.

Statistical Correlations

Logistic regression analysis was used to deter-mine if statistically significant correlations existedbetweendietaryadviceandothertreatmentprovid-edat thesameappointment.Therewasastatisti-callysignificantlinkbetweendietaryadviceandoralhygieneinstruction,withpatientswhoreceivedoralhygieneinstruction2.5timesaslikelytoalsoreceivedietaryadviceatthatappointment(OR:2.51,95%CI1.41to4.47,p<0.003).Patientswhoreceivedpro-phylaxiswerealsomorelikelytoreceivedietaryad-vicethanthosewhodidnot(OR:3.16,95%CI1.85to5.40,p<0.001).Topicalfluorideapplication(gel)significantlyincreasedthelikelihoodforapatienttoreceivedietaryadvice.Patientswhoreceivedtopicalfluoridewere7.8 timesas likely to receivedietary

Frequency PercentageGenderFemale 722 60.72Male 467 39.28

AgeUnder18 162 13.6218to65 723 60.81Over65 304 25.57

TableI:AppointmentsbyGenderandAge


advice(OR:7.80,95%CI4.39to13.86,p<0.001).Acorrelationwasalsofoundbetweenconcentratedflu-orideapplication(varnish)anddietaryadvice(OR:2.59,95%CI1.23to5.47,p<0.013),howeverthiscorrelationwasnotasstrong.Alternatively,nosta-tisticallysignificantcorrelationswerefoundbetweendietaryadviceanddebridementorperiodontalchart-ing.TableIIIreportsstatisticalcorrelationsbetweendietaryadviceandothertreatmentprovided.

Logisticregressionanalysiswasalsocarriedouttoexamine possible correlations between dietary ad-viceandageorgenderofpatients.Thedatadem-onstratedpatientsunder theageof18weremorelikelytoreceivedietaryadvicethanadultpatients.Patientslessthan18yearsoldweremorethan2.5timesas likelytoreceivedietaryadvice.Nostatis-tically significant correlations were discovered be-tweendietaryadviceandgender.

DiScuSSion

This study examined the frequency that dietaryadvicewasprovidedbydentalhygienestudentstopatients seenovera12-monthperiod.The resultsdemonstratedthatdietaryadvice isprovided infre-quently by dental hygiene students. These resultsare consistentwith thefindingsofMcKinneyet al,indicatingthatdietaryadvicemaybeoverlookedbyawiderangeofdentalprofessionals.18

Thefindingsfromthepresentstudyhavedemon-strateddietaryadvicewasonlyprovidedto6.48%ofpatients.Theseresultsarequiteconcerningandmayindicateaneed to reviewdentalhygienecurricula.Comparably,52%ofdentalhygienistsinOregonre-ported providing dietary advice in their practices,however,overhalfofthosesurveyedprovidedietaryadvicetofewerthan10%ofpatients.10Thelowpro-portionofpatientsreceivingdietaryadvicecouldbeattributedtobarrierssuchastimeconstraintsorlim-itedtrainingand/orpracticalexperienceinprovidingdietaryadvice.19Giventheresultsfromthepresentstudy,itmaybenecessaryforfurtherresearchtobecarriedouttoexaminebarrierstoprovidingdietaryadvice.Futureresearchmayalsoberequiredtoex-aminethecontentandapplicationofdietaryadvicetrainingfordentalstudents.

Astatisticallysignificantcorrelationwasobservedbetweendietaryadviceandage,withchildren lessthan18yearsofagebeing2.5timesaslikelyasold-erpatientstoreceivedietaryadvice.Thesefindingsmaybeattributedtocurrentpoliciesandguidelinesonappropriatefeedingpracticesforchildren,indicat-ingaviewthatchildrenareingreaterneedofdietaryadvicethanadults.20

A number of close associations were discoveredbetweendietaryadviceandothertreatmentprovid-

Treatment Frequency PercentageComprehensiveExamination 386 32.46PeriodicExamination 188 15.81LimitedExamination 114 9.59Radiograph 119 10.01OPG 118 9.92SalivaTesting 11 0.93PlaqueDisclosing 475 39.95Prophylaxis 139 11.69DebridementFirstVisit 385 32.38DebridementSecondVisit 235 19.76TopicalFluorideApplication 72 6.06ConcentratedFluorideApplication 63 5.30DietaryAdviceProvision 77 6.48OralHygieneInstruction 754 63.41SmokingCessationAdvice 41 3.45PeriodontalCharting 286 24.05SubgingivalDebridement 130 10.93Photographs 47 3.95

TableII:FrequencyofTreatmentsProvidedDuringPatientVisitsOver12Months

Description OddsRatio p-value 95%CI

Prophylaxis 3.16 <0.001 1.85to5.40Topicalfluorideapplication(gel,foam) 7.80 <0.001 4.39to13.86

Concentratedfluorideapplication(varnish) 2.59 <0.013 1.23to5.47

Oralhygieneinstruction 2.51 <0.003 1.41to4.47Age(under18years) 2.62 <0.012 1.24to5.55

TableIII:StatisticalCorrelationsBetweenDi-etaryAdviceandOtherTreatmentProvided

ed to patients. Patientswho received oral hygieneinstructionwere2.5 timesas likely toalso receivedietaryadvice, indicatingthatoralhygieneinstruc-tionisoftenprovidedinconjunctionwithdietaryad-vice. The authors hypothesize that dental hygienestudentsmayprovidebothdietaryadviceandoralhygieneinstructiontopatientstheyidentifyashigh-caries-riskpatients.Similarlycorrelationswereob-served between topical and concentrated fluorideapplication (varnish) and dietary advice provision,again indicating a possibility that patients identi-fiedasbeingatagreaterriskofdevelopingcariesaredeemedtorequiredietaryadvice.Interestingly,provisionofprophylaxiswasalsopositivelyassoci-atedwithdietaryadvice,withpatientswhoreceivedprophylaxismore than3 timesas likely to receive


concluSion

Insummary,thefindingsfromthepresentstudyhavedemonstratedthatdentalhygienestudentsinNSW, Australia provide dietary advice very infre-quentlytopatients.Theseresultsareimportant,asdietisakeyriskfactorformanyoraldiseases,yetitappearsthatdietaryadviceisanoverlookedcompo-nentofthepreventiveoralhealthcarepracticesofdentalhygienestudents.Theresearchalsodemon-stratesthatthere isarelationshipbetweenpatientageandstudentsdecidingwhetherornottoprovidedietary advice to patients. These results stronglysuggesttheneedforareviewofdentalcurriculatoensurethatdietaryadviceisamajorcomponentofthepreventiveservicesofferedbydentalhygienists.Recommendationsforfurtherresearchincludeiden-tifyingbarriers todietaryadviceprovision,percep-tionsofdentalpractitionersandstudents inregardtodietaryadviceandfurtherresearchexaminingthefrequencyofdietaryadviceprovisionbydentalprac-titioners inarangeofdifferentsettingsanditsas-sociationwithcariesrisk.

Melanie J. Hayes, BOH, BHSc(Hons), PhD, is an Oral Health Lecturer at the University of Melbourne. Johanna Franki, BOH, BHSc(Hons), is a registered dental hygienist. Jane A. Taylor, BDS, BScDent (Hons), MScDent, PhD, is an Associate Professor and Head of Discipline for Oral Health, at the University of Newcastle, NSW, Australia.

dietaryadviceduringthesameappointment.Itmaybe thatprophylaxis isprovidedmore frequently tochildren,explainingtheassociationwithdietaryad-vice.Nocorrelationswerepresentbetweendietaryadviceanddebridementorperiodontalcharting.

Given that hygiene students see patients forlengthyappointments,andaresupervisedandsup-portedbyclinicalfaculty,itwassurprisingthattheywerenotprovidingdietaryadvicemoreregularly.Itisimportantfordentalprofessionalstorecognizetheimportanceofdietaryadvice,notonlyforitsroleinoral health, but also for prevention of diet-relatedsystemic diseases such as diabetes and heart dis-ease.Dentalhygienists typically seepatientsquitefrequently for somewhat long appointments, argu-ablymakingthemideallysuitedtocounselpatientsaboutthelinkbetweendietanddisease.

Most studiesexamining the frequencyofdietaryadvice provision obtain data from self-reporting ofdental practitioners.10,21 One disadvantage of usingself-reportingisthatdentalpractitionersareessen-tiallyrequiredtoestimatetheirdietaryadviceprac-tices,potentiallycausing the results tobeaffectedbyover-reporting.Therefore,itislikelythatstudiesrelyingonself-reportingdonotaccuratelyreflectthetruedietaryadvicepracticesofdentalprofessionals.Thisstudyuseddatatakendirectlyfromclinicalre-cords;thus,havingthepotential tobemuchmoreaccurate.

Diet-relatedoralhealthproblemssuchasdentalerosionanddentalcariesposeasignificantchallengetooralhealthcareprofessionals.Dietaryadviceap-pears to be a valuable strategy in influencing eat-inganddrinkinghabits,inturnhavingthepotentialto prevent ormanage dental caries and erosion.22Dentalhygienistsmaybeideallysuitedtoprovidingdietaryadvicetopatientsaspartoftheirpreventiverole and therefore present an interesting area forresearch.Dental hygiene students offer a valuableinsightintothepracticesofdentalpractitionersandeducatorsshouldconsiderwhetherstudentsreceiveadequate training in dietary advice. These resultssuggest dietary advicemay be overlooked or pos-siblyunder-valuedasacomponentofthepreventiveoralcareregime.Furtherresearchmaybeusefultoinvestigate barriers to dietary advice provision, aswellastheperceivedimportanceofdietaryadvicetodentalpractitioners.

Itisimportanttorecognizelimitationstothepres-entstudy.Theconditionsforenteringtheitemnum-ber131specifythatat least15minutesofdietaryadvicearetobeprovided.Itispossiblethatstudentsmayhaveprovideddietaryadvicewhichlastedless

than15minutesandwas,therefore,notrecordedintheclinicalrecords.Thiswouldinfluencetheresultsof thestudy,potentially leading tounder-reportingofdietaryadvice.Infuturestudies,itmaybevalu-abletoproducea“dummy”itemnumberfordietaryadvice provision of less than 15minutes. Further,informationonthecariesrisk foreachpatientwasnotavailablewhenextractingthedata;itwouldhavebeeninterestingtodetermineifcorrelationsexistbe-tweencariesriskandtheprovisionofdietaryadvice.Asthestudysampleconsistedofdentalhygienestu-dentsatoneuniversityinAustraliathefindingsmayhavelimitedgeneralizability.However,thestudyhasprovidedusefuldatatohelpusunderstandtheprac-ticesofdentalhygienestudents inNSW,Australia.Furtherresearchisrequiredtoexaminethedietaryadvicepracticesofawiderangeofdentalpractitio-ners.As thestudyusedaretrospectivedesign thedatawas reliantonaccurate recordkeeping.How-ever, as the clinical records were recorded at thetimeoftheappointmentandstudentsarerequiredtoentertheitemnumberscorrespondingwithtreat-mentsprovided,therecordsappeartobeaccurateandreliable.


1. MoynihanP,PetersenPE.Diet,nutritionandthepreventionofdentaldiseases.Public Health Nutr.2004;7(1A):201-226.

2. Tinanoff N, Palmer CA. Dietary determinantsof dental caries and dietary recommendationsfor preschool children. J Public Health Dent.2000;60(3):197-206.

3. BartlettD.Etiologyandpreventionofaciderosion.Compend Contin Educ Dent.2009;30(9):616-620.

4. MejiaGC,AmarasenaN,HaDH,Roberts-Thom-son KF, Ellershaw AC. Child dental health sur-veyAustralia 2007: 30-year trends in child oralhealth.AustralianInstituteofHealthandWelfare.[Internet].2012[cited2016February5].Avail-able from: http://www.aihw.gov.au/publication-detail/?id=10737421875

5. KawashitaY,KitamuraM,SaitoT.Earlychildhoodcaries.Int J Dent.2011;725320:7.

6. NunnJH,GordonPH,MorrisAJ,WalkerA.Dentalerosion–changingprevalence?AreviewofBritishnational childrens’ surveys. Int J Paediatr Dent.2003;13(2):98-105.

7. WahlqvistML.Food&nutrition: foodandhealthsystems in Australia and New Zealand. 3rd ed.CrowsNest,NSW:Allen&Unwin;2011.

8. Boyd LD, Giblin L, Chadbourne D. Bidirectionalrelationshipbetweendiabetesmellitusandperi-odontaldisease:Stateoftheevidence.Can J Dent Hyg.2012;46(2):93-102.

9. WattRG,McGloneP,KayEJ.Prevention.Part2:Dietary advice in thedental surgery.Br Dent J.2003;195(1):27-31.

10.LevyTA,RaabCA.Astudyofthedietarycounsel-ingpracticesamongOregondentalhygienists.J Dent Hyg.1993;67(2):93-100.

11.KadingCL,WilderRS,VannWF,CurranAE.Fac-tors affecting North Carolina dental hygienists’confidence in providing obesity education andcounseling.J Dent Hyg.2010;84(2):94-102.

12.Manski MC, Parker ME. Early childhood car-ies: knowledge, attitudes, and practice behav-iors of Maryland dental hygienists. J Dent Hyg.2010;84(4):190-195.

13.SeowWK.Biologicalmechanismsof early child-hood caries. Community Dent Oral Epidemiol.1998;26(1SUPPL):8-27.

14.Sarmadi R, Gahnberg L, Gabre PIA. Clinicians’preventivestrategiesforchildrenandadolescentsidentifiedasathighriskofdevelopingcaries.Int J Paediatr Dent.2011;21(3):167-174.

15.HarrisR,GamboaA,DaileyY,AshcroftA.One-to-onedietaryinterventionsundertakeninadentalsettingtochangedietarybehaviour.Cochrane Da-tabase Syst Rev.2012;3:CD006540.

16.Professional attributes and competencies of thenewlyqualifieddentalhygienist.AustralianDen-tal Council [Internet]. 2011 [cited 2014 June].Available from: http://www.adc.org.au/index.php?id=14

17.Bowling A, Ebrahim S. Handbook of Health Re-searchMethods:Investigation,MeasurementandAnalysis.OpenUniversityPress.2007.

18.McKinneyL,KarpNV,KarpWB.Dentistpracticesandattitudestowardnutritioncounseling.J Mass Dent Soc.1996;44(4):10-13.

19.Franki J, Hayes MJ, Taylor JA. The provision ofdietary advice by dental practitioners: a reviewof the literature. Community Dental Health.2014;31:9-14.

20.AmericanAcademyonPediatricDentistryClinicalAffairsCommittee,AmericanAcademyonPediat-ricDentistryCouncilonClinicalAffairs.Policyondietary recommendations for infants, children,and adolescents. Pediatr Dent. 2008-2009;30(7Suppl):47-48.

21.KällestålC,WangNJ,PetersenPE,ArnadottirIB.Caries-preventivemethodsusedforchildrenandadolescents in Denmark, Iceland, Norway andSweden. Comm Dent Oral Epid. 1999;27:144-151.

22.ThompsonRL,SummerbellCD,Hooper L, etal.Relative efficacy of differential methods of di-etaryadvice:asystematicreview.Am J Clin Nutr.2003;77(4):1052-1057.

referenceS


Dental caries is an infectious, transmissible,bacterial disease affecting children and adults ofall races,ethnicitiesandsocio-economic levels.1,2ItisamajorpublichealthproblembothwithintheU.S. and around the world, and has devastatingeffects includingpain, infection,nutritional insuf-ficiencies,learningandspeechproblems,andevendeath.3Whiledisturbancesinthebalancebetweenbacteriaandhostare the factors traditionally re-sponsible forcariesdevelopment, factorssuchasfamily,economicandsocialconditionsalsohaveasubstantialimpactonthedevelopmentofthedis-ease.4,5 Current research has demonstrated thatmultipleriskfactorsareresponsiblefortheoccur-renceandprevalenceofcaries,includingfrequentsugar consumption, improper oral hygiene, highlevels of oral bacteria, cariogenic feeding prac-tices, socio-economic status,minority status andinconsistentoralhealthcareaccess.3,4,6-10

Early childhood caries (ECC) is defined as car-ies in children younger than 72 months of age,and disproportionately affects low-income fami-

AssociationbetweenEarlyChildhoodCaries,FeedingPracticesandanEstablishedDentalHomeErinA.Kierce,RDH,MS,MPH;LindaD.Boyd,RDH,RD,EdD;LoriRainchuso,RDH,MS;CaroleA.Palmer,EdD,RD,LDN;AndrewsRothman,MS,EIT

AbstractPurpose:EarlyChildhoodCaries(ECC)isasignificantpublichealthconcerndisproportionatelyaffectinglow-incomechildren.ThepurposeofthisstudywastoassesstheassociationbetweentheestablishmentofadentalhomeandECCprevalenceinagroupofMedicaid-enrolledpreschoolchildren,andtoexplorefeedingpracticesassociatedwithanincreasedprevalenceofECCinMedicaid-enrolledpreschoolchildrenwithanestablisheddentalhomewasevaluated.Methods:Across-sectionalsurveywasconductedamongMedicaid-enrolledchildren(n=132)between2and5yearsofagewithanestablisheddentalhomeandnodentalhometocomparefeedingpractices,parentalknowledgeofcariesriskfactorsandoralhealthstatus.Results: Children with an established dental home had lower rates of biofilm (p<0.05), gingivitis(p<0.05)andmeandecayed,missingandfilledteeth(DMFT)scores(p<0.05).Childrenwithnodentalhomeconsumedmoresodaandjuice(p<0.05)daily,andatemorestickyfruitsnacks(p<0.05)thanchildrenwithanestablisheddentalhome.EstablishmentofadentalhomehadastrongprotectiveeffectoncariesandDMFTindex(oddsratio=0.22)inbothunivariateandconfoundingadjustedanalyses.Conclusion: The results suggest establishment of a dental home, especially among high-risk, low-incomepopulations,decreases theprevalenceofECCandreduces thepracticeofcariogenic feedingbehaviors.Keywords: caries risk assessment, caries, diet, feedingmethods, socio-economic status, Medicaid,preventivedentistryThisstudysupportstheNDHRApriorityarea,Clinical Dental Hygiene Care: Assesstheuseofevi-dence-basedtreatmentrecommendationsindentalhygienepractice.

research

introDuction

lies.4,11-14 Populations with low-income levels andhigh utilization of Medicaid insurance have beenshowntohavean increasedriskofECCdevelop-ment.15 Preventive dental care and education iscriticalforparentsofhigh-riskchildrentoidentifycurrentdentalhealthconcernsandpreventfutureproblems.12However,withintheU.S.,only40%oflow-incomechildrenhavereceivedpreventiveden-tal care compared to54%ofhigher incomechil-dren.16Manybarriersaffectaccess todental ser-vicesfordisadvantagedchildrenincludingalackofproviders,costofservices,aswellascultureandoral health beliefs.12,17 Consequently, the preven-tionofECCinhighrisk,Medicaid-enrolledchildrenremains a challenge for health care personnel inthefieldsofdentistryandmedicine.5,8

An anticipatory approach emphasizing oralhealthpromotionislikelytohavethegreatestpos-itive effect on children’s oral health.5 Preventivecarevisitscanbeutilizedtoeducateparentsandcaregivers on proper oral hygiene techniques aswellasknownbehavioralandsocialriskfactorsfor


ECC development.6,9 Nutritional education shouldbeprovidedduringpreventivecarevisitsinordertoensurecariogenicfeedingpracticesareavoidedand proper dietary guidelines are being followedforoptimaloralandoverallheath.Thegoalofpro-vidinganticipatoryguidanceforthecaregiveristomodifyoreliminatepracticesandbehaviorsknowntoincreasecariesdiseaseriskforthechild.4,8

The American Academy of Pediatric Dentistry(AAPD) policy statement indicates the followingshouldbeprovidedbyadentalhome:18

• Comprehensiveassessment• Individualizedpreventivecarebasedoncariesandperiodontalrisk

• Anticipatory guidance related to growth anddevelopment including care of the child’s softandhardtissues

• Education of parents/caregivers on manage-mentofacutedentaltrauma

• Nutritionassessmentandcounseling• Comprehensive care including preventive ser-vicesaccordingtoAAPDguidelines

• Referralasneededtospecialists

There isa lackofevidenceevaluatingthe impactofanestablisheddentalhome(asdefinedbytheAAPD as “an ongoing relationship between thedentistandthepatient,includingallaspectsoforalhealthcaredeliveredinacomprehensive,continu-ouslyaccessible,coordinated,andfamily-centeredway”)onECCprevalenceandrisk,particularly inhigh-riskpopulations.19Thepurposeofthiscross-sectionalstudywastoexplore:

1.TheassociationbetweentheestablishmentofadentalhomeandECCprevalence inMedicaid-enrolledpreschoolchildren

2.Feedingpracticesassociatedwithanincreasedprevalence of ECC in Medicaid-enrolled pre-schoolchildrenwithanestablisheddentalhome


Anobservational,cross-sectionalstudyusingasurveyinstrumentwasconductedatadentalcen-terprovidingcaretoprimarilychildrenandado-lescents inManchester,NH.Data from the2010Censusestimates13.8%ofManchesterresidentshave incomes at or below the Federal PovertyLevel(FPL).20TheNewHampshireDepartmentofHealth andHumanServices (NHDHHS) indicatesthat of the 135,012 New Hampshire residentsenrolled within the Medicaid program in 2010,24,080resideinManchester,accountingfor12%of its total population.20 Overall, from 2009 to2010,therewasa5%increaseinMedicaidenroll-mentsthroughoutthestateandthepercentageofchildrenenrolledreached60.2%ofallenrollees.21

The dental center used for the present studyadheres to thepolicyof theAAPD regarding theexpectations of care within an established den-talhome.Patientsreceiveaprophylaxisandex-aminationonabi-yearlybasisduring45-minuteappointmenttimes.The4generaldentistsand5dentalhygienistsprovideallaspectsofthispolicyincluding:22

• Individualizedpreventivedentalhealthplans,specifictoachild’scariesriskassessment

• Anticipatoryguidanceaboutgrowthanddevel-opment

• Educationregardingproperoralhygienetech-niques

• Individualizednutritionalcounseling

Thisstudypopulationconsistedofaconveniencesampleof132Medicaid-enrolledmaleandfemalechildren between 2 and 5 years of age attend-ingtheirscheduledpreventiveappointmentatthedentalcenterduringthestudyperiod.Theestab-lisheddentalhomegroup(n=101)inclusioncrite-riawere thosechildrenwhohadpreventivecareandanticipatoryguidanceasoutlinedbytheAAPDpolicyonadentalhomewithinthelastyearatthedentalcenter.19Thenodentalhomegroup(n=31)inclusioncriteriaforchildrenwerethosewhohadnohistoryofpreventiveorrestorativedentalvis-its. Parental or guardian informed consent wasobtained for the child’s participation. The insti-tutional review board at the affiliated universityapproved and oversaw the administration of thestudy.

Sampling Procedure and Data Collection

Asurveyinstrumentwasadaptedfromthede-mographic, diet and nutritional sections of theNationalHealthandNutritionalExaminationSur-vey (NHANES) III.22The instrumentconsistedofquestions regarding the child’s demographics (2items), feeding practices (14 items), dental his-tory(3items)andcurrentparentalknowledgeofcariesriskfactors(1item).Thesurveyinstrumentwascompletedbytheparentorguardianduringthechild’spreventiveappointment.

Thevalidityofthequestionnairewasassessedusingacontentvalidity index(CVI).Sixexpertsin the fieldsof dentistryandnutritionevaluatedthesurveyanddeterminedthequestionswereanadequate representation of the study’s researchquestions.Eachexpertemployeda4-pointscaletocalculateavalueonthe individualcontent(I-CVI)aswell as theoverall content (S-CVI).ThecontentvaliditywasdeemedexcellentiftheI-CVIwas0.78orhigherfor3ormoreexpertsandtheS-CVIwas 0.90 or higher.23 For the study ques-tionnaire, 4 or more experts agreed with each


itemgivinganoverallI-CVIof0.97.TheS-CVIforthe questionnairewas 0.93 indicating an overallexcellentcontentvalidity.

Apilotsurvey(n=10)wasconductedtopre-as-sessparentor caregiver surveycompletion timeandeaseofcomprehension.Additionally, thepi-lotscreeningswereusedtoassessandimplementstandardpractices for thedentalhygienistspro-vidingthesurvey.Theresultsofthepilotassess-mentswerenotincludedinthefinalstudyresults.

The child’s current dental health status wascoded using an examinationmeeting the guide-lines from the dental center and forms adaptedfromtheWorldHealthOrganization’sBasicModelofOralHealthSurveys.24Documentedinformationincludedactivecaries,treatedcariesandoralhy-gienestatus.Alloftheclinicianswerecalibratedpriortothebeginningofthestudytoensureac-curaterecordingofdata.Eachclinicianperformedthedata retrieval process onat least 5 patientsand the results were compared and discussed,and methods modified until 100% agreementwasattainedtoensureconsistentdocumentation.ThistrainingpracticewasmodifiedfromtheCDC’sDental Examiners Procedures Manual developedfortheNHANES.22

During the prophylaxis appointment, the den-talcenter’sodontogramwasutilizedtodocumentany existing restorations and/or missing teeth.Throughout the clinical exam performed by thedentist, the areas of active carieswere also re-corded on the odontogram form. The data wasthentransferredfromtheodontogramtothede-cayed,missing and filled teeth (DMFT) index attheendofthequestionnaire.TheDMFTindexforprimaryteethwasemployedduetotheageofthestudy participants. The clinical assessment formwas also used to document the child’s oral hy-giene, indicating the presence of dental biofilmand/orgingivitis.Theprophylaxisandexamwasconducted using either the knee-to-knee tech-niquewiththeparentorguardianorwiththechildinthedentalchair,dependentuponpatientbehav-ior.Amouthmirrorwasutilized to identifyden-talbiofilm,gingivitis,restoredcariesandmissingteeth.Thedentalexaminationwasconductedus-inganexplorer,mouthmirrorandradiographs,ifpossible,todiagnoseactivecariouslesions.

The general dentists at the dental center em-ployed visual, tactile (using an explorer) andradiographic (using bitewing and/or occlusal ra-diographs) means for caries detection. Thesetechniques of caries detection are dependentuponpatientbehaviorand,consequently,notallmeanswereutilizedforeverypatient.Surfacede-mineralizationorawhite-spotlesionwasnotdoc-

umentedasacariouslesionbutratherusedasaneducationaltoolforparentsintermsofimprovingormodifyingtheirchild’snutritionororalhygiene.Followingtheprophylaxisandexam,thechildre-ceivedafluoridevarnishapplication,oralhygieneinstructionsandnutritionalcounseling.

Data Analysis

To investigate the association between ECCprevalenceinMedicaid-enrolledpreschoolchildrenandtheestablishmentofadentalhome,generalanddemographiccharacteristicsdatawerecom-pared between the 2 groups (established dentalhome vs. no dental home) (Table I). Categori-calandbinaryvariableswerecomparedutilizingglobalchi-squaretestsofindependence,withcon-tinuous variables comparedusingnonparametricMann-WhitneyUtests.25,26Feedingpracticeswerecomparedbetweenthe2groupsusingchi-squaretestsofindependence(Figures1,2,3).Notethatadjustments for multiple comparisons were notperformed due to a priori specification of com-parisons.27

As an indicator of the presence of caries,DMFT indexwas dichotomized intoDMFT>0 andDMFT=0. Univariate logistic regression associat-ingdichotomizedDMFT indexwithestablishmentofadentalhomewasperformed,with“Multivari-ateModelI”includingageandgenderascovari-atesusingmultivariate logistic regression (TableII).28For“MultivariateModelII,”amodelselectionprocedure was performed among candidate co-variatesage,sex,childbreastfed,agebottleus-ageended,usageofasippy-cup,dailyservingsofmilk,soda,andjuice,partakinginsnacking,ageof first dental appointment, presence of biofilm,andpresenceofgingivitis.Toassessandcontrolforpotentialconfoundingaswellasidentifystrongpredictorsofoutcome,inclusioninthe“Multivari-ate Model II” required meeting one or more ofthe following criteria: whether inclusion or ex-clusionofthevariablefromtheunivariatemodelchanged the adjusted odds ratio for establisheddentalhomeby≥10%,orinclusioninastepwiselogistic regression model met the pre-specifiedalpha threshold (alpha=0.05).29,30 Variables thatchanged the adjusted odds ratio by≥10%wereforced into the stepwisemodel. The finalmodelincludedage,gender,dailyservingofjuice,ageoffirstdentalappointment,presenceofbiofilm,andpresenceofgingivitis(TableII).ToinvestigatetheassociationsoffeedingpracticesonDMFTindexintheestablisheddental homegroup, over-disper-sioncorrectedunivariatePoissonregressionsviaascalingfactorwereperformed(TableIII).31Sta-tisticalanalyseswereperformedinSTATA®statis-tics/dataanalysissoftwareversion11.2.


NoDentalHome(n=31) EstablishedDentalHome(n=101)MeanAge,Months(SD) 47.77(13.92) 48.77(13.87)Gender,n(PercentMale) 17(54.8%) 54(53.5%)EverBreastfed,n(Percent) 17(54.8%) 35(34.7%)*On-Demand,n(Percent) 14(45.2%) 29(28.7%)

StoppedBreastfeeding*1To12Months,n(Percent) 15(48.4%) 33(32.7%)13To24Months,n(Percent) 2(6.5%) 2(2.0%)

BottleFeedingStillUsing,n(Percent) 4(12.9%) 3(3.0%)

StoppedBottleFeeding1To12Months,n(Percent) 17(54.8%) 72(71.3%)13To24Months,n(Percent) 8(25.8%) 22(21.8%)>25Months,n(Percent) 2(6.5%) 2(2.0%)

ChildPutToBedWithSippyCupWithMilk,n(Percent) 14(45.2%) 30(29.7%)WithJuice,n(Percent) 8(25.8%) 15(14.9%)WithMilkandJuice,n(Percent) 6(19.4%) 9(8.9%)

ChildDrinkingThroughoutTheDayMilk,n(Percent) 13(41.9%) 28(27.7%)Juice,n(Percent) 11(35.5%) 26(25.7%)ChildSnackingThroughoutTheDay 29(93.5%) 80(79.2%)TimeToFinishDrink≥1Hour 7(22.6%) 14(13.9%)

AgeAtFirstDentalVisit*<1Year,n(Percent) 0(0%) 24(23.8%)1To2Years,n(Percent) 8(25.8%) 67(66.3%)3To4Years,n(Percent) 9(29.0%) 7(6.9%)4To5Years,n(Percent) 14(45.2%) 3(3.0%)

FrequencyOfDentalVisitsEvery6Months,n(Percent) n/a 96(95.0%)DentalBiofilmPresent,n(Percent) 30(96.8%) 80(79.2%)*GingivitisPresent,n(Percent) 22(71.0%) 45(44.6%)*NewCaries,n(Percent) n/a 30(29.7%)MeanDMFTIndex(SD) 5.19(4.32) 1.80(2.90)**DMFT=0,n(Percent) 7(22.6%) 58(57.4%)*

*p<0.05NoDentalHomecomparedwithEstablishedDentalHomeviaglobalChi-squaretestofindependence**p<0.05NoDentalHomecomparedwithEstablishedDentalHomeviaNonparametricMann-WhitneyUtest

TableI:DemographicandCharacteristicofStudyPopulation

reSultS

Asperthedescriptiveunivariateanalysescom-paringtheestablisheddentalhomeandnodentalhomegroups,themeanageforthe2groupsweresimilarat48.7monthsand47.7months,respec-tively(TableI).Additionally,bothgroupshadcom-parabledistributionsbygender,with53.5%malein theestablisheddentalhomegroupand54.8%male inthenodentalhomegroup.Questionsre-

garding breastfeeding and bottle usage revealedmultiplicativeunivariatedifferences.Alargerper-centage of children in theno dental homegroupwerebreastfedon-demand(45.2%)andwerestillusingabottle(12.9%)comparedtotheestablisheddental home group (28.7% and 3%, respective-ly).Inregardstoageatfirstdentalappointment,66.3%oftheestablisheddentalhomegroupvisited


Figure 1: Comparison of Setting for Beverage Con-sumptionbetweenGroups

90

80

70

60

50

40

30

20

10

0

PercentChildren

Meal

Snack*

Anytime

Meal

Snack

Anytime

Meal

Snack*

Anytime

Milk Soda JuiceDrinkSetting(*p<0.05)

NoDentalHome(n=31)EstablishedDentalHome(n=101)

thedentistforthefirsttimebetween1and2yearsofage,whereasthegreat-estpercentageofthenodentalhomegroup had their first visit between 4and5yearsofage,45.2%(p<0.05).A greater percentage of the no den-talhomegrouppresentedwithdentalbiofilm (96.8%) and gingivitis (71%)compared to the established dentalhome group (79.2% and 44.6%, re-spectively) (p<0.05).MeanDMFT in-dex scores differed significantly, withindex 5.19 for the no dental homegroupand1.8fortheestablishedden-tal home group (p<0.05). A total of57.4%ofchildrenwithanestablisheddentalhomehadDMFTscoresofzero,comparedwith22.6%inthenodentalhomegroup(p<0.05).

Comparing feeding practices in the2groupsrevealedstatisticallysignifi-cant multiplicative differences. Chil-drenwithnodentalhomeweremorelikely to drink milk and juice duringsnack time (p<0.05) (Figure 1), tohave more than 6 servings of sodasperdayanddrinkmore than4 serv-ings of juice per day (p<0.05) (Fig-ure2).Figure3 illustratesthose inthenodentalhomegroupmorelikelytoconsume3servingsofstickysnacks,includingdriedfruitorgummyfruitsnacks,perday(p<0.05).

Univariatelogisticregressionassociatingdichot-omized DMFT index (DMFT>0 vs. DMFT=0) withestablishmentofadentalhome(yesvs.no)pro-ducedastatisticallysignificantoddsratio(OR)of0.22 with 95% Confidence Interval (CI) 0.08 to0.55(TableII),showingaverystronglyassociatedprotectiveeffectofestablishmentofadentalhomeonpresentationofcaries.Adjustmentforageandgenderviamultivariate logisticregressionfurtherloweredtheORforestablishmentofadentalhometo0.15(95%CI:0.05 to0.42)shownas“Multi-variateModelI”inTableII.Asperthemodelse-lection procedure to identify strong predictors ofoutcome and adjust for confounding, the OR forestablishment of adental homewas further low-eredto0.10(95%CI:0.02to0.40)afteradjustingforage,gender,dailyservingofjuice,ageoffirstdentalappointment,presenceofbiofilmandpres-enceofgingivitis,shownas“MultivariateModelII”inTableII.

Oftheover-dispersioncorrectedunivariatePois-son regressions performed to assess the associ-ations of feeding practices onDMFT index in theestablished dental home group, several practiceswere found to be strongly statistically associated

withamultiplicativeincreaseinDMFTindex.Suchfeedingpracticesinclude:drinkingjuicefrequentlyduringtheday(eβ=1.19,95%CI:1.04to1.36),eatingcandyfrequentlyduringtheday(eβ=1.21,95%CI: 1.01 to 1.45) consumingmilk atmeal-time (eβ=1.80, 95% CI: 1.25 to 2.59), havingjuiceduringsnacktime(eβ=1.78,95%CI:1.33to2.38)anddrinkingfromaglass(eβ=1.82,95%CI:1.29to2.58),asshowninTableIII.Drinkingfromasippycupalsoshowedaunivariatemultiplicativedecrease inDMFT index(eβ=0.44,95%CI:0.24to0.80).

DiScuSSion

Oral health is essential to general health andwell-being.32However,significantoralhealthdis-parities remain among certain socioeconomicgroupswithintheU.S.population.3,32Thedispar-ities in access to both medical and dental carehave significant and lifelong effects on the oralandoverall healthof childrenandadolescents.32Sincefamily,economicandsocialconditionshaveasubstantialimpactonthedevelopmentofECC,an approach emphasizing health-promoting be-haviorsattheindividuallevelislikelytohavethegreatestpositiveeffectonchildren’soralhealth.4,5Consequently, the establishment of a dentalhome, especially for high-risk, low-income chil-dreniscriticalforeducatingparentsandcaregiv-ersontheknownriskfactorsassociatedwithECC


Figure2:ComparisonofFrequencyofBeverageConsumptionBetweenEstablishedDentalHomeandNoDentalHome


90

80

70

60

50

40

30

20

10

0

PercentChildren

DrinkCountperDay(*p<0.05)Milk Soda Juice

0 1 2 3 4 5 0 1* 2 3>6* 0 1* 2 3

>4*

Figure3:ComparisonofSnackingPracticesBetweenEstablishedDentalHomeandNoDentalHome

90

80

70

60

50

40

30

20

10

0

PercentChildren

FoodCountperDay(*p<0.05)


Candy FruitSnacks DriedFruit0 1 2 >3 0 1 2

>3* 0 1 2 >3 0 1 2 >3

Crackers

development,includingfrequentsugarconsump-tion, inadequateoralhygiene,high levelsoforalbacteria and cariogenic feeding practices.3,4,6-10The care provided through a dental home mayalsodecreasetheprevalenceofrecurrentcaries.The current research has indicated over 50%of

low-incomechildrenexhibitrecurrentcariespostrestorativetreatment.33However,amongthepa-tients intheestablisheddentalhomegroupwithDMFTscoresof1orhigher,only29.7%presentedwithnewcariouslesions.


UnivariateModelOddsRatio(95%CI)

EstablishedDentalHome 0.22(0.08,0.55)*MultivariateModelI

OddsRatio(95%CI)EstablishedDentalHome 0.15(0.05,0.42)*Age 1.07(1.04,1.11)*Female 0.78(0.35,1.72)

MultivariateModelIIOddsRatio(95%CI)

EstablishedDentalHome 0.10(0.02,0.40)*Age 1.09(1.04,1.14)*Female 0.84(0.35,2.01)Juiceservingperday 1.34(0.92,1.95)Ageatfirstdentalvisit 0.53(0.27,1.04)PresenceofBiofilm 3.29(0.73,14.76)PresenceofGingivitis 1.10(0.47,2.61)

*p<0.05forparameterestimate

Table II: Univariate and Multivariate Logis-tic Regression Models for Caries Prevalence(DMFT>0vsDMFT=0);RecallPatients(n=101)

ParameterEstimates:OutcomeDMFTIndexFood/DrinkCountperDayMilk 0.87(0.76to1.01)Soda 0.80(0.62to1.03)Juice 1.19(1.04to1.36)*Candy 1.21(1.01to1.45)*FruitSnacks 0.90(0.73to1.14)DriedFruit 1.04(0.86to1.26)Crackers 1.03(0.87to1.22)

DrinkSettingMilkMeal 1.80(1.25to2.59)*Snack 1.03(0.74to1.44)Anytime 0.88(0.63to1.23)

SodaMeal 0.67(0.39to1.13)Snack 0.23(0.07to0.70)*Anytime 0.73(0.36to1.48)

JuiceMeal 1.25(0.93to1.68)Snack 1.78(1.33to2.38)*Anytime 0.74(0.51to1.06)

DrinkingSession≥1Hour 0.56(0.32to0.98)*ClinicalKnowledgeJuice 1.58(1.01to2.47)*Milk 1.28(0.87to1.88)Brush 1.16(0.81to1.66)Bottle 0.93(0.68to1.27)Snack 0.93(0.68to1.27)Food 0.85(0.61to1.18)

DrinkingMethodGlass 1.82(1.29to2.58)*SippyCup 0.44(0.24to0.80)*Straw 1.26(0.79to2.00)GlassandStraw 0.69(0.28to1.67)GlassandSippyCup 0.27(0.07to1.09)Glass,SippyCupandStraw 0.041(0.13to1.27)

*p<0.05forunivariateparameterestimate

TableIII:AssociationBetweenFeedingPrac-tices and DMFT Score Among EstablishedDental Home Group (n=101) (UnivariatePoissonRegressionforDMFTindex)

This study explored the association of an es-tablished dental home on ECC prevalence andcariogenic feeding practices in high-risk popula-tions. While it revealed significant consistencieswith thecurrent literatureaboutspecific feedingpractices and ECC prevalence in high-risk popu-lations,3,4,7 it also investigated theassociationofdentalhomeestablishmentandoralhygiene,car-ies status, and cariogenic feeding behaviors. Inaccordancewith the literature, the results dem-onstratedsignificantrelationshipsbetweenhigherDMFTscoresandafrequentconsumptionofstickysnacks(candy)andsugarydrinks(juice),aswellas prolonged drinking sessions.3,4,6,7,10 Childrenwith an established dental home had a lowerprevalence of caries, and lower rates of biofilmandgingivitis.Logisticregressionanalysisshowedaverystrongprotectiveeffect forestablishmentofadentalhomeoncariesstatus.Theabovefind-ingsaddfurtherevidencefortheeffectivenessoforalhygieneeducationandanticipatoryguidanceprovidedatpreventivecarevisitsonpreventionofadverseoralhealthoutcomes.

Thecurrentstudyalsorevealsignificantdiffer-ences in specific feeding behaviors between the2groups,withthenodentalhomegroupexhibit-ingmorecariogenicpracticesthantheestablisheddentalhomegroup.Thisfindingsuggeststhean-ticipatory guidance and nutritional counselingimplementedatthechildren’s’routinepreventive

dentalappointmentsmayplayan important roleinfeedingpracticesadoptedbyparents,particu-larlyinhigh-riskpopulations.


concluSion

acknowleDgmentS

Thefindingsofthisstudywillnotonlyaidindevel-opingastrongerpartnershipbetweenmedicineanddentistry in promoting oral health, but also in theimplementationofnewpolicies regardingprotocolsofpreventivedentalcare.Generalandpediatricden-tistscanusethecurrentresearchtodesignpoliciesspecific for theirpediatricpopulation tostrengthentheir preventive program’s nutritional counseling,parentalanticipatoryguidanceandoralhygienein-struction.

Erin A. Kierce, RDH, MS, MPH is Manager of Clinical Hygiene Practice and Professional Development at New England Family Dentistry in Marlborough, Mas-sachusetts. Linda D. Boyd, RDH, RD, EdD, is Dean and Professor at Forsyth School of Dental Hygiene at MCPHS University. Lori Rainchuso, RDH, MS, is an Associate Professor at Forsyth School of Dental Hy-giene at MCPHS University. Carole A. Palmer, EdD, RD, LDN, is a Professor at Tufts University, School of Dental Medicine and Friedman School of Nutrition Science and Policy. Andrews Rothman, MS, EIT, is a doctoral candidate at Harvard School of Public Health and Adjunct Faculty in Forsyth School of Dental Hy-giene at MCPHS University.

Theauthorswould like toacknowledgeand rec-ognizethefollowingindividualsfortheirwillingnessto cooperate with participant recruitment for thisstudy:DelphineSevere,DDS,DanetteManzi,ChiefComplianceOffice,CSHM,andDentalCenterStaff.Much appreciation is also extended to the expertswhowere instrumental insurveydevelopmentandvalidation:LisaF.HarperMallonee,BSDH,MPH,RD,LDandCyndeeStegeman,EdD,RDH,RD,LD,CDE.

However,therewasonefindingregardingadi-etarypracticethatdidnotcoincidewithwhathasbeendemonstratedinthe literature.Theregres-sionanalysisshowedconsumingmilkatmealtimewas associated with a multiplicative increase inDMFTscore(eβ=1.82,95%CI:1.29to2.58).Onepossibleexplanationcouldbethat theconsump-tionofmilkatmealtimehadanaddedamountofsugar,suchasflavoredmilk,soy,riceoralmondmilk.Thisisanareathatwouldbenefitfromfur-therresearchandinvestigation.

Itisimportanttoaddressthelimitationsinthisstudy. Like any observational study, structuralbiases including residual confounding, selectionbias,anddatamisclassificationandmisspecifica-tionareapossibility.Thepresentstudymaylackstatistical power to identify important statisticalassociationsduetothestudy’slimitedsamplesize.Thestudycohortwascreatedusingaconveniencesample, calling into question thegeneralizabilityof the study results to broader populations. Thepresent study was also a cross-sectional study,greatly limiting theability to “tease-out” thedi-rectionofcausalityandlimitingtheanalysistoas-sociationalmeasures. Additionally, the definitionofadentalhomewithinthestudypopulationwasoperationalizedashavingmadeatleastonepre-viousvisit to thedentalcenter.Thegoalsof thedentalhomemaynotbeachievablewithonevisittothedentaloffice.

The results suggest theestablishmentof aden-tal home, especially among high-risk, low-incomepopulations,isstronglyassociatedwithadecreasedprevalence of ECC and reduced cariogenic feedingpractices. Consequently, the collaboration betweendentistryandmedicineisasignificantaspectintheprevention andmanagement of ECC and the edu-cation of its risk factors. Therefore, in accordancewithrecommendationsfromtheCDC,theAAPDandtheAmericanAcademyofPediatrics(AAP),allchil-drenshouldestablishadentalhomenolaterthan1yearofage.34-37TheAAPalsoadvisesthatachild’sfirst caries risk assessment be completed by theirhealthprofessionalat6monthsofage,especiallyifthey are considered high risk for dental caries.35,36Pediatricians and physicians must also be aware

of theclinicalmanifestationsofdentaldiseaseandbe prepared to educate families on its risk factorsand consequences.4 It is alsobeneficial forpediat-richealthprofessionalstounderstandtheetiologicalcaries process, including enamel demineralization,andhave theability to identify thebehavioral anddietaryhabitsputtingachildathigherriskofdentaldisease.4


1. Guidelineonperinataloralhealthcare.AmericanAcademy of Pediatric Dentistry [Internet]. 2011[cited2016February5].Available from:http://www.aapd.org/media/policies_guidelines/g_peri-nataloralhealthcare.pdf

2. BaderJD,RozierG,HarrisR,LohrKN.Dentalcar-iesprevention:Thephysician’s role in childoralhealth systematic evidence review. Agency for Healthcare Research and Quality (US);2004Apr.

3. NunnME,BraunsteinNS,KrallKayeEA,DietrichT,GarciaRI,HenshawMM.Healthyeatingindexisapredictorofearlychildhoodcaries.J Dent Res.2009;88(4):361-366.

4. KawashitaY,KitamuraM,SaitoT.Earlychildhoodcaries.Int J Dent.2011;1-7.

5. Harrison R. Oral health promotion for high-riskchildren: Case studies from British Columbia. J Can Dent Assoc.2003;69(5):292-296.

6. MobleyC,MarshallTA,MilgromP,ColdwellSE.Thecontributionofdietaryfactorstodentalcariesanddisparitiesincaries.Acad Pediatr.2009;9(6):410-414.

7. PalmerCA,KentR,Jr,LooCY,etal.Dietandcar-ies-associatedbacteria insevereearlychildhoodcaries.J Dent Res.2010;89(11):1224-1229.

8. Kagihara LE,Niederhauser VP, StarkM. Assess-ment,management,andpreventionofearlychild-hoodcaries.J Am Acad Nurse Pract.2009;21(1):1-10.

9. WarrenJJ,Weber-GasparoniK,MarshallTA,etal.A longitudinal studyofdental caries riskamongvery young low SES children. Community Dent Oral Epidemiol.2009;37(2):116-122.

10.Prakash P, Subramaniam P, Durgesh BH, KondeS.Prevalenceofearlychildhoodcariesandasso-ciatedriskfactors inpreschoolchildrenofurbanbangalore, india: A cross-sectional study. Eur J Dent.2012;6(2):141-152.

11.Definitionofearlychildhoodcaries(ECC).Ameri-can Academy of Pediatric Dentistry [Internet].2003 [cited 2013 February 17]. Available from:http://www.aapd.org/assets/1/7/D_ECC.pdf

12.BugisBA.EarlychildhoodcariesandtheimpactofcurrentU.S.Medicaidprogram:Anoverview.Int J Dent.2012;1-7

13.Mouradian WE, Wehr E, Crall JJ. Disparities inchildren’soralhealthandaccess todental care.JAMA.2000;284(20):2625-2631.

14.VargasCM,RonzioCR.Disparitiesinearlychild-hood caries. BMC Oral Health. 2006;6(Suppl1):S3.

15.Reisine ST, PsoterW. Socioeconomic status andselected behavioral determinants as risk factorsfordentalcaries.J Dent Educ.2001;65(10):1009-1016.

16.EdelsteinBL,ChinnCH.Updateondisparities inoralhealthandaccesstodentalcareforamerica’schildren.Acad Pediatr.2009;9(6):415-419.

17.BrownJG.Children’sdentalservicesundermed-icaid: Access and utilization. Office of InspectorGeneral,DepartmentofHealthandHumanSer-vices.1996.

18.DefinitionofaDentalHome.AmericanAcademyofPediatricDentistry[Internet].2015[cited2016February 5]. Available from: http://www.aapd.org/media/policies_guidelines/d_dentalhome.pdf

19.Policyonthedentalhome.AmericanAcademyofPediatric Dentistry [Internet]. 2015 [cited 2016February 5]. Available from: http://www.aapd.org/media/policies_guidelines/p_dentalhome.pdf

20.Statequickfacts.U.S.CensusBureau[Internet].2011[cited2013March24].Availablefrom:http://quickfacts.census.gov/qfd/states/33/3345140.html

21.New Hampshire Medicaid Annual Report, 2011.NewHampshireDepartmentofHealthandHumanServices.2011.

22.NationalHealthandNutritionalExaminationSur-vey:Dentalexaminersproceduresmanual.Cen-tersforDiseaseControlandPrevention.2003.

23.PolitDF,BeckCT,OwenSV.IstheCVIanacceptableindicatorofcontentvalidity?appraisalandrecom-mendations. Res Nurs Health. 2007;30(4):459-467.

24.WorldHealthOrganization.Oral health surveys-basic methods. 4th Edition ed. Geneva: WorldHealthOrganization;1997.

25.McHughML.Thechi-squaretestofindependence.Biochem Med (Zagreb).2013;23(2):143-149.

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30.Harrell FE. Regression Modeling Strategies withapplicationstolinearmodels, logisticregression,andsurvivalanalysis.Springer-Verlag:NewYork.2001.

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Healthliteracyhasbeenattheforefrontofana-tionaldiscussionandhasbeendeterminedtobees-sentialforimprovingnotonlythehealthofthenationasawhole,butindividualhealthaswell.1DefinedbytheInstituteofMedicine,healthliteracyisthedegreetowhichindividualshavethecapacitytoobtain,pro-cessandunderstandbasichealthinformationandser-vicesneededtomakeappropriatehealthdecisions.2-4Understandingwrittenmaterials(informedconsent,patienteducationbrochuresandmedicationinstruc-tions)providedbyhealthcareproviders isjustoneaspect of health literacy.According to the InstituteofMedicane,“Health literacy isnotsimplytheabil-itytoread.Itrequiresacomplexgroupofreading,listening, analytical anddecision-making skills, andtheabilitytoapplytheseskillstohealthsituations.”2Patientsnotonlyneedtobeabletounderstandwrit-tenmaterials,butalsobeabletocommunicatewithhealthcareprovidersadequatelyabouttheirhealthcareneeds.Inadequatehealthliteracycannotonlyact as a barrier for obtaining, comprehending andmanaginghealthrelatedinformation,butcanalsoactasanobstacletoaccessingnecessaryhealthcare.1

ReadabilityLevelsofDentalPatientEducationBrochuresCatherineD.Boles,RDH,MS;YingLiu,PhD;DebraNovember-Rider,RDH,MS

AbstractPurpose:Theobjectiveofthisstudywastoevaluatedentalpatienteducationbrochuresproducedsince2000todetermineifthereisanychangeintheFlesch-Kincaidgradelevelreadability.Methods:Aconveniencesampleof36brochureswasobtainedforanalysisofthereadabilityofthepa-tienteducationmaterialonmultipledentaltopics.ReadabilitywasmeasuredusingtheFlesch-KincaidGradeLevelthroughMicrosoftWord.Pearson’scorrelationwasusedtodescribetherelationshipamongthefactorsofinterest.Backwardmodelselectionofmultiplelinearregressionmodelwasusedtoinves-tigatetherelationshipbetweenFlesch-KincaidGradelevelandasetofpredictorsincludedinthisstudy.Results: Aconvenience sample (n=36)ofdental educationbrochuresproduced from2000 to2014showed amean Flesch-Kincaid reading grade level of 9.15.Weak tomoderate correlations existedbetweenwordcountandgradelevel(r=0.40)andcharacterscountandgradelevel(r=0.46);strongcorrelationswerefoundbetweengradelevelandaveragewordspersentence(r=0.70),averagechar-actersperword(r=0.85)andFleschReadingEase(r=-0.98).Only1brochureoutofthesamplemettherecommendedsixthgradereadinglevel(Flesch-KincaidGradeLevel5.7).Overall,theFlesch-KincaidGradeLevelofallbrochureswassignificantlyhigherthantherecommendedsixthgradereadinglevel(p<0.0001).Conclusion:ThefindingsfromthisstudydemonstratedthattherehasgenerallybeenanimprovementintheFlesch-Kincaidgradelevelreadabilityofthebrochures.However,themajorityofthebrochuresanalyzedarestilltestingabovetherecommendedsixthgradereadinglevel.Keywords:healthliteracy,oralhealthliteracy,readability,Flesch-Kincaidgradelevel,patienteducationmaterialsThisstudysupportstheNDHRApriorityarea,Health Promotion/Disease Prevention: Assessstrate-giesforeffectivecommunicationbetweenthedentalhygienistandclient.

research

introDuctionIn the Surgeon’s General Report Healthy People

2010, health literacy is identified as an importantcomponentofhealthcommunication,medicalprod-uct safety and oral health.2 Efforts remain steadyto educate and inform health care providers as tomethodsandstrategiesforimprovinghealthliteracyto their patients. As evidenced in themost recentreport, Healthy People 2020, Health Communica-tionandHealthInformationTechnologyalsoaddresshealth literacy.5 The goal simply stated, is to usehealth communication strategies and health infor-mationtechnology(IT)toimprovepopulationhealthoutcomes,healthcarequalityandtoachievehealthequity.Objectivestoreachthisgoalinclude:deliver-ingaccurate,accessible,andactionablehealthinfor-mationthatistargetedortailoredtoaspecificaudi-ence,increasinghealthliteracyskills,andprovidingpersonalizedself-managementtoolsandresources.5

LiteracyratesintheU.S.arestaggeringconsider-ing 24million Americans (8.7%) are not proficientinEnglish.6Inregardstohealth literacy,thatnum-berisevenhigher.In2003,theNationalCenterfor


EducationStatisticsconductedanationallyrepresen-tativeassessmentofEnglish literacyamongAmeri-canadults(age16andolder)titledtheNationalAs-sessmentofAdultLiteracy(NAAL).TheNAALhealthliteracy levelswere categorized into4performancelevelsdeterminedbytheU.S.DepartmentofEduca-tion:Proficient,Intermediate,BasicandBelowBasic(Figure1).7Thereisalsoafifthlevel(NonliterateinEnglish)which includes adultswhowere unable totakethetestbecausetheycouldnotspeakEnglishorSpanish.Thisstudyfound14%ofadultAmericansdemonstrated“below”basic literacy levels.Regard-inghealth literacy, theNAALstudy found thatonly25million(12%)haveproficienthealthliteracy.Themajorityoftheadults(53%)scoredintheintermedi-ate levelandtheremaining77million fell ineitherthebasicorbelowbasicliteracylevels.8Thisstatisticindicatesthatapproximately47%ofadultAmericanshaveproblemsinunderstandingcomplexhealth in-formationgiventothembyhealthcareproviders.1

Thereisawiderangeofdemographicsthatareaf-fectedbylowhealthliteracy.Olderadults(65yearsandolder)werefoundtohavethelowesthealthlit-eracyscoreswhencomparedwithothergroups,with23%fallingbelowbasicproseliteracyrange.7,9Alongwitholderadults,individualswithlimitededucation,low English skills, low income, and those of ethnicor racial minority backgrounds aremore common-lyfoundtohavelowerhealthliteracy.1One-thirdofadultsintheU.S.havedifficultyreadingandfollowingthroughonhealthrelatedinformation.10Patientswithlimitedhealthliteracyreportedhavinglower-qualitycommunicationwithhealthprofessionalsandconfu-sionregardingmedicalterminology.6Evenindividualsat the intermediate or proficient literacy levels canstillhavedifficultycomprehendingthe“medicaljar-gon”andthetechnicalaspectofhealthinformation.Comprehensionlevelshavebeenfoundtobeabout2ormoregrade levelsbelow readingoreducationlevel,andwhenaperson isunderstress, the leveldropsevenlower.11Whatismorealarmingisthatpa-tientswithlimitedhealthliteracyarelesslikelytousepreventiveservices6andhaveinaccurateknowledgeabout preventivemeasures such aswater fluorida-tion,dentalcarevisitsandoralhealth-relatedqualityoflife.12

Thereisevidencetosuggestthatthereisastrongcorrelation between a person’s health literacy levelandhealthoutcomes.6Specifically,thosewithlimitedhealthliteracyareatareducedcapabilitytoreadla-belsandhealthmessages,limitstheirabilitytotakemedications, and lowers their likelihood of receiv-ing preventive care and using emergency servicesinstead.Studiesalso indicate that these individualsin turnhavemorehospitalizationsand thatamongelderly people with limited health literacy skills, apoorer overall health status and higher mortalityrates.6TheAmericanMedicalAssociation(AMA)also

supportsthesefindingsthroughitsreportHealthLit-eracyandPatientSafety:HelpPatientUnderstand.4,5It states, “Health literacy isa strongerpredictorofperson’shealththanage,income,employmentsta-tus,educationlevel,andrace.”4

Much ofwhatwe need to know or do regardingpreventing,maintaining or improving our health isfoundinthewrittenformat.1,6Accordingtothe2003NAALreport,mostU.S.adultsat thebasic readinglevel obtained their health care information fromthesetop3sources:radioorTV(92%),healthcareproviders(89%)andfamily/friends(85%)(TableI).Yet, books or brochures (80%), magazines (79%)and newspapers (77%)were referenced almost asoftenasevenhealthcareproviders(TableI).Thus,patientsareobtaining theirhealthcare informationfromwrittenmaterials or other sources as well asfromtheirhealthcareproviders.Writtenpatientedu-cationmaterials that are given to the patientmaynotbeatanappropriatereadinglevelandthereforeshouldnotbeusedaloneforeducatingandorinform-ingthepatient.Withpatienteducationmaterialsbe-ingdistributedbyhealthcareproviders,thereadabil-ityofthedocumentsshouldbelookedatcloselytodetermineifthepatientcanread,understandandre-

BelowBasic:OnlythemostsimpleandconcreteliteracyskillsareobtainedBasic:Skillsnecessarytoperformeverydaysimplelit-eracyactivitiesIntermediate:Theability toperformmoderatelychal-lengingactivitiesProficient: Skills necessary to performmore complexandchallengingactivities

Source:U.S.DepartmentofEducation,InstitutionofEdu-cationSciences,NationalCenter forEducationStatistics,2003NationalAssessmentofAdultLiteracy

Figure1:LevelsofLiteracy

ReadingLevelSource BelowBasic BasicInternet 19% 42%Magazine 60% 79%BooksorBrochures 60% 80%Newspapers 63% 77%FamilyandFriends 77% 85%HealthcareProviders 82% 89%RadioorTV 86% 92%

Source:U.S.DepartmentofEducation,InstitutionofEdu-cationSciences,NationalCenter forEducationStatistics,2003NationalAssessmentofAdultLiteracy

TableI:HowU.S.AdultsObtainHealthCareInformation



reSultS

A convenience sample of 36dental patient edu-cation brochureswas obtained fromprivate dentalpractices,adentalschoolandresearchfacilitytode-termine the readability level. The inclusion criteriawerebrochuresproducedbetween2000and2014,fromprofessionalorganizationsAmericanDentalAs-sociation(ADA),AmericanAcademyofPeriodontol-ogy(AAP),AmericanAcademyofPediatrics(AAPD),AmericanAcademyofOrthodontists(AAO),andonlyinEnglish.EachbrochurestextwasinputtedintoMi-crosoftWordtodeterminethereadabilityusingtheFlesch-Kincaid grade formula. The Flesch-Kincaidformulacalculatesthereadinggrade levelwiththefollowingformula:

1.Thetotalwordsaredividedbythetotalsentenc-esandmultipliedby0.39

2.Thetotalsyllablesaredividedbythetotalwordsandmultipliedby11.8

3.The resulting numbers from steps 1 and 2 areaddedtogether

4.Finally, 15.59 is subtracted from the resultingnumberofstep3

ThisformulawaschosensinceitiseasilyaccessibletousersandwidelyusedonbothPCandMaccom-putersasabuilt-inreadabilitytoolforMicrosoftOf-ficeWordsoftware.Otherreadabilitystatisticswerealsocalculatedthroughthistoolsinceitcontributedtotheoverallreadabilityofthedocument.Thesein-cluded: word count, characters count, paragraphs

count,sentencescount,averagesentencesperpara-graph,averagewordsper sentence,average char-actersperword,readability(passivesentencesper-centage),andreadabilityFleschReadingEase.TheFleschReadingEaseformulacalculates:

1.Average sentence lengthwhich ismultipliedby1.015

2.Averagenumberofsyllablesperwordmultipliedby84.6

3.Boththeseproductsaresubtractedandthedif-ferenceissubtractedfrom206.835todeterminethereadingeaseofadocument

TheFleschReadingEasescorecorrelateswithanes-timatedreadinggradelevel.Thescoreindexrangeis0to100,thehigherthescoreequatestotextthatiseasier to read.Conversely,ascore that is lowerthan30isconsideredtobeatthecollegegraduatereadinglevel.1

Descriptive statistics were conducted based onthepublicationsbyprofessionalorganizations(ADA,AAP,AAPD,AAO)aswellasthemeanandstandarddeviationoftheFlesch-Kincaidgradelevelforall36brochures collectively. Correlations between read-ability statistics were performed using the Pear-son’s correlation.Aone-sample t-testwasused todetermine the Flesch-Kincaidgrade level of all thebrochures.Lastly,modelbuildingusingabackwardmodelselectionwasperformedonthesestatisticstodeterminefactorsassociatedwiththeFlesch-Kincaidgradelevel.Ap-valueof<0.05wasconsideredsig-nificant.DataanalysiswasperformedwiththeSta-tisticalPackagefortheSocialScience(SPSSversion22,IBMSPSS,Inc.,Chicago,Ill).

Aconveniencesampleof36dentaleducationpa-tient brochureswas collected and analyzed (TableII).Thesebrochuresconsistedofbifold,trifoldandbooklet designs. Topics includedwere diverse andconsisted of specific information about diseases,conditions or procedures. All brochures includedwere produced by professional organizations withthebreakdownofpublicationsasfollows:ADA(26),AAPD(3),AAP(4)andAAO(3).Descriptivestatis-ticswereperformedforeachprofessionalorganiza-tionpublicationset.FocusingontheFlesch-Kincaidgradelevel,theaveragemeangradelevelfortotalbrochureswascalculatedaswellasperprofessionalorganization.Theaveragemeangrade level forall36brochureswas9.15withastandarddeviationof1.77.Foreachprofessionalorganization,theaver-agemeangradelevelandstandarddeviationswere:ADA–gradelevel8.67(SD1.63),AAPD–gradelevel8.90(SD1.05),AAP–gradelevel11.30(SD1.70)andAAO–gradelevel10.70(SD0.61).ItisworthnotingthatthecollectiveFlesch-Kincaidgradelevel

tainthisinformationfortheirhealthbenefit.Regard-ingwrittenpatienteducationmaterials,theNationalInstitutesofHealth(NIH),theNationalWorkGrouponCancerandHealth,andtheAmericanMedicalAs-sociation(AMA)all recommendedthereadabilityofpatienteducationmaterialsshouldbenohigherthanthesixthgradelevel.13

In2000,asimilarstudywasconductedbyAlex-ander,andpublishedintheJournaloftheAmericanDentalAssociation.14Theauthorselected24patienteducationmaterialsfromseveralsourcesanddeter-mined the Flesch-Kincaid readability level using acomputer-basedprogram.Theconclusionsfromthisstudyfoundthatthereadabilitywashigher(41.7%)than the recommended reading level of seventh toninth grade. The author concluded there needs tomoreattentiononthepreparationofpatienteduca-tion materials by making the documents easier toreadandunderstoodbythelayperson.14

Thepurposeofthisstudywastoevaluatedentalpatienteducationbrochuresproducedsince2000todetermineiftherehasbeenanychangeintheread-abilitylevelsofthebrochuresthatarecurrentlybeingdistributedtodentalpatients.


ArticleTitle Publication Year WordCount

FleschReadingEase

Flesch-KincaidGradeLevel

1 Healthymouthhealthybody-Makingtheconnection ADA 2000 851 47.1 11.52 Askyourdentistabouttoothwhitening ADA 2002 956 39.7 12.23 Whataredentalveneers? ADA 2003 807 57.1 9.14 Whydoesmyfillingneedreplacing? ADA 2003 376 58.5 8.85 Understandingrootcanaltreatment ADA 2003 924 59.5 9.16 Temporomandibulardisorders(TMD) ADA 2003 919 62.7 7.87 Temporomandibulardisorders(TMD) ADA 2009 552 55.6 8.78 Yourwisdomteeth ADA 2004 604 53.8 9.99 Whatiscrownlengthening? ADA 2004 221 64.4 8.410 Periodontalmaintenanceprocedures ADA 2004 1,012 45.4 10.811 WhydoIneedacrown? ADA 2006 433 65.0 8.112 WhydoIneedabridge? ADA 2006 513 75.1 5.713 Doyougrindyourteeth? ADA 2007 423 65.8 7.714 Doyougrindyourteeth? ADA 2010 314 70.3 6.815 Doyouhaveacrackedtooth? ADA 2007 450 77.0 5.716 Snackandsipallday?RiskDecay! ADA 2008 490 56.8 8.417 Oralpiercing-Isitworthit? ADA 2008 527 55.9 9.6

18 Periodontalmaintenance-Preservetheprogressyouhavemade ADA 2008 934 47.1 10.8

19 Scalingandrootplaning-Treatmentsforperiodontaldisease ADA 2008 1,288 52.0 9.7

20 Yourchild’steeth0to6 ADA 2009 1,655 63.5 8.1

21 Scalingandrootplaning-Periodontaltherapywithoutsurgery ADA 2011 820 54.9 9.4

22 Dentalimplants-Aretheyanoptionforyou? ADA 2011 1,139 66.0 7.623 Dentalimplants-Aretheyanoptionforyou? ADA 2014 1,088 68.9 6.824 Periodontaldisease-Don’twaituntilithurts ADA 2011 1,789 53.3 9.425 Periodontaldisease-Don’twaituntilithurts ADA 2014 1,147 60.1 8.026 Yourchild’sfirstvisittothedentist ADA 2012 592 70.0 7.227 Askyourdentistaboutx-rayuseandsafety AAPD 2008 357 47.8 9.9

28 Askyourdentistaboutthumb,fingerandpacifierhabits AAPD 2009 341 67.2 7.8

29 Askyourdentistaboutregulardentalvisits AAPD 2009 406 53.9 9.030 Dentalimplants AAP 2000 578 58.2 9.031 Periodontaldiseases-Whatyouneedtoknow AAP 2005 1,278 37.7 12.232 Targetingtobaccouse AAP 2006 957 47.6 11.1

33 Periodontalhealth-Maintainingperiodontalhealththroughoutawoman’slife AAP 2006 1,825 36.6 12.9

34 Yourchild’sfirstorthodonticcheck-up:Nolaterthanage7 AAO 2004 1,626 46.1 11.1

35 Allaboutorthodontics-Helpingpeopleachievehealthy,beautifulsmiles AAO 2008 599 48.0 10.0

36 Tobaccouseandyourorthodontictreatment AAO 2013 308 46.7 11.0

TableII:SummaryofDentalPatientEducationBrochures


readabilityofallbrochureswassignificantlyhigherthantheeighthgradereadinglevel(p<0.0001).

Pearsoncorrelationswerecomputedtodeterminethestrengthofrelationshipbetweenpairsofread-abilitystatistics(wordcount,characterscount,para-graphscount, sentencescount,averagesentencesperparagraph,averagewordspersentence,aver-agecharactersperword,readability-passivesen-tences percentage, and readability-Flesch ReadingEase).Weaktomoderatecorrelationsbetweenwordcountandgradelevel(r=0.40)aswellaswithchar-acterscountandgradelevel(r=0.46)werenoted.Strongcorrelationswerefoundbetweengradelevelandaveragewordspersentence(r=0.70),averagecharacters per word (r=0.85) and Flesch ReadingEase(r=-0.98).Wordcount,characterscount,para-graphs count and sentences count are highly cor-relatedtoeachother,andthePearson’scorrelationcoefficientsamongthemarefrom0.86to0.996.

There were 4 groups of brochures (n=8) thatwerenearly identical in textbutwereproduced indifferentyears.Adescriptiveanalysisshowedthatwithinthegroups,themeanreadinggradelevelre-ductionwasbetween0.8and1.4.Theoneexceptionbeing the brochure, Temporomandibular Disorders–TMD(ADA2003,2009), thathadan increase inthe Flesch-Kincaid reading level of almost an en-tiregrade,7.8(2003)to8.7(2009).Thebrochure,“Periodontal Disease – Don’t Wait Until it Hurts”(ADA,2011,2014)reportedaFlesch-Kincaidread-inggradelevelof9.4and8.0,respectively.Thebro-chure,“DoYouGrindYourTeeth”(ADA,2007,2010)hadaFlesch-Kincaidreadinggrade level reductionfrom7.7to6.8,andthebrochure,“DentalImplants–AreTheyanOptionforYou?”(ADA,2011,2014)reducedtheFlesch-Kincaidgradereadinglevelfrom7.6to6.8.Withinthese4groupsofbrochures,themostcurrentversion in3of the4groupsdemon-strated a reduced grade level readability. Only 1brochure,the2014ADAversionof“DentalImplants–AreTheyanOptionForYou?”wasabletoreducethe readinggrade level to the recommendedsixthgradelevel(Flesch-Kincaid6.8).Overall,theread-inggradelevelofallthebrochurescollectivelywasfoundtobestatisticallysignificantlyhigherthantherecommended sixth grade or below reading level(p<0.0001).

Lastly, model building using a backward mod-el selection was performed to see what variableswere associated with grade level. Average wordsper sentence (p≤0.0001) and Flesch reading ease(p<0.0001)wereleftinthefinalmodel.Nomulticol-linearitywasnotedbetweenthese2factorswithallvarianceinflationfactorsforeachvariablebeinglessthan2.15TheadjustedR-squared is0.996,whichindicatesthefinalmodelisadequateforthisdata.

DiScuSSion

Theimportanceofhealthliteracyanditsrelation-ship toan individual’shealthstatushasbeendoc-umented in the literature.1,6 Health professionalsincluding dental care providers still utilize writtenpatient educationmaterials asamethod to informand educate patients.16With an estimated 90mil-lionU.S.adultswhohavelimitedhealthliteracy,50million are reading between the sixth and eighthgradelevelwhiletheother40millionhaveliteracyskillsscoringatorbelowthefifthgrade level.2,4,7,13It is imperativethatthehealthcarecommunitybecognizantofthepotentialdisparitybetweenanindi-vidual’sliteracylevelandtheiractualhealthliteracy.Researchhasshownthatwrittenpatienteducationmaterialsarestillacommontoolgiventopatientsasameansofinformingandeducatingthepatient.Healthcareprovidersincludingmembersoftheden-talteamneedtotakeintoaccountthatthepatienteducationmaterialstheymaygivetoapatientde-scribingaconditionorproceduremaybeabovetheirhealthliteracyreadinglevelandthereforeshouldnotbesolelyreliedonforadequatelyeducatingandin-formingthepatient.

A study conducted in 2005 evaluating the read-ing level of patient educationmaterials from vari-oushealth journals found that 50%of the samplehada reading levelofeighthgradedeterminedbythe Flesch-Kincaid readability formula from Micro-softWord.17Alexander’sstudyfrom2000alsofoundthattheFlesch-Kincaidreadinglevelsofthepatienteducationmaterialsthatwereevaluatedwereabovetherecommendedreadinggradelevelatthattime.14BothofthesestudiesillustratedthatnotonlyistheFlesch-Kincaidcomputerformulaoftenusedforde-termining the readability level of a document, butalsomanyofthepatienteducationmaterialsthatareoftendistributedtopatientsmaybeabovetherec-ommendedreadinglevel.

UtilizingMicrosoftWord Flesch-Kincaid computerformula, thedata fromthis studyshowed that themean range for reading grade level was between8.67 to 11.30. Brochure topic areas of periodon-tics,orthodonticsandtoothwhiteninghadthehigh-est reading levelcomparedtobrochures thatwereabout implants, sealants, cracked teeth, the firstdentalvisitorneedingabridge.Perpublication,bro-churesproducedby theAAPand theAAOhad thehighest readability levelcomparedto thosewrittenbytheADAandtheAAPD.Therewasastrongcor-relation between the Flesch Reading Ease and theFlesch-Kincaid grade level, but weak to moderatecorrelations with word and character count in re-gards to the reading grade level. Therefore, wordand/orcharactercountalonecannotbeapredictorofoverallreadingability.TheuseofMicrosoftWordis one way to evaluate the readability of patienteducation brochures. It is considered an easy and


concluSion

convenientmethod,butPlainLanguageexpertsdonotconsidercomputertestsasareliabletoolusedsolelyby themselves.TheFlesch-Kincaidcomputerformulahasbeenfoundtocalculatelowerreadabil-itymeasurescomparedtoothercomputertestsandalsowhencomparedtocalculatingthereadabilitybyhand.

The findings from this study demonstrated thatthere has generally been an improvement in thereadabilitylevelofthebrochuresthatweresampledsinceAlexander’sstudyin2000.However,themajor-ityofthebrochuresanalyzedarestilltestingabovetherecommendedsixthgradereadinglevel.

Limitations of This Study

The36brochuresthatwerecollectedandanalyzedwereaconveniencesampleofwhatwasavailableatthetimeofcollectioninthesummerof2014.There-fore, it is not reflective of every patient educationmaterialthatiscurrentlyavailable.Alargersamplesizewouldincreasethestatisticalpowerofthisstudy.Anotherlimitationisutilizingacomputerprogramfordeterminingthereadabilitylevelofadocument.TheFlesch-Kincaidformuladeterminesthereadabilityofatextbasedontheaveragesyllablesperwordand

Greatstridesarebeingmadebyprofessionalden-tal organizations to reduce the readability level ofwrittendentalpatienteducationbrochures.Howev-er, thedata fromthisresearchshowsthatthere isstillaneedtocontinuetoreducethereadabilitylevelso that written patient educationmaterials will bemoreeasilyunderstoodbyalargersegmentofthepopulation.

Catherine D. Boles, RDH, MS, is an Assistant Pro-fessor in the Department of Periodontics at the Uni-versity of Missouri-Kansas City, School of Dentistry. Ying Liu, PhD, is an Assistant Professor and Statisti-cian in the Department of Biostatistics and Epide-miology in the College of Public at East Tennessee State University. Debra November-Rider, RDH, MS, is the Institutional Review Board Administrator at The Forsyth Institute and adjunct Assistant Profes-sor at the Forsyth Dental Hygiene Program at MCPHS University.

1. WilsonM.Readabilityandpatienteducationmate-rialsusedforlow-incomepopulations.Clin Nurse Spec.2008;23(1):33-40.

2. Office ofDisease Prevention andHealth Promo-tion,U.S.DepartmentofHealthandHumanSer-vices.HealthyPeople2010.U.S.DepartmentofHealthandHumanServices.2001.

3. HealthLiteracy:APrescriptiontoEndConfusion.InstituteofMedicine.2004.

4. NationalNetworkofLibrariesofMedicine.HealthLiteracy.NationalLibraryofMedicine.2014.

5. Office ofDisease Prevention andHealth Promo-tion,U.S.DepartmentofHealthandHumanSer-vices.HealthyPeople2020.U.S.DepartmentofHealthandHumanServices.2010.

6. KohHK,BerwickDM,ClancyCM,etal.Newfed-eralpolicyinitiativestoboosthealthliteracycanhelpthenationmovebeyondthecycleofcostly‘crisiscare’.Health Affairs.2012;31(2):434-443.

7. Kutner M, Grenberg E, Jin Y, Paulsen C. Thehealth literacyofAmerica’sadults:Results fromthe 2003National Assessment of Adult Literacy(NCES2006-843).U.S.DepartmentofEducation,NationalCenterforEducationStatistics.2006.

8. CutilliCC,BennettIM.Understandingthehealthlit-eracyofAmericaresultsofthenationalassessmentofadultliteracy.Orthop Nurs.2009;28(1):27-34.

9. SchillingerD,PietteJ,GrumbachK,etal.Closingthe loop physician communication with diabeticpatientswhohavelowhealthliteracy.Arch Intern Med.2003;163(1):83-90.

10.U.S.DepartmentofHealthandHumanServices.SimplyPut–Aguideforcreatingeasy-to-under-standmaterials.2009.

11.BarzelR.AWaywithWords:GuidelinesforWritingOralHealthMaterials forAudienceswithLimitedLiteracy.NationalMaternalandChildOralHealthResourceCenter.2008.

referenceS

averagewordsper sentence. It doesnot take intoaccount the layoutordesign featuresof thedocu-mentswhichareother factors thatcan impact theoverallreadabilitylevel.


12.IOM workshop examines oral health literacy.American Dental Association [Internet]. 2013February 26 [cited 2014 October 12]. Availablefrom: http://www.ada.org/en/publications/ada-news/2013-archive/february/iom-workshop-ex-amines-oral-health-literacy

13.Sabharwal S, Badarudeen S, Kunju SU. Read-ability of Online Patient Education MaterialsfromtheAAOSWebSite.Clin Orthop Relat Res.2008;466:1245-1250.

14.AlexanderRE.Readabilityofpublisheddentaledu-cationalmaterials.J Am Dent Assoc.2000;31:937-942.

15.KutnerMH,NachtsheimCJ,NeterJ.AppliedLin-earRegressionModels.4thed.McGraw-HillIrwin.2004.

16.RozierG,HorowitzAM,PodschunG.Dentist-pa-tientcommunicationtechniquesusedintheUnitedStates.J Am Dent Assoc.2011;142(5):518-530.

17.Vickery CE, Carpenter-Haefele KM. Evaluationof literacy level of patient education papers inhealth-related journals. J Community Health.2005;30(3):213-219.


Theintroductionoffluorideasapreventativemea-sureagainsttoothdecaydatesbacktotheearly20thcentury,duringatimewhendentalcarieswereubiq-uitousamongchildrenofallclasses.1Today,fluorideis considered, by many, the best defense againstdental caries. Fluoridation ofwaterwas named bythe Centers for Disease Control and Prevention(CDC)as1ofthe10most importantpublichealthmeasures.2 There has been significant support fordentalproductswithfluoride, including toothpaste,mouthwash,multivitamins,dietarysupplementsandin-officetreatments.3Withthecombinationoftopicalandsystemicfluoride,adecline incarieshasbeen

AnalysisofPhoneCallsRegardingFluorideExposuremadetoNewJerseyPoisonControlCenterfrom2010to2012SnehaShah,RDH,MPH;SamuelQuek,DMD,MPH;BruceRuck,PharmD

AbstractPurpose:TheAmericanAssociationofPoisonControlCenter’sannualreportsdemonstratethatacutefluorideexposureisnotanuncommonoccurrence.Despiteitsprevalence,therehasbeenlittlepublishedresearchonthetopicinthelast10years.ThepurposeofthisstudywastocalculatetheincidenceofacutefluoridetoxicityandlethalityasitoccursinNewJerseyandprovideadescriptiveepidemiologyofacutefluorideexposures.Methods:Thestudydesignwasretrospective innature.Recordsofphonecallsmadeby individualsreportingexcessivefluorideexposure(inanamountgreaterthandirected/prescribed)toNewJersey’spoisoncontrolcenter,knownasPoisonInformationandEducationSystemfromtheyears2010through2012,wereextracted fromToxicall® (ComputerAutomaticSystems, Inc.)database.A totalof2,476human-onlyexposurerecordsmettheinclusioncriteriaandwereanalyzed.Incidencerateswerecalcu-lated,andpopulationcharacteristics,circumstancesandmedicaloutcomesofacutefluorideexposurecaseswereassessedandcategorized.Results: Atotalof2,476phonecallrecordsmettheinclusioncriteria.Thefluorideexposuresreportedwerefromtoothpastewithfluoride(49%,n=1,214),mouthrinsewithfluoride(21.6%,n=536),multivi-taminwithfluoride(21.4%,n=530)andpurefluoride(0.08%,n=199).Medicallyspeaking,94.75%ofcallswereasymptomaticcases(n=2,346),4.24%weresymptomatic(n=105)and1.01%wereinforma-tionalinquiries(n=25).Adversesymptomsreportedweremostlyminor(83.9%ofsymptomaticcases,n=88)andmoderate(16.1%ofsymptomaticcases,n=17).Theagegroup18monthsto3yearsofageshowedthehighestincidenceofacutefluorideexposure(53.2%,n=1,317).Therewasaslightlyhigherincidenceofacutefluorideexposuresamongmales(n=1,317)vs.females(n=1,159).Mostincidencesoccurred in thehome(93.1%of records,n=2,305)andoccurredunintentionally (96.7%,n=2,394).Callsweremainlymadebythesubject’smother(67.5%,n=1,671).Conclusion:Basedonthedata,therewerenoreportsoflethalityortoxicityduetoacutefluorideex-posureinNewJerseyfrom2010through2012.Symptomaticreportsandinformationalinquirieswerefew.Alladverseoutcomesduetoexcessivefluorideintakewereremediedwithcalciumastheantidote.Dentalhygienistsshouldeducatepatientsonsafetymeasuresoffluoride-containingproductsandevalu-ateoverallfluorideexposurepriortomakingrecommendations.However,findingsinthisstudysuggestthatlevelsoffluorideinavailablecommercialproductswillnotproducelife-threateningevents,eveniftakenindoseshigherthanrecommended.Keywords:fluoride,poisoning,dentifrice,toothpaste,childrenThisstudysupportstheNDHRApriorityarea,Occupational Health and Safety: Investigatemethodstodecreaseerrors,risksandorhazardsinhealthcareandtheirharmfulimpactonpatients.

research

introDuction

seenglobally.4 Studies also show that the benefitsoffluoridearelifelongandnotrestrictedtochildrenwithdevelopingteeth.5

Despitethebenefitsoffluoride,thereisapotentialforharmresultingfromchronicandacuteexposuretofluoride.Chronicexposuretofluoridecanleadtofluorosis,whichissystemicinnatureandcausedbydisruptions in enamel formation that occur duringtooth development.4 Long-term exposure can alsocausecripplingskeletalfluorosis,whichischaracter-ized by increased density of bone (osteosclerosis)andtheformationofbonyoutgrowths.6


Acutefluoridepoisoning is contingentupon sev-eralfactorsandcancauseavarianceofsymptoms.Whenproductsareusedinthevolumesorweightsindicated, there is usually little danger of serious,systemicacutetoxicity.However,whentopicalgelsareappliedtosmallchildrenincorrectlyoringestedinquantitiesthatexceedrecommendeddoses,symp-tomsoftoxicityandpotentialforserioustoxicity ispresent.7Acuteingestionoffluoridecanleadtonau-seaandgastrointestinalirritation.Largeamountsofingestionoffluoridecanleadtoorgandamageandevendeath.8

Acute fluoride toxicity depends not only on theamountoffluorideintakebutthepatient’sweight.4Childrentendtobemoresusceptibletoharmfromfluoridetoxicitythanadults.Thedose-responsere-lationship is important to understand that healthresponseischemical,doseandorganspecific.4ThevaluesofacutefluoridetoxicitycanbeseeninTableI.9Anaverage2-year-oldchildweighing30poundswouldrequire67mgoffluoridetoreachtheacutetoxicdose,andanadultweighing180poundswouldrequire400mg.

Asfluorideisadrug,theU.S.FoodandDrugAd-ministration(FDA)isresponsibleforapprovingpre-scription and over-the-counter fluoride products intheU.S.andforsettingstandardsforlabeling.16Theamount of fluoride permitted in dental products isunder theongoing regulatoryauthorityof theFDAto prevent fluoride toxicity. The American DentalAssociation(ADA)setscriteria forproductstogainthevoluntaryADACommissiononScientificAffairsSealofAcceptance,whichisincompliancewiththeFDA regulations. To meet FDA regulations, over-the-counter toothpastes must have less than 276mgFpertube.21Ifneededfortherapeuticreasons,toothpastes containing more fluoride are availablebut usually obtained only with a prescription. Theamountoffluoridecontainedinadentalproduct issometimesgivenasapercentofvolumeorin“partspermillion”fluoride(ppmF)inthelabelingtomakeitmoreconsumerrelatable.21

Mostcurrentresearchonfluoridetoxicityhasfo-cusedonchronicexposure.Therearealimitednum-berofpublicationsonacutefluoridetoxicity,despiteitscommonoccurrenceasdemonstratedbythena-tional-basedAmericanAssociationofPoisonControlCenter (AAPCC). According to the AAPCC NationalPoison Data System’s (NPDS) 29th report (2011),30,000 calls regarding excessive fluoride exposureweremadetopoisoncontrolcentersacrossthena-tion.10 The report reveals thatmost acute fluorideexposureswereinchildren5yearsandyounger.Al-mostallofthecaseshadnomedicaloutcomes,how-ever,therewereacouplecasesresultinginmoderateandmajoradversemedicaloutcomes,suchasmajorgastrointestinalsymptoms,andindirectdeaths.10Al-

ThresholdAmountsofFluoride Toxicity

3to5mg/kgGastrointestinalsymptoms(minorandmoderatesymp-

toms)

5mg/kgAcutetoxicdose;requiresimmediatemedicalinterven-tion(majorsymptoms)

32to64mg/kg Acutelethaldose(death)

TableI:ValuesandEffectsofAcuteFluorideToxicity1,9

thoughstatisticsaboutfluorideoverexposureasre-ported to poison control centers across the nationis published in AAPCC’s annual report, the specificwidespreadissueisnotexploredoranalyzedfurther.Thelackofrecentdatainliteraturehasunderminedtheimportancetostudyandanalyzecurrenttrendsinacutefluorideexposure.Fluorideplaysapromi-nent role in current preventative practices againstcaries;therefore,itisimportantoralhealthcarepro-fessionalsremaincurrentonthetopic.

Astudyoffluoridetoxicityisalsoimportanttohelpinlightofrecentcontroversiesinthemediaregard-ing the safety of fluoride.While numerous studiesestablishacausalrelationshipbetweenfluorideandthepreventionofdentalcaries,3anti-fluoridepropo-nentsarguethatfluorideisa“potentpoison.”11Theyarguethatthewarninglabelonfluoridatedproductsrequired by the FDA (as is for all drugs under itsregulatoryauthority)isreasontobelievethatfluo-rideisdangerous.16Thelabelstates:“Ifmorethanrecommendedisaccidentallyswallowed,getmedicalhelporcontactapoisoncontrolcenterrightaway.”16Anti-fluorideproponentsalsousethefactthattherearethousandsofcallsmadetopoisoncontrolcen-terseveryyearasaresultofexcessiveingestionoffluoride,“manyofwhichresultinemergencytreat-ment at amedical facility” as evidence to supporttheirclaims.11

TheADA,however,statesthatmostmediacover-agehasnotrevealedthattheADAlimitedtheamountoffluorideallowedinADA-accepteddentifricesyearsago.Toreducethelikelihoodofaccidentalpoisoningamongchildren,theADArequiresthatnomorethan120mgoffluoride,or264mgof sodiumfluoride,bedispensedinonecontaineroffluoriderinse,gelorsupplement.8ThisislessthanwhatismandatedbytheFDA(whichis276mgF).9TheCDCandADAencouragespractitionerstoevaluateallpotentialflu-oridesourcesandconductacariesriskassessmentprior to prescribing fluoride supplements. ADA ar-guesthatthewarninglabel“greatlyoverstates”anydangerposedbyfluoridatedproducts.13


Thepurposeof thisstudywastoexplorethe is-suefurthertounearthsomeofthesecontroversiesandupdatecurrent literatureonacutefluorideex-posures.Anadditionalpurposewastocalculatetheincidence of acute fluoride toxicity and lethality asreportedtoNewJersey’sPoisonControlCenter.Thestudywillfollowadescriptiveepidemiologicalformattoprovideinsightoncommonlyaffectedgroupsandmedicaloutcomesofexcessivefluorideexposure.

Forpurposesofthisstudy,acuteexposure/exces-siveexposureisdefinedastheamounttakentobegreaterthanwhathasbeenprescribed,suggestedorthoughttobenormal.Thisisnotnecessarilyatoxicorpoisonousamount.Thiscanincludecasesofacuteonchronicexposure,butnotchronicexposurealone.


Theresearchdesignisaretrospectivecohortstudy.CollaborativeInstitutionalTrainingInitiativetrainingwas completed by all investigators. The study ob-tainedinstitutionalreviewboardapprovalandfund-ingwasprovidedbyRutgersSchoolofPublicHealthExploratoryGrantProgram.Recordsofphone callsmadebyindividualsreportingexcessivefluorideex-posuretoNewJerseyPoisonInformationandEduca-tionSystemwereextractedfromToxicallelectronicdatabase.

New Jersey Poison Information and EducationSystem is the regionally certified poison center inthe state ofNew Jersey that receives calls relatedtofluorideexposurefromall21counties.ToxicallisusedatNewJerseyPoisonInformationandEduca-tionSystemtocollectandrecorddataoncallsmadetothecenterregardingpossiblepoisoningandover-exposuretosubstances,inadditiontoanyquestionsrelatedtomedicalsubstances,chemicals,foodborneillness,etc.ThetrainedSpecialistinPoisonInforma-tion (SPI)with a background in pharmacology an-swerscallsmadetoNewJerseyPoisonInformationandEducationSystemandcollectsasmuchinforma-tionaspossibleaboutthesuspectedoverexposure.Thisinformationincludesdateandtimeofcall,typeof substance, patient’s age andgender, reason forexposure,countyofcaller,caller’szipcode,relation-ship of caller to patient, location of exposure, andmedical outcome of exposure (none,minor effect,moderateeffect,majoreffectordeath).Medicalad-viceisprovidedaccordingtothedetailsofthecasepresented.TheSPIhandlingthecalldocumentsallpertinentdataandentersitintothedatabaseinac-cordancetothepoisoncontrolcentercodinghand-book.Forfluorideexposure,theSPIdeterminestox-icitybasedonacalculationtodeterminetheratioofmg/kg.Forexample,achildwhoingested50tabletsof0.25mgfluoridewithaweightof11.36kghasingested1.1mg/kgfluoride.Todemonstrate:

50 tablets x 0.25 mg/tablet = 12.5 mg NaFl /11.36kg=1.1mg/kgNaFl

Figure1liststheinclusionandexclusioncriteriaoftheextracteddata.ClassificationsweredeemedandcodedbySPI’s.Nopersonalidentifyinginformationwasassignedtoanydataandadherencetoallper-tinent federalandstate regulations concerning theprotectionof the rights andwelfare of all subjectswerehonored.

Approximately210,000totalpoison-relatedphonecallrecordsweresearchedforasubsetofinclusioncriteriacases,with2,476recordsmeetinginclusioncriteria.Informationonthefollowingparameterswasobtained:age,gender,locationofexposure,relation-shipofcallertopatient,reasonforexposure,typeoffluoride-containingdentifrices involved inacuteex-posure, andmedical outcomes of exposures. Datawas thencategorizedbymedicaloutcomes(Figure2).

Themedicaloutcomecategoriesweredefinedbythe parameters used by the AAPCC 2011 report.Thosewhoweredeemedtobe“asymptomatic”didnot develop any signs or symptoms as a result ofthe exposure. Individualswhowere deemed to be“symptomatic” showed minor, moderate or majormedicaleffects.“Minoreffect”isdefinedasthepa-tientdevelopingsomesignsorsymptomsasaresultof the exposure, but they were minimally bother-someandresolvedrapidlywithnoresidualdisability.“Moderateeffect”isdefinedasthepatientexhibitingsignsorsymptomsasaresultoftheexposurethatweremorepronouncedormoreprolonged.Usually,someformoftreatmentisindicated.Symptomswerenotlife-threateningandthepatienthadnoresidualdisability.“Majoreffect”isdefinedasthepatientex-hibitingsignsandsymptomsasaresultoftheexpo-surethatwerelife-threateningorresultedinresidualdisabilityordisfigurement.“Death”wasdefinedasa

InclusionCriteria• NewJerseyareacode• Callsmade1/1/1012:00AMto12/31/1211:59PM

• Humanexposures/questions• Fluorideexposures/questions• Malesandfemales• Ages0to100years• Recordedmedicaloutcome,ifany• “Closed” classification (no follow-up requiredandnofurtherinformationavailable)

ExclusionCriteria• Non-fluorideexposures• Animalexposures

Figure 1: Inclusion/Exclusion Criteria ofDataforStudy


reSultS

Category Definition

AsymptomaticCases

Individualswhowereasymptomaticafteracuteexposuretofluoride,anddeemedbyNewJerseyPoisonIn-formationandEducationSystemtohavenoeffect,orjudgedtobenon-toxicand,therefore,notfollowed.

SymptomaticCases

Individualswhowereadverselysymptomaticafteracuteexposuretofluoride,anddeemedbyNewJerseyPoisonInformationandEducationSystemtohaveatleastaminormedicaleffectduetoexposure.Thesecaseswerefollowed.

InformationalCases

Individualswhocalledinthatwerenotexposedtofluoridebutwereseekingtogainmoreinformation

aboutfluorideexposure.*

Figure2:ClassificationsofRecords,BasedonMedicalOutcome/Type

patientdyingasresultoftheexposureorasadirectcomplicationoftheexposure.10

Additionally, each case reportwas searched andreviewed individually to obtain specific informationoncircumstancesofeachcaseandthespecificad-vice thatwas provided to the caller.Data analysisandincidencerateswerecalculatedinMicrosoftEx-cel.Graphsused95%confidenceintervalstocalcu-latethesignificanceindifferencesbetweengroups.

Frequency and Incidence of AcuteFluoride Exposure

Basedontheinclusioncriteria,theacutefluorideexposuresreportedwerefrompurefluoride(whichincluded professionally applied and/or prescribedsupplements),toothpastewithfluoride,mouthrinsewith fluoride and multivitamin with fluoride (withand/orwithoutiron).

“Pure fluoride” included gel forms of acidulatedphosphate fluoride (APF) which contained 1.23%(12,300ppm)fluoride,gelorfoamofsodiumfluo-ride(NaF)at0.9%(9,040ppm)fluorideandappliedgelof sodiumfluoride (NaF)at0.5%(5,000ppm)fluorideorstannousfluoride(SnF2)at0.15%(1,000ppm) fluoride. Overexposure/ingestion of NaF var-nishesthatwereappliedin-officebydentalprofes-sionalswere also included in the study, usually at2.26% (22,600 ppm) fluoride preparation. Dietaryfluoride supplements were in the form of tablets,lozengesorliquids.Mostsupplementscontainedso-diumfluorideastheactiveingredientwith1.0,0.5or0.25mgfluoride.Thefollowinghighlightsthecon-versionoffluoridetoitsion/compound:

• APF=1.23%F=2.7%NaF-• NaF=2%NaF=0.09%F-• SnF2=10%SnF2=2.5%F-• NaFVarnish=50mgNaF-/ml=2.3%F-

Concentrationsoffluorideintoothpasterangedfrom1,000 to 1,100 ppm. Fluoride in toothpaste camefrom3compounds(aspermittedbytheFDA):so-diummonofluorophosphate (MFP), sodium fluoride(NaF) and stannous fluoride (SnF2). Product labelsfor1,000and1,100ppmproducts readas follows(note:1,000ppmequals1.0mgF/mland1,100pmequals1.1mgF/ml):21

• 0.76%w/vMFP,whichequals1,000ppmF(or30mgF/oz)

• 0.243%w/vNaF,whichequals1,100ppmF(or33mgF/oz)

• 0.0454%w/vSnF2,whichcontains1,100ppmF(or33mgF/oz)

Toothpastetubesizesvaried;however,generally,a largetubeof toothpastewasusually6.4ozand,therefore,contained192to211mgF.Asmalltubeoftoothpastewasusually4.6ozandcontained138to152mgF.(6.4oztube(1,000ppmF)x30mgF/oz=192mgF).

Fluoridemouth rinse is a concentrated solution,andthemostcommonfluoridecompoundusedwassodiumfluoride(0.05%,or230ppmfluoride).Mul-tivitaminsmostlycontainedsodiumfluorideat1.0,0.5or0.25mgfluoride.

AsTable IIdepicts, therewasadecreasing inci-denceofacutefluorideexposureovertheyears2010to2012.Toothpastewithfluoridecausedthehighestincidenceofcallsrelatedtoacutefluorideexposure,eachyearandasatotal.

Population Characteristics andCircumstances of Acute FluorideExposure Cases

Age trends toward a unimodal distribution (Fig-ure 3) among victims of acute fluoride exposure,with 53.2%of cases involving individuals between18monthsand3yearsofage.Ata95%confidenceinterval, thedevelopmentalagegroups18monthsto2yearsand2to3yearsdonothaveoverlappingbars (Figure 3), indicating a significant differencefromotheragegroups.Ofacutefluorideexposurevictims,79.9%were5yearsandunder.

Maleshadaslightlyhigher incidenceofreportedacutefluorideexposures(TableIII).Overlappinger-rorbarsat95%confidenceintervalinFigure4,how-


Substance Toothpastewithfluoride

Mouthrinsewithfluoride

Multivitaminwithfluoride Purefluoride

Year n n n n Totals2010 440 174 200 66 8802011 398 176 181 56 8112012 375 185 148 77 785

Totals 1214(49.0%) 536(21.6%) 530(21.4%) 199(0.08%) 2,476(100%)

TableII:IncidenceofPhoneCallRecordsRelatedToAcuteFluorideExposureinNewJer-sey,ByYearandFluoride-ContainingProduct

1,000

900

800

700

600

500

400

300

200

100

0

NumberofCases

0.2% 0.5%1.8%

6.0%

28.4%

24.8%

12.3%

5.9%9.0%

2.2%

5.7%

1.3% 1.8%

Under6Months

6to9Months

9to12Months

12to18Months

18Monthsto2Years

2to3Years

3to4Years

4to5Years

5to12Years

12to18Years

18to65Years

65+Years

Unknown

Age*Ageincrementsonverticalaxisbrokendownbycognitivedevelopmentstages

Figure3:AgeDistributionofAcuteFluorideExposureCasesinNewJersey,2010to2012*

ever,showthatthisdifferencemaynotbesignificant(i.e.itmaybeduetochance).Themajorityofacutefluorideexposuresoccurredinone’sownresidence,while under the watch of the mother (Table III).Acutefluorideexposurewasmainlyunintentional.

Characteristics of Cases by Medical Outcome

As Table IV depicts, most cases would be con-sidered asymptomatic. Of the symptomatic cases,therewasmainlyaminormedicaleffectandasmallnumberhadamoderateeffect.Therewerenoma-jormedicaleffectsordeath,asdeemedbytheSPI

(TableV).AsTableVIdemonstrates,mostsymptom-aticcaseswerecausedbytoothpastewithfluoride.Peoplehadthemostquestions(informationalcases)aboutpurefluoride.

DiScuSSion

Thisstudyshowedadecreasingtrendofcallsre-portingacutefluorideexposureovertheyears2010to 2012 and follows the trend of decreasing callssince 2000 as per the 2011 AAPCC NPDS report.ThisdeclinemayreflectthedecreasinguseofPCC’sforacuteexposures,possiblyduetotheincreasing


Characteristic PercentGenderMale 53.2Female 45.8Unknown 1.45

LocationofAcuteExposureOwnResidence 93.1OtherResidence 1.6Workplace 0.1HealthCareFacility 0.5School 0.7Restaurant 0.0PublicArea 0.2Other 0.9Unknown 9.2

Characteristic PercentReasonforAcuteExposureUnintentional 96.65Intentional 1.45AdverseReaction 0.85Missing 1.05

CallersMother 67.5Father 15.2Self 5.2OtherRelative 3.1MedicalDoctor 2.1Nurse 1.6OccupationalTherapist 0.5Grandparent 2.1Other 2.6

TableIII:CharacteristicandCircumstancesofAcuteFluorideExposures inNewJersey,2010to2012

2,000

1,500

1,000

500

0

-500

-1,000

NumberofCases

Male Female UnknownNumberofCalls 1,317 1,133 26

Figure4:GenderDistributionofAcuteFluorideExposureCasesinNewJersey,2010to2012

useoftextovervoicecommunication,andincreaseduseandrelianceontheinternet.10Additionally,theAAPCC report demonstrates that toothpaste com-prisedmostofthefluoride-relatedcalls.Thisisinac-cordancewiththisstudy’sdata,whichdemonstratedthattoothpastecausedthehighestincidenceofacutefluorideexposureinNewJersey.Toothpasteisoneofthemostcommonat-homedentalproductscontain-ingfluorideandeasilyaccessible.Childrenyoungerthan5yearstendtoswallowtoothpastewhilebrush-ing.19Children6yearsandyoungerhaveaswallow-ingreflexthatisnotalwayswellcontrolled.22

The age groupsmost affected by acute fluorideexposure(forbothsymptomaticandasymptomaticpatients),in2010to2012,was18monthsto3yearsofage.Thisisavulnerablepopulationconsistingoftoddlersinaninquisitiveandexploratorysensorimo-tor stage.Other studiesalsodemonstrate that theincidenceofpoisoningpeaksbetween1and3yearsof age.14Males and females seemed to be equallyaffected, although Swierzewski’s study shows thatmales tend to bemore affected.14 Themost com-monsiteofacutefluorideexposureoccurredinthehomewhile childrenwereunder thewatchofpar-ents/guardians.

The most common reason for excess exposurewas found tobeunintentional/accidental.Commonreasonscitedforreasonsofexcessiveorinappropri-ate ingestion were related to taking older siblingsprescription,playingwithproductsandaccidentallyingesting,andaccidentallyingestingmorethanpre-scribed, either by fault of guardian or individually.However,asmanydentalproductsathomedonot

taste good to children, several phone records citethatthechildstoppedingestingtheproductontheirown. Other phone records, however, cite that thechildrenwantedtoingesttheproductsduetotheir“bubblegum”and“orange”flavorswhicharecom-monamongpediatricdentalproducts.

Basedontheresultsofthisstudy,therewerenolife-threateningeventsorfatalitiesduetoacuteflu-orideexposures, evenwhen taken indoseshigherthanrecommendedorprescribed.Fluoridesinavail-ableover-the-counterandprescriptionproductsarerelativelysafeandcommonacutedoseshavegener-allynontoxicandminoroutcomes.Itwouldrequireaverylargeamountofingestionoffluoride-contain-


ClassificationofCallType Totalnumber Percent

Asymptomatic 2,346 94.75Symptomatic 105 4.24Informational 25 1.01

Table IV: Classification of Phone Call Re-cords,BasedonMedicalOutcome

SymptomaticMedicalOutcome Totalnumber Percent

Minor 89 83.96Moderate 17 16.04Major 0 0Death 0 0

Table V: Symptomatic Cases, CategorizedbyTypesofSymptoms

ClassificationType PercentAsymptomaticToothpastewithFluoride 49.0MouthRinsewithFluoride 21.6MultivitaminwithFluoride 21.4PureFluoride 8.0ProductNotDefined 0.0

SymptomaticToothpastewithFluoride 57.0PureFluoride 22.0MouthRinsewithFluoride 14.0MultivitaminwithFluoride 7.0ProductNotDefined 0.0

InformationalPureFluoride 45.0ToothpastewithFluoride 24.0MouthRinsewithFluoride 17.0MultivitaminwithFluoride 0.0ProductNotDefined 14.0

Table VI: Breakdown of Medical OutcomeClassificationbyProductType

ingproducttoevenrequiremedicalintervention,letalonedirectfatality.Recallthatitwouldtake67mgofingestionoffluorideforanaverage2yearoldchildat 30 lbs. Toput it intoperspective, itwould takenearlyanentiretubeofanaveragesizedchildren’stoothpaste tube to reach theacute toxic doseandingestionof3tubesoftoothpastetoreachtheacutelethaldose.

Therewasasmallgroup(4.24%oftotalcases)ofsymptomaticcases,whoexhibitedminorandmoder-ateeffectsofacutefluorideexposure.Mostofthesecasesreportedgastrointestinalsymptoms(includingnauseaandvomitingand less frequently,diarrhea,abdominalpainandcoloredurine).Themechanismof toxicity is thought to occur by corrosive action,wherefluoridereactswithhydrochloricacidsinthestomach, resulting in gastrointestinal irritation.15These symptoms were generally easily remediedwith calcium as the antidote, in the form ofmilk,cheese, yogurt, etc., to bind the fluoride. InducedvomitingwasnotrecommendedbySPI’s.Themainconcernwasnotpoisoning,butratheraspirationordehydrationfromthevomitingandtherareallergy.Basedonthisstudy,therewerenohospitalizationsnecessaryduetoacutefluorideexposure.

NewJerseyPoisonInformationandEducationSys-tem,likeotherpoisoncontrolcentersacrossthena-tion,receivesalargevolumeoffluoride-relatedcallslargelyconcerningyoungchildren’sexcessexposure.While the warning labels are effective in alarmingpeople to thedangersofexcessivefluoride intake,this study found several cases of parents rushingtheirchildrentothehospitalsduetothestatementto“seekmedicalhelprightaway.”Itwasfoundthatitwasunnecessarytodoso;allofthechildrenweredischargedanddidnotneed further treatment (as

confirmedbyafollow-upcall fromNewJerseyPoi-son Information and Education System). Visits totheemergencydepartmentcancostresourcesanditmaybemorecost-effectiveforthelabeltoindicatemakingaphonecalltoaPCCfirst.Theauthorssup-port ADA’s statement that the FDAwarning labelsmaybemakingparentsandguardiansoverlyfright-ened.

Thisstudyisimportantforthedentalhygienistinlight of clinical practice, patient education and thecurrent controversies in themedia regarding fluo-ride.

Clinical Practice

Guidelines for in-office ingestion of fluoride:Ifthechild patient in the dental chair accidentally swal-lowsfluorideduringanin-officefluoridetreatment,the child should be given water and any calcium-containingproduct(milk,cheese,yogurt,icecream)assoonaspossible.Ifvomitingoccursanddoesnotstop,and/orsevereabdominalpain,itmaybeneces-sarytotakethechildtotheemergencydepartment.Themain concernwith vomiting is dehydration. Ifthechildisvomiting,makesuretheyareseatinguprightandnotsleepingontheirbacktopreventas-piration.

When prescribing/recommending fluoride as a supplement:Asdentalprofessionals,itisimportant


to perform a caries risk assessment before mak-ingrecommendationsassociatedwithpreventingorcontrollingcaries.AstheAmericanAcademyofPe-diatricDentistry(AAPD)recommends,dentalcariesriskassessmentshouldbebasedonapatient’sage,biologicalfactors,protectivefactorsandclinicalfind-ings.25Biological factors includeprimarycaregivershavingactivecaries, lowsocioeconomicstatus,thenumberofmeal sugar-containingsnacksorbever-agesconsumedperday, thepatienthavingspecialhealthcareneeds,and/orthepatientisarecentim-migrant.Protectivefactors includewhetherthepa-tient receives optimally-fluoridated drinking water,other fluoride supplements and the patient followsregulardentalhomecareandin-officevisits.Clinicalfindingsincludehavingmorethan1decayed/miss-ing/filledsurfaces,havingactivewhitespot lesionsorenameldefects,elevatedmutansstreptococcilev-els,orplaqueonteeth.25

Itiscriticaltoassessachild’stotalfluorideexpo-surefromallsources(food,drink,optimallytreatedwater,toothpaste,supplements,topicalapplicationsin-office,etc.)whendevelopingoralcarerecommen-dationsandtreatmentplans.23TheADA,AAPDandtheAmericanAcademyofPediatrics(AAP)encourag-espractitionerstocalculateappropriatedosebasedon a child’s total fluoride exposure and caries riskstatus.17,21,25Fluoridesupplementsarerecommendedonlyforchildrenlivinginnon-fluoridatedareasandathighriskfortoothdecay.23Whilestudiesdemon-stratethatfluoridecanprovideatremendousben-efit,2-5andthisstudysupportstherelativesafetyoffluoride,ariskstillremainswithoverexposurecall-ingforitsjudiciousapplication.4,6-8Fluoridetherapycanbecustomized,anditmustberememberedthatmodifications to therapyarenecessarybasedonapatient’s changing risk assessment, disease statusandfluorideexposure.

Iffluoride levels inwaterareunknown,drinkingwater should be tested for fluoride content beforesupplements are prescribed. If the water comesfromapublicorcommunitywatersupply,thelocalwatersuppliercanhelptodeterminetheamountoffluoride.TheEnvironmentalProtectionAgency(EPA)regulatesfluorideindrinkingwater,althoughthede-cisiontofluoridateawatersupplyatallismadebythestateorlocalmunicipality.24TheCDCandEPA’swebsitescanbevaluableresourcestodeterminewa-terfluoridationlevels.Ifthewatersourceisaprivatewell, it will need to be tested and the results ob-tainedfromacertifiedlaboratory.24

Ifafluorideprescription isdeemednecessary, itshouldbewrittenlegiblyanddistinguishbetweenmgFandmgNaF.Nomorethan120mgoffluorideinabottleshouldbeprescribedtoavoidpossible lethaldose,althoughmultiplerefillsarepermitted.

Dental hygienists must remember to carefullyevaluate newfluoride products in themarket, andreview laboratory and clinical evidence supportingtheefficacyoftheseproductsbeforeapplyingthemin-officeorrecommendingthemtopatients.

Education

Dental hygienists provide valuable informationtotheirpatientsregardinghomecareandeffectivedentalproducts.Itisimportantthattheyremembertoremindpatientsofproperdosageandsafetymea-sureswhenhandling theseproductsateveryvisit.Theactofremindinghelpstosolidifyknowledgeandgoodhabits.Toothpasteisthenumberonefluoride-containing dentifrice in acute fluoride exposures;therefore,dentalhygienistsshouldeducateandre-mindparentstoputawaytheirtoothpasteinaplaceathomethatisfarfromreachfromtheirtoddlers.

Afewdaysafterbirthandevenbeforetheteetherupt, caregivers should clean their child’s mouthandgumswithasoftmoistenedwashclothorgauzepadatbathtime.Thishelpsreadythechildforthetoothbrushcleaningtocome,andtheybecomeac-customed to having something in their mouth insuchamanner.26Additionally,thisroutinewillwashoffbacteriathatcouldotherwisedamagetheinfantteethastheycomein.27Forchildrenyoungerthan3yearsofage,caregiversshouldstartbrushingchil-dren’steethassoonastheybegintocomeintothemouthwithfluoridated toothpaste–nomore thanasmearorsizeofagrainofrice.17Forchildren3to6yearsofage,caregiversshoulddispensenomorethanapea-sizedamountoffluoridatedtoothpaste.17Childrenshouldalwaysbesupervisedtoensurethattheyusetheappropriateamountoftoothpasteandtominimizeswallowingoftoothpaste.Itisimportantto provide counseling to these caregivers at everydentalvisitwiththeuseofcleardescription,visualaids and demonstration to ensure that the appro-priateamountof toothpaste isused.Studies showthatcaregiversapplyuptotwicetherecommendedamountoftoothpaste–itisimperativethattheyarewell-educated.18,20

Aspartoforalhealtheducation,dentalhygienistscanalsoassureconcernedparentsthatiftoomuchfluorideintakeissuspected,itishelpfultohavetheirchild ingest a calcium-containingproduct. It is notrecommendedtoinducevomiting.Ifanyuncertain-tiesarise,patientsshouldbeeducatedontheroleofthepoisoncontrolcenterwhichisopen24hoursadayand365daysayear.

Thisstudyrevealedthatmanyinformationalcallswere made by concerned parents and guardiansregarding the safetyoffluoride, further illustratingthecurrentcontroversies.Recently,manydentalhy-gienistsarefacedwithquestionsfrompatientsand


concluSion

Basedon the results in the study, therewasnoincidenceoflethalityortoxicityduetoacutefluorideexposure in New Jersey from 2010 through 2012.Almostallcaseshadnomedicaloutcomes;veryfewcaseshadmostlyminorsymptomsfromacutefluo-rideexposure.Thebenefitsoffluoridegenerallyout-weightherisks.

Dentalhygienistsareadvisedtoperformcariesriskassessment and evaluate overall fluoride exposureforeachpatientbeforemakingrecommendationsas-sociatedwithpreventingorcontrollingcaries.Dentalhygienists should remind patients or caregivers tocalltheAmericanAssociationofPoisonControlCen-ter(800-222-1222)immediatelyiffluoridetoxicityissuspected.

Sneha Shah, RDH, MPH, is employed in private practice and in extended sales at SolutionReach Pa-tient Relationship Management Company. Samuel Quek, DMD, MPH, is a Professor, Director of General Practice Residency Program, Director of Division of Hospital Dentistry, at the School of Dental Medicine at Rutgers Department of Diagnostic Sciences. Bruce Ruck, PharmD, is Diplomate of the American Board of Applied Toxicology (DABAT) at New Jersey Poison Information and Education System.

parentsofpatientsregardingthesafetyoffluoride.While toomuch of any substance can be harmful,patientscanbeassuredthatthebenefitsoffluorideinfightingtoothdecayoutweighpotentialharms.Ifpatientsexpressdoubtsaboutfluorideuseandev-idence-based discussions do not placate concerns,dentalprofessionalsmust respect thepatient’spo-sitionandemphasize theneed forpropernutritionandmeticulousoralhygiene.Dietarycounselingandeducationonsugar,formsofsugarandunhealthyvs.healthysnacksisimportant.

Wheneducatingpatients and/or caregivers, it isimperative that dental hygienists are conscious oftheir communication techniques to help drivemo-tivation and compliance. The patient will be mostmotivatedtolearnwhengoodrapport,speech,toneofvoice,bodylanguageandfacialexpressionhavebeenestablished.28Basicprinciplesofteachinghavebeenshowntoincreasetheeffectivenessofcompli-ance,including:28

• Presentingsmallamountsof informationatonetimeinsimplifiedwords

• Letting thepatient set theirownpacebymak-ingsuretheyhavelearnedthetechniquebeforemovingontoteachotherthings

• Supervisingthepatientandmakingsuretheyarepracticingthecorrecttechnique

• Providingfeedbackduringvisitsandteachingthepatientself-evaluationtools

• Usingpositivereinforcement

Takingthetimetoperformthecorrectassessmentand employing proper communicative techniquesduringeducationarethefundamentalsofsuccessfulcompliance.

Thereweresomelimitationstothestudyduetoits retrospectivenature.Thedata is limited in thatitonlydealswithcasesreportedtoNewJerseyPoi-sonInformationandEducationSystem.Thatis,theactualnumberofactualexposuresthatoccurinthepopulationisunknown,astheymaygounreported.Additionally, thedata isallbasedonhistorygiven,andsomewereestimates.Therewassomemissingandunknowndatainsomesubcategories,includingage, gender, locational site, medical outcome andreasonforexposure.Itispossiblethatsomeoftheadversereactionstoingestionoftheproductswererelatedtoingredientsotherthanfluoride.

Futurestudiesmaywanttotestandverifyaccu-rate amounts of fluoride ingested, rather than ac-cepting caregiver reports. In the future, it wouldbehelpfultoseparateandevaluatedentalproductsbasedonthetypeoffluoridepresent(whetherso-dium fluoride, stannous fluoride, etc.) instead ofgroupingall toothpaste,mouth rinse,purefluorideandmultivitaminswithfluoridetogether.Itwasdif-ficulttoseparatethetypesoffluorideinthisstudyduetothesecond-handnatureofobtainingthedatabasedonpersonalreports.

acknowleDgmentS

DiScloSure

TheauthorswouldliketothankDr.StevenMarcus,Dr.TeriLassiter,andDr.WilliamHalperinofRutgersUniversityfortheirhelpwiththisresearchstudy.

ToxicallisaregisteredtrademarkofComputerAu-tomaticSystems,Inc.


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Theuseof simulation inmedicalandhealthsci-enceeducationhasemergedasaseminalpedagogi-caltoolinthepastseveraldecades.1-3Theneedsandapplication of simulation technology for training indentalanddentalhygieneeducationhaveprogres-sivelyparalleled thesameutilityofsupportingandimproving student learning.4-6 Incorporating simu-lationintopre-clinicalcurriculumacknowledgestheInstituteofMedicine’sattemptatimprovingpatientsafetyandenhancesstudentabilityandconfidencepriortoencounteringlivepatients.7,8Simulationcanbe incorporated into various pre-clinical phases ofdental and dental hygiene education but must befinancially feasibleandsupportedby the facultyofeachinstitution.

Priortoprovidingoralhealthcaretopatients,un-dergraduatedentalhygienestudentsmustdemon-strateproficiency inallareasofpatientoralhealthassessment, treatmentandevaluation. Included inthe oral health assessment are identification, andrecording of specific dental restorative conditions.Historically, students struggle with demonstratingtheseskillsdespitedidacticand laboratory instruc-

EffectofaSimulationExerciseonRestorativeIdentificationSkillsofFirstYearDentalHygieneStudentsMargaretLemaster,RDH,MS;JoyceM.Flores,RDH,MS;MargaretS.Blacketer,MPH

AbstractPurpose:Thisstudyexploredtheeffectivenessofsimulatedmouthmodelstoimproveidentificationandrecordingofdentalrestorationswhencomparedtousingtraditionaldidacticinstructioncombinedwith2-dimensional images.Simulationhasbeenadopted intomedicalanddentaleducationcurriculumtoimprovebothstudentlearningandpatientsafetyoutcomes.Methods:A2-sample, independentt-testanalysisofdatawasconductedtocomparegradeddentalrecordingsofdentalhygienestudentsusingsimulatedmouthmodelsanddentalhygienestudentsus-ing2-dimensionalphotographs.Evaluations fromgradeddental chartswereanalyzedandcomparedbetweengroupsofstudentsusingthesimulatedmouthmodelscontainingrandomplacementofcustompreventiveand restorativematerialsand traditional2-dimensional representationsofdidacticallyde-scribedconditions.Results: Resultsdemonstratedastatisticallysignificant(p≤0.0001)difference:forexperimentalgroup,studentsusingthesimulatedmouthmodelstoidentifyandrecorddentalconditionshadameanof86.73andvarianceof33.84.Thecontrolgroupstudentsusingtraditional2-dimensionalimagesmeangradeddentalchartscoreswere74.43andvariancewas14.25.Conclusion:Usingmodifiedsimulationtechnologyfordentalchartingidentificationmayincreaselevelofdentalchartingskillcompetencyinfirstyeardentalhygienestudents.Keywords:simulation,pre-clinical,dental,dentalhygiene,dentalmaterials,identification,restorative,theoreticalframeworksThisstudysupports theNDHRApriorityarea,Professional Education and Development: Validatemeasuresthatassesscontinuedclinicalcompetency.

research

introDuction

tionindentalmaterialsandtheory.9Pre-clinicallabo-ratorysessionstypicallyincludestudentspartneringwith one another to practice identification and as-sessment skills; however, traditional undergradu-atedentalhygienestudentsareoftenyoungadultsandmayhavelimiteddentalrestorations,reducingpracticalexperiencebeyond2-dimensionaltextbookanddidacticinstruction.Advancesindentalmaterialshade-matchingandcontouringabilitieshaveintro-ducedclinicalsimilaritiesbetweenvariousmaterialsand tooth structures with seemingly undetectablemargins.10,11Although,theseattributescontributetothe successof estheticdentistry, identificationandchartingofthesematerialshaveprovedtobechal-lenging forpre-clinicaldentalhygienestudents.12,13Although these concepts are reviewed didacticallyusingphotographsandwrittendescriptions,studentscontinuetohavedifficultycomprehending2-dimen-sionalmodelsandhavelimitedpre-clinicallaboratoryexperiences.Theultimategoalofdentalanddentalhygiene education is to become proficient in skillsset forth by the Commission on Dental Education.Deliberatepracticeisaneducationalapproachtobe-come proficient in these skills by using repetition,


assessmentofperformanceand feedback resultinginimprovedskillperformancebythestudent.

Otherhealthsciencedisciplinescontinuetodem-onstratesuccessintheuseandeffectivenessofsim-ulationasanadjunct toclinicalanddidactic learn-ing.Simulationcloses thegapbetweenpre-clinicalknowledge building and actual hands-on patientcare. In the 1960s, the cardiology patient simula-torwasdeveloped.Stillinusetoday,thissimulatorisabletoreproduce30differentcardiacconditionsallowing medical students to successfully improvetraining in cardiacandpulmonaryclinical skills.14,15Manyprogramsinemergencymedicineusesimula-tionscenarios forrapidresponseteamstopracticecritical skills such as intubation and resuscitation.Theseactivitiesimproveteammemberrolesduringreallifetraumasandhospitalemergencies.16-18Neu-rosurgery,vascularandorthopedicsurgerystudentsalsobenefitfromsimulationtechnologytobuildandimprovesurgicalskills.19,20

Inthenursingeducationandpracticesetting,sim-ulation programs have been developed to improvelearningenvironmentsfornursesofvaryinglevelsofexperienceandexpectedscenarios,suchascriticalcare, acute care, infant care, obstetrics andgyne-cology.21-23Hospitals arenow incorporating simula-tion into theirorientations.Onehospitaldevelopedasimulationprogramconcurrentlywiththeircardiacsurgery unit and developed scenarios that reflect-edtypicalcareacardiacpatientmayrequire.24,25Inobstetrics,simulationtrainingiscommon.Newandseasonedpracticingnursesaswell asotherhealthprofessionals have opportunities to participate incommonneonataldiagnosessuchassepsisandre-spiratory distress. The team approach to learningwithsimulationaddressestheneedtoimproveneo-nataloutcomes.26

Simulationinanesthesiaeducationhasbeenusedsincethe1980s.Giventhenatureofthepracticeen-vironment,teachablemomentsareoftenovershad-owed by the necessity for seasoned anesthesiolo-giststoresponsestocriticalpatientneedsinsteadofallowingforstudentinstruction.Simulationinanes-thesiologyofferslearnerstheopportunitytoexperi-encecriticaldecisionmakinginasafeenvironment.27In addition, the American Board of Anesthesiologynowrequiressomeformofsimulationtrainingtoful-fillcertificationrequirements.28

The 2 theoretical frameworks used in this studyincludeBenner’sstagesofclinicalcompetence29andKirkpatrick’s trainingoutcomesmodel.30,31Studentsinteracting with the simulated dental conditions inthis investigationwereprovidedwithbothavisualandtactilesenseofexperiential learning.32 “Learn-ingbydoing,observing,andparticipating”providesexperiential learning in the form of apprenticeship

ratherthanisolateddidacticclassroominstruction.32Benner’stheoryreflectsuponthesevitalexperiencesrelated tobothphilosophicalbehaviorismandcon-structivism, and is basedon theDreyfusmodel ofskillacquisition.32-35Thistheoryalsorecommendsco-hesiveadoptionofexperientiallearningintoalargerdidactic training process including a well-designedcurriculumandevaluationprotocol.33Benner’stheo-retical framework is ubiquitous among educationalresearchinnursingandhasdirectionforinterprofes-sionalapplications.36-38

Theaimofthisstudywastoinvestigatetheuseofcustomizedsimulatedmouthmodelsimprovediden-tificationandrecordingofdentalrestorationsinfirst-yeardentalhygienestudentswhencomparedtotheuseof traditionaldidactic instructionand2-dimen-sionalimages.


TheSchool ofDentalHygieneatOldDominionUniversity enrolls 48 students into their entry-level Baccalaureate degree program each year.Theprogramrequires2yearsofpre-requisiteandgeneral education courses preceding 2 years ofdental sciences, dental hygiene theory and prac-tice, community oral health, research methodol-ogy, and teaching strategies. Participants of thisstudyweredentalhygienestudentswhohadcom-pleted 2 years of pre-requisite courses andwererecognized as first year dental hygiene students.Students completed 1 semester of a dental ma-terials course andhad knowledge of Blacks clas-sification.TheSchoolofDentalHygienesupportedthis research studybyprovidingparticipantsandthe facility for conducting the clinical trial. Priortothestartofthisinvestigation,theprotocolwasreviewedandapprovedbytheinstitutionalreviewboardensuringtheprotectionofhumansubjects.

Using an A-Dec 42L Stationary Simulator, 11stock interchangeableFrasacoA-PZDAperiodon-tal simulated mouth models were customized toreflectrestorativefindingsofatypicalpatientre-ceivingcareinthedentalhygieneclinic.Eachmod-elwasuniquelymodifiedbyafacultydentistwho“restored”themtorandomlyinclude10chartableitems:2sealants,3posteriormulti-surfaceamal-gams,3posteriormulti-surfacecompositesand2anteriormulti-surfacecomposites.Two-dimension-al imageswereobtainedbyphotographingdenti-tion of 3 patients from the clinic facility with 10chartable itemssimilar to themodifiedsimulatedmouthmodels.

Aconveniencesampleofdentalhygienestudentsfromthefirstyear,baccalaureatedegreeprogramwere chosen for this study. At the time of thestudy, 48 studentswere enrolled in the program


asfirstyeardentalhygienestudentsandwereeli-gible for participation in the investigation (TableI). Following recruitment,34students committedtoenrollmentinthestudy.Thenumberofsampleparticipantswasbasedonthetotalavailablestu-dents starting their first-year dental hygiene co-hortexperience,havingall beenequallyexposedto 1 semester of dental and dental hygiene sci-encestudies.Itwasimportanttostudythissamplepopulationbecauseallparticipantswereidentifiedas having the same formal pre-requisite educa-tionandonly1cohortsemesterofeducationinthedentalhygieneprogram.Thesamplewasrandomlydividedinto2groups:theDidacticGroup(control)andtheSimulatorGroup(experimental).Fourstu-dentsreportedhaving2yearsorlessofdentalas-sisting experienceprior to entering theprogram.Twoofthesestudentswererandomlyassignedtoeachgroup.

Randomassignmentrendered17studentsintheSimulator Group (experimental) and 15 studentsintheDidacticGroup(control).Twostudentsfromthecontrolgroupdidnotcompleteallsessionsandweredisqualified from thestudy.Students in theSimulatorGrouputilizedarandomlyselectedcus-tomsimulatedmouthmodel for3 sessionsof15minutes each to practice identification and docu-mentation of dental conditions. Both groups hadprevious identical didactic and laboratory lessonsondentalcharting.StudentsintheDidacticGroupviewed randomly selected 2-dimensional imagesfor3sessionsof15minuteseachtoalsopracticeidentification anddocumentation of dental condi-tions.Studentsfrombothgroupsrecordedfindingsusing standard dental charting criteria. Studentsin SC scheduled individual 15minute timed ses-sionswithasupervisingfacultyinaprivateroomwith 1 simulator. Students in the Didactic GroupSCscheduledindividual15minutetimedsessionswithasupervisingfacultyinaquietroom.Sessionswere scheduled over a 3 week time frame. Stu-dentschartedfindingsateverysession.Studentswerenotabletoaskquestionsorcollaboratewithotherstudents.Bothgroupsreceivedfeedbackim-mediately after the 15 minute time ended. Onedental hygiene facultymember graded all dentalchartsanonymouslyanddidnotseethestudent’sname or any identifying information to maintainintra-rater reliability. Since there were 10 chart-ableitemsineachscenario,eachitemwasworth10pointsforatotalof100possiblepointsearnedpersession.

A2-sample,independentt-testanalysisofdatawasconducted tocomparegradeddental record-ings of dental hygiene students using simulatedmouthmodelsanddentalhygienestudentsusing2-dimensionalphotographs.

DiScuSSion

reSultS

UsingMicrosoftExcel2010,at-testfor indepen-dent samples assuming unequal variance was cal-culated. Thevarianceswereunequal basedon thef-test,whichresulted inap-valueof0.055.Thet-testgaveap-valueof<0.0001.Figure1illustratesmean Simulator Group (Experimental) and Didac-ticGroup(Control)Scores.TableIIdemonstratesastatisticallysignificantdifferenceinthegradedden-talchartscoresforSimulatorGroup(mean=86.73,variance=33.84) and control (mean=74.43, vari-ance=14.25).Consideringthisstudywasrestrictedto a small, unique population group, generalizabil-ityoftheresultsmaybelimitedtofirst-yeardentalhygiene students. Overall, students who identifiedrestorationson the simulatoryieldedamean87%successratewhilethosestudentswhoidentifiedres-torationsusing2-dimensionalphotographsyieldedamean74%successrate.

Findingsofthisstudyreflectthecollectiveevidenceof beneficial outcomes published in current dentalandhealth care simulationeducation literature.39-43Comparatively, the beneficial outcomes in this andother current studies consistently demonstrate theeffectivenessandmajorbenefitsofusingsimulation.Thesebenefitsincludeincreasingskillacquisitionbe-forepatientexposureand theability to repeatedlypractice identification skills in a safe environment.Specificdiagnosticandassessmentskillsareespe-ciallyimportantindentalhygieneeducationtoensuresafedeliveryofcareastheevolvingprofessionuseshighlyrealisticrestorativeandprostheticmaterials,conservativecariesdetectionmethods,androlesfordentalhygienistscontinue toexpandnationally.42,44Theresultsofthisstudyshoweddiagnosticandas-sessment skills can be increased by using simula-

ExperimentalGroup

ControlGroup

Age18to25 14 1226to33 3 3

RaceCaucasian 9 8AfricanAmerican 4 4Asian 4 2Hispanic 0 1

GenderMale 1 0Female 16 15

TableI:CohortDemographics


concluSion

Using this type of simulation tool in conjunctionwithtraditionalteachingstrategiesofdidacticeduca-tionmayallowstudentstophysicallyassess,identifyandchartcertainrestorationspresentedintheclini-calsetting.Althoughusingsimulatedmouthmodels

t-Test:Two-SampleAssumingUnequalVariancesVariable1 Variable2

Mean 86.73529 74.43333Variance 33.84743 14.25417Observations 17 15HypothesizedMeanDifference 0 -

df 28 -tStat 7.17306 -P(T<=t)one-tail 4.16E-08 -tCriticalone-tail 1.701131 -P(T<=t)two-tail 8.32E-08 -tCriticaltwo-tail 2.048407 -

TableII:StatisticalAnalysest-testResults

88

86

84

82

80

78

76

74

72

70

68MeanTestScores

TestingGroups

ExperimentalScores

ControlScores

Figure1:MeanSG(Experimental)andDG(Control)Scores

tionwhichshouldbeadoptedasproficientlearningtoolstohelpdentalhygienestudentsincreasetheirsuccessrateofprovidingeffective,safecareforpre-paredness in expanding roles such as nursesusedtopreparestudentsformidwiferyroles.44Studiesinnursingsimulationalsoprovideevidencesimilar tothis study in demonstrating how low-cost, low-to-mediumlevelfidelitysimulationallowsstudentsanopportunityto increasesuccesswhen learningnewskills.39,44Methodsandoutcomesinthisstudyfurthermirrored nursing simulation studies which imple-mentedbestpracticesandstandardsforsimulationuseineducationandresearch.43,45

Theuseofmodelingandsimulationhasshowntobeaneffectivemethodtotransferknowledgefrominstructor to studentwhen compared to traditionalteaching methods in dentistry.46-48 Simulators pro-vide integration of psychomotor skill training withproblem-basedlearning,suchasdidacticinstruction.Inthisstudy,dentalhygienestudentswereabletoidentifyandcorrectlycharteachpreventiveandre-storativedentalmaterialbasedonvisual,tactileandauditorysenses.Thisleadstoimprovedperformancewhen compared to isolated classroom deliveredlearning.Inaddition,thisallowedforstudentstobe-come confident and proficient in critical skills nec-essary forsuccessfulassessmentoforalconditionswhenevaluatinglivepatientsandin-vivoscenarios.

Limitationsof thestudy includedasmallsamplesize.Additionally,duetobudgetconstraints,exten-siverestorations(suchascastporcelainandmetalcrowns)werenotusedinthesimulation.Educatorswithinthedisciplinesofbothdentalanddentalhy-gienecurriculummaybeabletousethefindingsofthisstudytoimproveassessmentskillsofstudents.Thesupportingdata,whichprovestheeffectivenessofthesimulatedtechnology,demonstratestheneedforeducators to considerandadopt realistic, safe,efficient, inexpensive and effective teachingmeth-odologies.Simulationoftheoralcavityenhancedthepedagogical transferofdidactic clinicalassessmentandevaluation skills into a realistic scenario. Eachinterchangeable modified simulated mouth modelservedasatooltoenhancedentalhygienestudents’abilitytoaccuratelyidentifyspecificdentalmaterialsandconditions.Thismodelingandsimulationexer-cisewillbeimplementedintothejunioryeardentalhygienepre-clinical laboratorycoursetoassiststu-dents in accurately identifying dental restorationspriortoactualpatientcare.

isnotanewconcept indentalanddentalhygieneeducation, thisstudy reaffirms the importanceandsuccessofthistypeofeducationaltool.Inthisstudy,modifiedsimulatedmouthmodels improved identi-ficationandrecordingofdentalconditionsbydentalhygiene studentswhen compared to studentswhoused2-dimensionalimages.Futureresearchshouldincludelargersamplesizes,morecomplexrestora-tionsandanevaluationoftheeffectsofexperientiallearning with modeling and simulation using out-comesassessmentindentalhygieneeducation.

Margaret Lemaster, RDH, MS, is an Assistant Pro-fessor, Gene W. Hirschfeld School of Dental Hygiene,


DiScloSure

This research study wasmade possible throughthe financial support of Old Dominion University’sCenterforLearningTechnologies,FacultyInnovatorGrant.

Old Dominion University. Joyce M. Flores, RDH, MS, is an Assistant Professor, Gene W. Hirschfeld School of Dental Hygiene, Old Dominion University. Marga-ret S. Blacketer, MPH, is a Senior Business Informa-tion Developer, Medicare Medical Economics, Well-Point, Inc., Norfolk, Va.

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Professionalschoolsrarelyprepareprospectiveaca-demicfacultyfortheresponsibilitiesofcollegeanduni-versityteaching.Withoutthistraining,facultyareoftenleft todiscover jobexpectationson theirown.At thesametime,universitiesandcollegesrecognizethatre-tentionoffacultydependsonthesuccessfultransitionofacademicsintotherelatedrolesandresponsibilitiesof theprofessoriate.This issue is further complicatedbytheobservationthatthelandscapeofteachingandlearning has changed dramatically in the last 2 de-cades.Onlinelearning,learningmanagementsystemsand technology make it possible to teach and learnfromany location, fromacoffeeshopto thecomfortofone’shome.Supplementedbytechnology,changesencompassingopportunitiestoteachfromandlearninavarietyofenvironmentsnowrequirethatuniversityandcollegefacultyassessthecurrencyoftheirteachingskills.Takingtimetoassesswhat facultyknowaboutteaching,educationalresearch,andtryingtodiscoverwhattheirteachingandlearningneedsareiscrucialto

AssessingFacultyDevelopmentNeedsamongFlorida’sAlliedDentalFacultyLindaS.Behar-Horenstein,PhD;CyndiW.Garvan,PhD;FrankA.Catalanotto,DMD;YuSu,MEd;XiaoyingFeng,BS

AbstractPurpose:Professionalschoolsrarelyprepareprospectiveacademicfacultyfortheresponsibilitiesofcollegeanduniversityteaching.Withoutthistraining,facultyareoftenlefttodiscoverontheirownandtovaryingdegreesofsuccesswhatisexpectedofthemoncetheyentertheacademy.Atthesametime,universitiesandcollegesrecognizethatretentionoffacultydependsonthesuccessfultransitionofacademicsintotherelatedrolesandresponsibilitiesoftheprofessoriate.Thepurposeofthisstudywastoassessthefacultydevelopmentneedsamongallieddentalfaculty,specificallythestateofFlorida’sdentalhygieneanddentalassistingfaculty,bymeasuringthefollowing:therelationshipbetweentheirknowledgeandprioritiesforfurthertraining,theirlevelofsatisfactionwithcurrentfacultydevelopmentopportunitiesandmentoring,andtheirperceptionsofwhatadditionaltrainingandresourcesmightadvancetheircareers.Methods:Twohundredand four full-timeandpart-time facultywere invited toparticipate in thissurveyresearchstudy.McNemar’stestforpairedbinarydatawasusedtoanalyzethelevelofagreementbetweenknowledgeandindicatedpriority.Responsestoopenendedquestionswerecodedandcategorizedthematically.Results: Therewere115responses(n=204,74%).Therewerestatisticallysignificantdifferencesbetweenparticipants’ratingsofknowledgeandprioritiesforfurthertrainingonmanyitemsrelatedtoteaching,scholar-shipandleadershipskills.Participantsalsoidentified5categoriesofunmetneeds.Conclusion:Thefindingssuggestthatuniversitiesandcollegesneedtoofferlearningexperiencesaimedatstrengtheningtheteaching,scholarshipandleadershipskillneedsoftheirallieddentalfaculty.Additionally,professionalschoolsmightconsiderofferingaprogramtrackthatprovidesprospectiveallieddentalfacultywiththetypesofopportunitiesthatdevelopsteaching,scholarshipandmentoringskillspriortograduation.Keywords:allieddentalfaculty,continuingeducation,facultydevelopment,quantitativeanalysis,surveyre-searchThisstudysupportstheNDHRApriorityarea,Professional Education and Development: Identifythefac-torsthataffectrecruitmentandretentionoffaculty.

research

introDuction

ensuringthatfacultyremaincurrentintheirpedagogicalexpertise.Thepurposeofthisstudywastoassessthefacultydevelopmentneedsamongallieddentalfaculty,specificallythedentalhygieneanddentalassistingfac-ultyteachinginthestateofFlorida.

Previous research highlights the importance of ad-dressingtheneedsofdentalhygienefacultiesregardingfaculty development programs.1 Such initiatives havebeenlinkedtofaculty’sdecisiontoremaininacadem-ics. In a study of 167 baccalaureate dental hygienefaculty,40%(n=35)ofparticipantsreportedthattheyweresomewhatorverydissatisfiedwiththeamountoftimeallowedforkeepingabreastofnewandemergentknowledgeinthefield.2IntheCollinsetalstudy,themajorityoftheparticipants(96%,n=107)reportedthatadvancementopportunitiesweresomewhatoraveryimportantfactorintheirdecisiontoleavetheircurrentpositionandacceptanotherposition.Amajority(85%,n=96)alsoindicatedthathavingnopressuretopublish


wassomewhatoraveryimportantfactorintheirdeci-siontoleavetheircurrentpositionandacceptanotherposition.Facultyreportedthattheyhadlittletimeavail-able for research/scholarshipandprofessional growthactivities,althoughtheseareoftendecidingfactorsintenuredecisions.Whenaskedtoratethemostimpor-tantskillsforfuturedentalhygienefaculty,morethan90%of592participantsintheCoplenetalstudyidenti-fiededucational,technologicalandclinicalskills.3

Facultydevelopmentprogramshavebeen reportedtoenhanceparticipants’senseofbelongingness.Forex-ample,adentalhygienefacultydevelopmentprogramenhancedfacultysenseofcommunityandsatisfaction.4Yet,theavailabilityoffacultydevelopmentopportunitiesfordentalhygieneanddentalassistingfacultyorpro-fessionalpreparationineducationalmethodologiesforthesefacultyarenotreadilydiscussedeitherinscholar-shiporreportedintheliterature.5

Inarecentstudy,severalauthorssoughttoexplorehowtheadoptionofe-coursescouldbeincreasedamongdentalanddentalhygienefacultymembers.6Usingfo-cusgroupinterviews,27dentaland23dentalhygienefacultymembersfrom6institutionsparticipated.6Thisstudy identified 4 barriers to e-course adoption: lowperceivedrelativeadvantagetofacultymembers, lowcompatibility with current curriculum, high perceivedtimecommitmentandcomplexityofe-coursedevelop-ment.Comparedtotraditionalcourses,participantsre-portedthate-coursesincreasedaccessibilityandconve-nienceforstudents,allowedfacultymemberstomakeadditional materials such as websites, readings, andactivitiesavailable,andofferedarelativelyeasywaytoassessstudentprogresswiththeuseofonlinequizzes.6

Thepurposeofthisstudywastoassessthefacultydevelopmentneedsamongallieddentalfaculty,specifi-callythestateofFlorida’sdentalhygieneanddentalas-sistingfaculty,bymeasuringtherelationshipbetweentheirknowledgeandprioritiesforfurthertraining,theirlevel of satisfactionwith current faculty developmentopportunitiesandmentoring,andtheirperceptionsofwhatadditionaltrainingandresourcesmightadvancetheircareers.


The university’s institutional review board ap-provedthestudy(IRB#U-989-2013).AnOfficeofEducationalAffairs’committeeattheUniversityofFlorida’sJacksonvilleCollegeofMedicineoriginallydevelopedthesurveyinresponsetoarequestthattheycreateaneedsassessmenttohelpplananewfacultydevelopmentcurriculum.Sincenodatabasewasavailableofalldentalhygieneanddentalas-sistingfacultyinthestateofFlorida,theresearch-erscompiledalistofalloftheinstitutionsthathaveadentalhygieneanddentalassistingprogram inthestate.Eachoftheidentified31programdirec-

torswere contacted via email and asked to pro-vide a list of full-time and part-time facultywiththeirfirstandlastnameandcorrespondingemailaddress.Twohundredandfourfullandpart-timefacultyteachingfacultywereinvitedtoparticipatein the facultydevelopmentneedsassessmentviaa 37-item questionnaire. The questionnaire wasdeveloped tomeasure participants’ knowledge ofand priorities in teaching, scholarship and lead-ership skills. Participants were asked to indicateandrateofsatisfactionwiththeirinstitution’sfac-ulty development opportunities, the frequency oftheir participation and level of satisfaction withthe mentoring they received. Next, they wereaskedtoratetheirknowledgeof itemsrelatedtoteaching, scholarship and leadership using a Lik-ert response scalewhere: 1=none, 2=very little,3=some,4=approachingmasteryand5=mastery/couldteachothers.Theywerealsoaskedtoindi-cate theirpriority for each item in theirpersonaldevelopmentusingaLikertresponsescalewhere:1=low,2=mediumand3=high.Finally,theywereaskedtolist3needsthattheybelievedthat,ifful-filled,wouldadvancetheircareer.

The survey was sent to participants using theprofessionalandencryptedversionofSurveyMon-key.Remindermessagesweresenttoparticipantsseveral times to enhance the response rate. Therateofreturnwas74%,or115of204.Thesampleincludedalmostanequalamountof fullandparttimefaculty,73(48.3)and78(51.6),respectively,fromdental hygiene and dental assisting schoolsacrossFlorida.Alldatawerede-identifiedpriortotheanalysis.

Statistical Analysis

Summarystatisticswerecomputedforallitemsin the survey. The authors dichotomized scores(lower: knowledge=1, 2, 3 versus high: knowl-edge=4,5)andpriorityscores(lower:priority=1,2versushigh:priority=3)fortheknowledgeandpri-orityitems.UsingMcNemar’stestforpairedbinarydata, the level of agreementbetweenknowledgeand indicatedprioritywastested.Asignificantp-valuefromMcNemar’sstatisticaltestprovidedevi-dence that therewas disconnect between knowl-edgeandpriority,eitherevidence that therewasalackofknowledgeinanareaandthatitwasnotprioritizedforfuturetrainingorthattherewasnotalackofknowledgebutitwasgivenhigherprior-ity.

Hypothesistestingwassetatalevelof0.05toascertain statistical significance. SAS version 9.3(Cary,NC)wasused forall dataanalysis.A reli-abilityanalysiswasruntocomputeCronbach’sal-phasforeachofthe3subscalesforbothknowledgeand priority. The internal estimates of reliability


reSultS

Faculty’s Rating of and Level ofParticipation in Faculty DevelopmentPrograms

With regard to program quality of faculty de-velopment opportunities, participants (34.71%)ratedthemaspoororfair33.53%ratedgoodand31.76% indicated theywereverygood toexcel-lent. Of those who frequently participated in afaculty development program (5 to 7 times peryear),11.86% indicatedapoor/fair rating,21%selectedagoodratingand44.44%,averygoodtoexcellentrating.Ratesofparticipationacross3levels(neverto1or2peryear,some,3to4peryear,andoftenandfrequently)werecomparableat32.94%,30%and37.05%,respectively(TableII).Nostatisticaldifferenceswerefoundbetweenratingsofandlevelofparticipationinfacultyde-velopmentopportunities.

Faculty’s Perceptions of Mentoring

About one-third of the respondents rated thequality of the mentoring they received as poor(11.18%) or fair (23.53%). Of those who ratedmentoring quality positively, 33.53% reported agoodrating,23.53%reportedaverygoodratingand8.24%reportedaratingofexcellent.

Faculty Priorities in Teaching, Scholarship and Leadership

There was a statistically significant differencein 4 of the 9 teaching items. As shown in TableIII,36.18%oftheparticipatingfacultyratedtheirteaching knowledge as low on providing con-structivefeedbacktolearners.Morethanathird(35.57%)ratedtheirknowledgeaslowondesign-ing courses. Faculty who identified these activi-tiesashighpriorityneedsranged from71.81to80.92%, respectively. The findings showed thatfacultyhaveaneedfortheseskills.Morethanhalf

werestrongforallsubscalesrangingfrom0.78to0.89.Cronbach’salphaforknowledgeandprioritybysubscale isshown inTableI.Therespondentslistedupto3currentneeds.Overall,413currentneedswerelisted.Theitemswereopencodedandcategorized by the authors independently. Themostfrequentcategoriescoalescedinto5themes(professional development and skills, need for aposition/job, continuous education, completing adegree,andfinancialneedsandotherresources).Operationaldefinitionswerecreatedfromthefreeresponsesbypayingspecialattention to thewaythat responses overlapped or conflicted and theoverarchingconcepttheyillustrated.Datawasex-tractedtoexemplifyeachofthethemes.

Subscale Knowledge PriorityTeaching 0.889 0.779Scholarship 0.857 0.826Leadership 0.866 0.851

TableI:InternalEstimatesofReliabilitybySubscale

LevelofParticipation

CurrentStateofFacultyDevelopmentProgram

Poor/Fair Good

VeryGood/Excellent

OverallPercent

Neverto1or2perYear 40.68 38.60 18.52 32.94

Some(3to4peryear) 42.37 31.58 14.81 30.00

Often(5to7peryear) 11.86 21.05 44.44 25.29

Frequently(8ormoreperyear) 5.08 8.77 22.22 11.76

OverallPercent 34.71 33.53 31.76 –

Table II: Perceptions of Faculty Develop-mentbyLevelofParticipation

(59.73%)reportedhavingalowknowledgeontheitemsofteachingeffectively,and73.97%report-ed low knowledge on developing an educationalportfolio.Morethanathird(35.57%)reportedahigh priority for training on teaching effectively,and 25.34% indicated that they had a need fortrainingindevelopinganeducationalportfolio.Oftheremaining5items,nostatisticallysignificantdifferenceswereobservedbetweentheir levelofknowledgelevelsandpriorityforadditionaltrain-ing.

With respect to scholarship there was a sta-tistically significant difference (p<0.05) be-tweenratingsofknowledgeandpriorityonall5items.Almosttwo-thirdstonearlyallofthefac-ulty (63.16% to 97.37%) rated their knowledgeaslowonthefollowingrelateditems:grantpro-posal writing in discipline research, conductingliteraturesearches,developingresearchdesigns,documentingeducationoutcomesandwritinganeducationmanuscript.However,only15.65%and34.21% identified these activities as a high pri-orityneed.Thediscrepancybetweenthepartici-pant’sidentificationoftheseitemsasareasoflowknowledgeandthelowpercentagethatidentifiedthesebehaviorsasareasofhighprioritysignifyalackofawarenessamongtheparticipants inpri-oritizingtheseneedsforpersonaldevelopment.


Item PercentLowerKnowledge PercentHighPriority p-value#

TeachingTeachingEffectively 59.73% 35.57% 0.0004*ProvidingConstructiveFeedbacktoLearners 36.18% 80.92% <0.0001*

UsingEffectiveAssessments 59.87% 53.95% 0.371EnhancingSmallGroupTeaching 60.14% 55.41% 0.453UsingEmergingTechnologyintheClassroom 53.33% 55.33% 0.742

SelectingAppropriateTeachingMethods 50.67% 58.67% 0.190

EnhancingMyClassroomTeaching 61.49% 49.32% 0.075

DesigningCourses 35.57% 71.81% <0.0001*DevelopinganEducationalPortfolio 73.97% 25.34% <0.0001*

ScholarshipGrantProposalWritinginDisciplineResearch 63.16% 25.00% <0.0001*

ConductingLiteratureSearches 74.34% 34.21% <0.0001*DevelopingResearchDesigns 97.37% 16.45% <0.0001*DocumentingEducationOutcomes 94.08% 15.13% <0.0001*

WritinganEducationManuscript 93.20% 15.65% <0.0001*LeadershipBalancingWorkandPersonalResponsibilities 69.33% 30.67% <0.0001*

ManagingStress 33.33% 59.33% <0.0001*ManagingTime 76.67% 32.00% <0.0001*DemonstratingLeadershipSkills 41.33% 58.00% 0.0095*SustainingPassionforTeaching 53.33% 56.67% 0.574ManagingConflict 42.67% 58.67% 0.005*UtilizingNegotiationSkills 30.26% 64.47% <0.0001*PreparingforPromotionand/orTenureReview 56.67% 39.33% 0.008*

CreatingaTeachingPortfolio 70.39% 35.53% <0.0001*MentoringPeers 77.48% 31.13% <0.0001*PeerObservationofTeachingwithFeedback 28.08% 67.81% <0.0001*

TableIII:RelationshipbetweenParticipants’KnowledgeandPriorityforTraining

#p-valuefromMcNemar’stest*Denotesstatisticallysignificantdifferencebetweenlevelofknowledgeandprioritygiven

Withrespecttoacquiringleadershipskillsthatmightfulfillcareeradvancementtherewasasta-tistically significantdifference (p<0.05)betweenratingsofknowledgeandpriorityon8of the11items. Of the participants, 73.8 to 91.8% ratedtheirknowledgeas lowon itemsrelatedto:bal-ancing work and personal responsibilities, man-

aging stress,managing time,managing conflict,preparing for promotion and/or tenure review,creating a teaching portfolio, mentoring peers,andpeerobservationof teachingwith feedback.However, 55.7% rated these activities as a highpriority.


ItemPercentLower

Knowledge

PercentHighPriority

p-value

TeachingUsingeffectiveassess-ments 59.87% 53.95% 0.3705

Enhancingsmallgroupteaching 60.14% 55.41% 0.453

Usingemergingtech-nologyintheclass-room

53.33% 55.33% 0.7419

Selectingappropriateteachingmethods 50.67% 58.67% 0.1904

Enhancingmyclass-roomteaching 61.49% 49.32% 0.0747

LeadershipDemonstratingleader-shipskills 41.33% 58.00% 0.0095*

Sustainingpassionforteaching 53.33% 56.67% 0.5737

Managingconflict 42.67% 58.67% 0.0053*

TableIV:SummaryofItemsthatParticipantsIndirectlyIdentifyasHighNeedandPriority

TypeofNeed FrequencyProfessionalDevelopmentandSkills 108NeedforaPosition/Job 39ContinuousEducation 36CompletingaDegree 34FinancialNeedsandOtherResources 33

Table V: Most Frequently Reported UnmetFacultyNeeds(n=413)

Relationships among Faculty’s Level of Knowledge and Priorities for Additional Training on Teaching, Scholarship and Leadership Skills

AnyitemintheKnowledgeandPrioritycolumnswith a percentage ofmore than 40%was ratedasahighneedandhighpriority(TableIV).Fac-ultyidentified8itemsthatwerebothhighneedsand a high priority. Five teaching and 3 leader-shipskillsitemswereidentified,althoughthisdidnotapplytoscholarshipitems.Theteachingitemsincluded:usingeffectiveassessments,enhancingsmallgroupteaching,usingemergingtechnologyin the classroom, selecting appropriate teachingmethods and enhancingmy classroom teaching.The leadership items included: demonstratingleadership skills, sustainingpassion for teachingandmanagingconflict.

Unmet Faculty Needs

Participants were asked to list up to 3 itemsthat they believed would advance their career.Fourhundredandthirteenparticipants’responseswere reported. Participants most frequently re-porteditemspertainingto:professionaldevelop-mentandskills,needforaposition/job,continu-ouseducation,completingadegree,andfinancialneeds and other resources. Overall, these ac-countedfor60.53%oftheresponses(TableV).

Responsesintheprofessionaldevelopmentandskills category included classroom managementtraining,trainingonlargeandsmallgroupinter-actions,coursedevelopment,learningbetterstu-dent-teacherdialogue,teachingmethodologyandskills, and updating technology skills, outcomesassessment and assessment methods, teachingorganizationanddesign,peerpresentations,edu-cationaltheory,evaluatingcriticalthinking,inter-disciplinaryteaching,currenttrendsineducation,cooperative learning, publishing, and enhancingstudent retention of information. Those in thepositionneed/jobopportunity categorywerede-scribedasadesireforfulltimejobopeningoranopenposition, theopportunity toattain fullpro-fessorship or promotion, a desire to eventuallyteach full time, and participate in other didacticteachingopportunities.Thecontinuingeducationcategoryincludedacquiringeducationbasedcon-tinuingeducationunits.Otherscitedtheneedtolearnmore about educationalmethodologies foraccreditation, finish continuing education cred-its foranupcomingcertifieddentalassistantre-newal and access to continuing education unitson education. Some participants identified com-pleting a degreewould advance their career in-cluding obtaining bachelor of science, master’s,postgraduateordoctoraldegree,orahigherlevel

of education. Finally, financial or other resourc-es were indicated by participants as needed forcareer advancement. This included paid time toplancoursesandattendmeetings,aswellasad-ditionalresourcessuchasbooksandofficespace,funding,increasedpay,payfortimespentgradingassignments,andcorporateinvestments.

DiScuSSion

Theneedforeffectivefacultydevelopmentinthehealth sciences in general and for dental hygieneandassistingfacultyspecificallyisdrivenbysignifi-cantchangesinthehealthcareenvironmentintheU.S.7Previousresearchindicatesthatdentalfacultydevelopment programs are significantly importantfor faculties, students and community. The waysinwhichfacultydevelopmentprogramsfosteraca-demiccareersinthehealthsciencehasbeenstud-


ied in medical, pharmacy, nursing, dentistry anddentalhygiene.8-13

The findings of the current study showed thatthereweredifferencesintheknowledge,needs,andprioritiesamongFloridadentalhygieneanddentalassistingfacultywhoteachfull-timeandpart-time.Thisstudywasaimedatthe institutionalofferingsfor faculty development provided at each partici-pant’s respective college/university. As might beexpected,at timesfaculty judgedtheirknowledgetobelowandtheirpriorityoftheseitemstobelow.Atothertimes,facultyjudgedtheirknowledgetobehighandtheirpriorityforadditionaltrainingamongitems to be high. Alsowhen their knowledge andprioritywerebothgreaterthan40%onanitem,itwasdeterminedthatparticularitemwasapriority.Overall participants indicated low knowledge andhighpriorityneedsamong17of25facultydevelop-mentassessmentitems.

Comparedtopreviousresearchonfacultydevel-opment needs among dental faculty participants,thesefindingsaresimilarinsomeaspects,althoughdissimilar inothers.Onestudyof facultydevelop-ment needs among University of Tennessee (UT)HealthScienceCenterfacultyfoundthatoneteach-ingitem,assistancewithinstructionaldesign,wasratedhighestwhich is inagreementwith thecur-rentstudy,“designingcourses.”7TheauthorsoftheUT study suggested that improved teaching skillsisparticularlyimportantbecause“muchofthecur-riculumismandatedbytheprofessionalhealthcareorganizationsthatoverseeandaccreditprofession-alschools,”andbecausefacultydonotoftenreceivetraininginpedagogyintheirprofessionalprogramsofstudy.7

Thefindingsinthecurrentstudyarecomparabletoanotherstudyconductedofdentalfaculty.14Forexample,participants in thecurrentstudypartici-pated more frequently in annual faculty develop-mentopportunitiesof3 tomorethan5 timesperyear(67.1%)comparedtodentalfaculty(49.3%).An infrequent rate of participation among dentalfaculty (0 to 2 times per year) was considerablyhigherthanasimilarrateofparticipationreportedbydentalhygieneanddentalassistingfacultysug-gesting that dental hygiene and dental assistingfaculty tend to take greater advantage of facultydevelopmentopportunities.14

Inthecurrentstudytherewere5teachingitems(using effective assessments, enhancing smallgroup teaching,usingemerging technology in theclassroom,selectingappropriateteachingmethodsand enhancing my classroom teaching) in whichratingsofknowledgeandprioritywerenotstatisti-cally significant.However, these itemswere ratedasstatisticallysignificantbydentalschoolfaculty.14

Itmaybethatdentalhygieneanddentalassistingfacultyfeelmorepreparedforteachingthandentalfaculty.Dentalhygieneanddentalassistingfacultyrated the knowledge and priority among severalitems (teaching effectively, conducting literaturesearches,managingstressanddemonstratinglead-ership skills) as statistically significant. However,theywerenot ratedas statistically significant bydental school faculty participants.14 This findingsmaybeduetostricterrequirementsincollegesofdentistryatacademicinstitutionscomparedtotherequirementsforpromotionthatdentalhygieneanddentalassistingfacultyneedtoattain.

Although entry level programs are designed toprepare clinicians for professional careers in den-tistryandnot forpreparingacademicians,promo-tionrequirementscontinuetoincreaseatalllevelsof education including community colleges wheremanydentalhygieneeducationalprogramsarelo-cated,aswellatuniversities.Astheserequirementschange,morefacultyinpostsecondaryinstitutionsarebeingaskedtoshowevidenceofscholarlyac-tivitiessuchasteachingportfolios,increaseduseofactive teaching strategies, information supportingtheuseoflearningactivitiesthatpromoteculturalcompetence,evidence-basedassessmentandcriti-calthinking.Withincreasingopportunitiesforonlineprogramsthatprovideaccess tomore individuals,manyoptions toenroll inpost-graduateprogramsarenowavailableforallieddentalhealtheducators.Therearedegreecompletionandmaster’sdegreeprograms. Individualswho seek academic careersaretypicallythegroupsthattaketheseprogramsofstudybutthereisnorequirementthattheyincludecoursesineducation.

Research has shown the benefits of faculty de-velopmentopportunitiesusingvariedformatssuchas workshops, seminars and courses. Studies ofmedical school faculty development programs in-dicate the urgency of improving teaching skills,strengthening colleague relationships and improv-ing the overall academic advancement of healthcare faculties.15,16Wallace et al reported that fac-ultydevelopment focusedon thereinforcementofclinicalteachingpracticesandmethods,leadingtoincreasedknowledgeincompetency-basedteachingandpositivechanges tocommunicationskillswithstudents.1Clinicalteachersdemonstratedimprovedteachingskillsfollowingtheirparticipationinfacultydevelopment.17

Onelimitationofthestudyisthattheresearchersdidnotdifferentiateresponsesbasedoninstitution-altype,fullorpart-timeemployment,positiontype(suchasfacultyorchair),andwhetherthepartici-pantwasadentalhygienistordentalassistant.Thereasonwasthattheresearcherswerelookingtoob-taina“snapshotintime”viewofparticipationand


concluSion

Findingsfromthisstudysupportpreviousresearchwhichreportsthatfacultydevelopmentisparticular-ly important indentaleducation for improving fac-ulty skills, for ensuring the effectiveness of futureacademicdentistsandforrecruitingdentalhygienefaculty.18,19Takingtimetoassessfacultyknowledgeabout teaching,educational research,and identify-ing their teaching and learning needs is crucial toensuring that faculty remaincurrent in theirpeda-gogical expertise. Such initiatives may ultimatelyensurethatfuturefacultyarepreparedtoenterthe

DiScloSure

ThisprojectwassupportedbytheHealthResourc-esandServicesAdministration (HRSA)of theU.S.Department of Health and Human Services (HHS)under grant number and title for grant amount(Award #1 D86HP24477-01-00, Faculty develop-mentsupportingacademicdental institutioncurric-ulum for 21st century. Awarded $2,552,191). Thisinformationorcontentandconclusionsarethoseoftheauthorandshouldnotbeconstruedastheofficialpositionorpolicyof,norshouldanyendorsementsbeinferredbyHRSA,HHSortheU.S.Government.

satisfactionwithfacultydevelopmentopportunities,mentoring,andidentificationoftheteaching,schol-arship and administrative and leadership skills/careeradvancementneedsamongapopulationoffacultyparticipantsinalliedhealthprogramsacrossthestateofFlorida.

Overall, the findings in this study showed thatparticipants overwhelmingly reported the needfor professional developmentopportunities. In re-sponse to that need, following the completion ofarelatedstudyconductedwithdental faculty thatdemonstrated similar outcomes, the authors havedeveloped3onlineaccreditedcoursesintheuniver-sity’scontinuingdentaleducationprogram.8Futureresearchshouldincludewaystoprovideprofession-alopportunitiestofacultyatalllevelsoftheircareerinformatswhichareeasilyaccessibleandcostef-fectiveforallfaculty.

academy,andforotherssuchinitiativesmayensuretheirretention.

Linda S. Behar-Horenstein, PhD, is a Distinguished Teaching Scholar and Professor at the Colleges of Dentistry, Education and Veterinary Medicine, and Director, Clinical Translational Science Institute, Ed-ucational Development and Evaluation University of Florida. Cyndi W. Garvan, PhD, is a Research Associ-ate Professor at the College of Nursing, University of Florida. Frank A. Catalanotto, DMD, is a Profes-sor and Chair, Department of Community Dentistry and Behavioral Science at the College of Dentistry, University of Florida. Yu Su, MEd, is a Doctoral Stu-dent, Research Evaluation Methods at the College of Education, University of Florida. Xiaoying Feng, BS, is a Doctoral Student, Educational Leadership at the College of Education, University of Florida.

1. Wallace JS, Infante TD. Outcomes assessment ofdentalhygieneclinicalteachingworkshops.J Dent Educ.2008;72(10):1169-1176.

2. CollinsMA,ZinskiCD,KeskulaDR,ThompsonAL.Characteristics of full-time faculty in baccalaure-atedentalhygieneprogramsandtheirperceptionsof the academicwork environment. J Dent Educ.2007;71(11):1385-1402.

3. CoplenAE,KlausnerCP,TaichmanLS.Statusofcur-rentdentalhygienefacultyandperceptionsofim-portantqualificationsforfuturefaculty.J Dent Hyg.2011;85(1):57-66.

4. Johnstone-DodgeV,BowenDM,CalleyKH,PetersonTS.Afacultydevelopmentcoursetoenhanceden-talhygienedistanceeducation:apilotstudy.J Dent Educ.2014;78(9):1319-1330.

5. Paulis MR. Comparison of dental hygiene clini-cal instructorandstudentopinionsofprofessionalpreparation for clinical instruction. J Dent Hyg.2011:85(4):297-305.

6. DeBateRD,CragunD,SeversonHH,etal.Factorsforincreasingadoptionofe-coursesamongdentalanddentalhygienefacultymembers.J Dent Educ.2011;75(5):589-597.

7. ScarbeczM,RussellCK,ShreveRG,RobinsonMM,ScheidCR.Facultydevelopmenttoimproveteach-ing at a health sciences center: A needs assess-ment.J Dent Educ.2011;75(2):145-159.

8. Behar-HorensteinLS,ChildGS,GraffRA.Observa-tionandassessmentoffacultydevelopmentlearningoutcomes.J Dent Educ.2010:74(11):1245-1254.

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Clinicalpracticeguidelines(CPG)areintendedtoprovideclinicianswithguidanceindiagnosis,treat-mentplanning,andclinicaldecision-making.1CPGshavebeenshowntoimprovepatientcareprocess-es and clinical outcomes, and to better identifyand limit treatment risks.1-4 Although empiricallydeveloped CPGs have been used inmedicine forhundreds of years, in the 1990s systematic ap-proacheswereadvancedandadvocatedforCPGs.Inanextensivesystematicreviewof59published

ClinicalPracticeGuidelinesforRecallandMaintenanceofPatientswithTooth-BorneandImplant-BorneDentalRestorationsAvinashS.Bidra,BDS,MS,FACP;DianeM.Daubert,RDH,MS;LilyT.Garcia,DDS,MS,FACP;TimothyF.Kosinski,MS,DDS,MAGD;ConradA.Nenn,DDS;JohnA.Olsen,DDS,MAGD,DICOI;JeffreyA.Platt,DDS,MS;SusanS.Wingrove,RDH,BS;NancyDealChandler,RHIA,CAE,CFRE;DonaldA.Curtis,DMD,FACP

AbstractPurpose:Toprovideguidelinesforpatientrecallregimen,professionalmaintenanceregimen,andat-homemaintenanceregimenforpatientswithtooth-andimplant-borneremovableandfixedres-torations.Methods: The American College of Prosthodontists (ACP) convened a scientific panel of expertsappointedby theACP,AmericanDentalAssociation (ADA),AcademyofGeneralDentistry (AGD),andAmericanDentalHygienistsAssociation(ADHA)whocriticallyevaluatedanddebatedrecentlypublishedfindingsfrom2systematicreviewsonthistopic.Themajoroutcomesandconsequenc-esconsideredduring formulationof theclinicalpracticeguidelines(CPGs)wererisk for failureoftooth-andimplant-bornerestorations.Thepanelconductedaroundtablediscussionoftheproposedguidelines,whichweredebatedindetail.Feedbackwasusedtosupplementandrefinetheproposedguidelines,andconsensuswasattained.Results: AsetofCPGswasdevelopedfortooth-bornerestorationsandimplant-bornerestorations.EachCPGcomprisedof1)patientrecall;2)professionalmaintenance,and3)at-homemaintenance.For tooth-borne restorations, theprofessionalmaintenanceandat-homemaintenanceCPGsweresubdivided for removable andfixed restorations. For implant-borne restorations, the professionalmaintenanceCPGswere subdivided for removableandfixed restorationsand furtherdivided intobiologicalmaintenanceandmechanicalmaintenanceforeachtypeofrestoration.Theat-homemain-tenanceCPGsweresubdividedforremovableandfixedrestorations.Conclusion:Theclinicalpracticeguidelinespresentedinthisdocumentwereinitiallydevelopedus-ingthe2systematicreviews.Additionalguidelinesweredevelopedusingexpertopinionandconsen-sus,whichincludeddiscussionofthebestclinicalpractices,clinicalfeasibilityandrisk-benefitratiotothepatient.Totheauthors’knowledge,thesearethefirstCPGsaddressingpatientrecallregimen,professionalmaintenanceregimen,andat-homemaintenanceregimenforpatientswithtooth-borneandimplant-bornerestorations.Thisdocumentservesasabaselinewiththeexpectationoffuturemodificationswhenadditionalevidencebecomesavailable.Keywords:clinicalpracticeguidelines,tooth-borne,implant-borne,patientrecall,maintenanceThis reviewwas funded in part by an unrestricted educational grant to the American College ofProsthodontistsEducationFoundationfromtheColgate-PalmoliveCompany.GuidelinesPromulgatedandPublishedbytheAmericanCollegeofProsthodontists(ACP)intheJour-nalofProsthodontics.Copyright2016.Allrightsreserved.ReproducedunderagreementwithACP.

PracTice guiDeliNes

introDuction

CPGsinmedicine,GrimshawandRussell4showedthatexplicitCPGsimprovedclinicalpracticewhenintroduced inthecontextofrigorousevaluations.Indentistry,afewoft-citedCPGs includetheuseofantibioticprophylaxisbeforedentalprocedurestopreventendocarditisincertaincardiacpatients,5theuseofprophylactic antibioticsprior todentalproceduresinpatientswithprostheticjoints,6an-tibiotic prophylaxis for dental patients at risk forinfection,7 oral health care for thepregnant ado-


lescent,8guidelinesforthecareandmaintenanceof complete dentures,9 management of patientswithmedication-relatedosteonecrosisofthejaws(MRONJ)10 andmany others.11 The United Statesmaintains a national registry in the NationalGuidelineClearinghouse for evidence-based clini-cal practice guidelines, which are submitted andendorsedbyvariousmedicalandprofessionalor-ganizations.11 It is important to note that unliketraditional CPGs based on empiricism ormedicalauthority,modernCPGs involveasystematicandtransparent process for scrutiny of scientific evi-dence, and recommendations aremade with theintent that theywill be updated andmodified asscientific evidence becomes available.1-4 Despitethis, recommendationsmade inCPGs arenot al-wayssupportedbyscientificevidence.Thisisbe-causemanyempiricalproceduresand treatmentsthat yield favorable outcomes do not necessarilyhavescientificevidenceatthepresenttime.12

Patientsseekingprosthodonticcareoftenpres-ent with significant previous dental treatment, acomplex etiology of factors contributing to theloss of teeth, loss of tooth structure, and equal-ly complex treatment needs to restore functionandesthetics.Treatmentplanstoaddresspatientneeds using tooth- or implant-borne restorationsrequire careful diagnosis, risk assessment, treat-mentplanning,meticulousexecutionofcare,andalong-termpartnershipwiththepatientandtreat-ment team to maintain an enduring result. Giv-en the resources required to treat patients withcomplexdentalneeds,anappropriatepatient re-call regimen, professional maintenance regimen,andat-homemaintenanceregimenareparamountforlong-termsuccess.13,14Furthermore,itislikelythat the professional and at-home maintenanceprotocolsinhealthyadultpatientswithtooth-andimplant-borne restorations may be significantlydifferentwhencomparedtopatientswithnoresto-rations,orpatientswithacuteorchronicoralandsystemic diseases. For tooth-borne restorations,guidelines on the options and relative merits ofprofessional and at-home maintenance protocolstopredictablyachievestableresultsarelacking.13Currentguidelinesforthemaintenanceofimplantrestorationsarepoorlydefinedandoftenbasedonempiricismortraditionalprotocolsforpatientswithnaturaldentitionratherthanwhatismostsuitableformaintenanceof implant restorationsandsup-porting tissues.14 Therefore, professional and at-home maintenance guidelines are necessary forpatientswithtooth-andimplant-borneremovableand fixed restorations to improve the health ofsupportingtissues,limitdiseaseprocessessuchascaries,periodontitis,orperi-implantdisease,andimprovetheexpectedlongevityofrestorationsaswell as the supporting teeth and implants them-selves.Guidelinesareneededtoprovidedirection

forthedentalhealthcareproviderwiththegoalofimprovedclinicaloutcomesforthepatient.

Patientswithcomplextooth-andimplant-bornerestorations require a lifelong professional recallregimentoprovidebiologicalandmechanicalmain-tenance customized for each patient. Therefore,thepurposeofthisCPGdocumentistoprovide:1)guidelinesforpatientrecall regimen,professionalmaintenance regimen, and at-homemaintenanceregimen for patients with tooth-borne restora-tionsand2)guidelinesforpatientrecallregimen,professional maintenance regimen, and at-homemaintenance regimen for patients with implant-bornerestorations.Thetargetpopulationsof thisCPGarepatientswithtooth-andimplant-bornere-movableandfixedrestorations.The intendedus-ers of the presented CPGs are: general dentists,dentalhygienists,prosthodontistsandotherden-talspecialists,dentalhealthcareproviders,alliedhealthpersonnel,nurses,socialworkers,students,patients, medical and dental insurance carriers,andpublichealthdepartments.


Totheauthors’knowledge,thisisthefirstCPGaddressing patient recall regimen, professionalmaintenance regimen, and at-homemaintenanceregimenforpatientswithtooth-andimplant-bornerestorations and serves as a baseline for futuremodifications and versions based on future sci-entificevidence.Twoseparatesystematicreviewsof the literature were conducted to evaluate therecall and maintenance regimens for tooth- andimplant-bornerestorations.13,14Thesystematicre-viewontooth-bornerestorationsincludedarticlespublishedfromJanuary1,1999toDecember31,2014.Thesystematicreviewonimplant-borneres-torationsincludedarticlespublishedfromJanuary1,2004toDecember31,2014.Thedetailedmeth-odologyforthesearchprocessesaredescribedinthe respective systematic review articles.13,14 Fortooth-borne restorations, 16 studies were identi-fiedinthesystematicreviewthatreporteddataonacombined3569patients.Ofthese,ninewereran-domizedcontrolledclinicaltrials(RCT),andsevenwereobservationalstudies.Forimplant-borneres-torations,20studieswereidentified,reportingon1088 patients. Of these, eleven were RCTs, andninewere observational studies. Results from allof these studieswere scrutinized, tabulated, andanalyzedtoformulateconclusionsandthencreatetheCPGs.

AscientificpanelcomprisedofexpertsappointedbytheAmericanCollegeofProsthodontists(ACP),American Dental Association (ADA), Academy ofGeneral Dentistry (AGD), and American DentalHygienists Association (ADHA) critically evaluat-


DiScuSSion

reSultS

edanddebated thepublishedevidence from twosystematicreviewsonthistopic.Aratingschemefor strength of recommendation as described byShekelle et al1was used as itwasmost applica-bletothis topicand iswidelyusedandvalidatedin the medical literature (Tables I, II). The ma-joroutcomesandconsequencesconsideredduringformulation of these CPGs were: 1) risk for fail-ureoftooth-bornerestorationsand2)riskforfail-ureof implant-bornerestorations.Thereafter, themembersofthetaskforceconductedaroundtablepeerreview/evaluationdiscussionoftheproposedguidelines,andtheguidelinesweredebatedinde-tail. These inputs were used to supplement andrefinetheproposedguidelines,andconsensuswasattainedforthevariousguidelinespresented.

Patientswithtooth-andimplant-bornerestora-tionsrequirealifelongprofessionalrecallregimentoprovidebiologicalandmechanicalmaintenance,customized for each patient. Therefore, a set ofCPGswascreatedforeachtypeofrestorationcom-prising:1)patient recall;2)professionalmainte-nance, and 3) at-home maintenance. The CPGsare presented in Table III for tooth-borne resto-rations15-30 and Table IV for implant-borne resto-rations.31-50Fortooth-bornerestorations,thepro-fessionalmaintenance and at-homemaintenanceCPGs were subdivided for removable and fixedrestorations. For implant-borne restorations, theprofessionalmaintenance CPGs were sub-dividedfor removable and fixed restorations and furtherdivided intobiologicalmaintenanceandmechani-calmaintenanceforeachtypeofrestoration.Theat-home maintenance CPGs were subdivided forremovableandfixedrestorations.Thestrengthofevidenceandsubsequentrecommendationthatispresentlyavailablewasappliedforeachguideline.Whenaguidelinecomprisedmultipleaspects,thenmultiplestrengthsofavailablerecommendationsindescendingorderwereapplied.Additionally,whenmultiplestrengthsofrecommendationwereavail-ableforaspecificguideline,theywereallappliedaccordingly.

The scientific panel considered the potentialbenefits, harms, contraindications, and scope oftheseguidelines. Thepotential benefits for theseguidelines include: 1) improved oral health andlongevity of natural teeth, tooth-borne, and im-plant-borne restorations and 2) improved oralhealthrelatedqualityof life.Thepotentialharmsconsidered were 1) increased short-term cost topatientstoadheretorecall regimen,professionalmaintenance regimen, and at-homemaintenanceregimenand2)adverseeffects related toanyof

the professionally used oral topical agents or at-home oral topical agents and oral hygiene aids.The contraindications to these guidelines includeallergies or adverse effects related to any of theprofessionallyusedoraltopicalagentsorat-homeoraltopicalagents.

Apotentialsourceofbiasconsideredduringde-velopmentoftheCPGswasthatauthorsofthesys-tematicreviewsalsoservedaspanelmembersfortheCPG.51,52Tominimizethispotentialbias,effortsweremadeduringthescientificpanelmeetingstodebateand justifyeachguideline inanopenandtransparent format. Financial and organizationalconflictsofinterestswerenotidentified.Strengthofevidencewasdebatedforeveryguideline.Thus,theeffectof“groupthink”maynotbeasourceof

Level CategoryofEvidence

Ia Evidencefromsystematicreviewofran-domizedcontrolledtrials

Ib Evidencefromatleastonerandomizedcontrolledtrial

IIa Evidencefromatleastonecontrolledstudywithoutrandomization

IIb

Evidencefromatleastoneothertypeofquasi-experimentalstudy,suchastimeseriesanalysisorstudiesinwhichtheunit

ofanalysisisnottheindividual

III

Evidencefromnon-experimentaldescrip-tivestudies,suchascomparativestudies,correlationstudies,cohortstudies,and

case-controlstudies

IVEvidencefromexpertcommitteereportsoropinionsorclinicalexperienceofrespected

authoritiesorboth

TableI:LevelsandCategoryofEvidenceasDescribedbyShekelleetal1

Classification Strengthofrecommendation

A DirectlybasedoncategoryIevi-dence

BDirectlybasedoncategoryIIevi-denceorextrapolatedfromcat-

egoryIevidence

CDirectlybasedoncategoryIIIevi-denceorextrapolatedfromcat-

egoryIorIIevidence

DDirectlybasedoncategoryIVevi-denceorextrapolatedfromcat-egoryI,II,orIIIevidence

TableII:RatingSchemefortheStrengthofRecommendationasDescribedbyShekelleetal1


TableIII:ClinicalPracticeGuidelinesforRecallandMaintenanceofPatientswithTooth-BorneDentalRestorations

Number Topic Guideline StrengthofRecommendation

1. Patientrecall

Patientswithtooth-bornerestorations(fixedorremovable)shouldbeadvisedtoobtainadentalprofessionalexaminationat

leastevery6monthsasalifelongregimen.D

Patientscategorizedbythedentistashigherriskbasedonage,abilitytoperformoralselfcare,biologicalormechanicalcom-plicationsofnaturalteethortooth-bornerestorationsshouldbeadvisedtoobtainadentalprofessionalexaminationmoreoftenthanevery6months,dependingupontheclinicalsituation.

D

2A.

Professionalmain-tenance:Tooth-borneremovablerestorations(partialremovabledentalprostheses)

Professionalmaintenanceforpatientswithtooth-borneremov-ablerestorationsshouldincludeanextraoralandintraoralhealthanddentalexamination,oralhygieneinstructionsforexistingnaturalteethandanyrestorations,oralhygieneintervention

(cleaningofnaturalteethandrestorations),anduseoforaltopi-calagentsasdeemedclinicallynecessary.

A,C,D

Professionalmaintenanceofthepartialremovabledentalpros-thesesshouldincludehygieneinstructions,detailedexaminationoftheprosthesis,prostheticcomponentsandpatienteducationaboutanyforeseeableproblemsthatcouldimpairoptimalfunc-tionwiththerestoration.Thepartialremovabledentalprosthesisshouldbeprofessionallycleanedextraorallyusingprofessionally

acceptedmechanicalandchemicalmethods.

D

Professionalsshouldrecommendand/orprescribeappropriateoraltopicalagentsandoralhygieneaidssuitableforthepatient’s

at-homemaintenanceneeds.D

2B.

Professionalmain-tenance:Tooth-

bornefixedrestora-tions(intracoronalrestorations,ex-tracoronalresto-rations,veneers,singlecrowns,andpartialfixeddentalprostheses)

Professionalmaintenanceforpatientswithtooth-bornefixedrestorationsshouldincludeanextraoralandintraoralhealthanddentalexamination,oralhygieneinstructionsfornaturalteethandthefixedrestorations,oralhygieneintervention(cleaningofnaturalteethandrestorations),anduseoforaltopicalagentsas

deemedclinicallynecessary.

A,C,D


at-homemaintenanceneeds.D

Whenclinicalsignsindicatetheneedforanocclusaldevice,pro-fessionalsshouldeducatethepatientandfabricateanocclusal

devicetoprotectthetooth-bornefixedrestorations.D

Professionalmaintenanceoftheocclusaldeviceshouldincludehygieneinstructions,detailedexaminationoftheocclusaldevice,andpatienteducationaboutanyforeseeableproblemsthatcouldimpairoptimalfunctionwiththeocclusaldevice.Theocclusal

deviceshouldbeprofessionallycleanedextraorally,usingprofes-sionallyacceptedmechanicalandchemicalmethods.

D

Note:Guidelines2A,2B,3Aand3Baresupportedbyreferences15through30

bias in this baseline CPG document. Conversely,having the same author group to draft theCPGsmay be viewed as a strength of this document,duetotheprofoundinsightobtainedbytheauthorgroupduringthesystematicreviewprocess.

Most of the guidelines in this document aregradedascategoryDforstrengthofrecommenda-tion,butitisanticipatedthatthestrengthofrec-ommendationwouldbehigherinthefuture.UsingShekelle’smethod1forgradingthestrengthofrec-ommendation allowed incorporation and delinea-tionofvarioustypesofevidence,includingexpert

opinion/consensus,intofourcategories,whilefor-mulatingtheseguidelines.Additionally, itallowedextrapolation of higher categories of evidence tolower categories and provided more freedom indesignationofanarticletoaspecificcategory.Theauthors considered other widely popular alterna-tives such as Grading of Recommendations As-sessment, Development and Evaluation (GRADE)method,53 and the Strength of RecommendationTaxonomy (SORT) method.54 However, these al-ternativeswerelessapplicabletothetopicofthisbaselineCPG.TheGRADEmethoddividestheex-pressionofevidenceintoonlytwocategories,weak



3A.

At-homemainte-nance:Tooth-borneremovableres-torations(partialremovabledentalprostheses)

Patientswithtooth-borneremovablerestorationsshouldbeeducatedaboutbrushingexistingnaturalteethandrestorationstwicedaily,andtheuseoforalhygieneaidssuchasdentalfloss,waterflossers,airflossers,interdentalcleaners,andelectric

toothbrushes.

C,D

Patientswithtooth-borneremovablerestorationsshouldbeedu-catedaboutcleaningtheirprosthesisatleasttwicedailyusingasoftbrushandtheprofessionalrecommendeddenture-cleaning

agent.D

Patientswithmultipleandcomplexrestorationsonexistingteethsupportingorsurroundingtheremovablerestorationshouldbeadvisedtouseoraltopicalagentssuchastoothpastecontaining5000ppmfluorideortoothpastewith0.3%triclosan,andtoaddsupplementalshort-termuseofchlorhexidinegluconatewhen

indicated.

A,C,D

Patientswithtooth-borneremovablerestorationsshouldbeadvisedtoremovetherestorationoutofthemouthduringsleep.Theremovedprosthesisshouldbestoredinaprescribedclean-

ingsolution.D

3B.

At-homemainte-nance:Tooth-bornefixedrestorations(intracoronalresto-rations,extracoro-nalrestorations,veneers,single

crowns,andpartialfixeddentalpros-

theses)

Patientswithtooth-bornefixedrestorationsshouldbeeducatedaboutbrushingtwicedaily,andtheuseoforalhygieneaidssuchasdentalfloss,waterflossers,airflossers,interdentalcleaners,

andelectrictoothbrushes.A,D

Patientswithmultipleandcomplexrestorationsonexistingteethshouldbeadvisedtouseoraltopicalagentssuchastoothpastecontaining5000ppmfluorideortoothpastewith0.3%triclosan,andtoaddsupplementalshort-termuseofchlorhexidinegluco-

natewhenindicated.

A,C,D

Patientsprescribedwithocclusaldevicesshouldbeadvisedtoweartheocclusaldeviceduringsleep. D

Patientsprescribedwithocclusaldevicesshouldbeeducatedaboutcleaningtheirocclusaldevicebeforeandafteruse,withasoftbrushandtheprescribedcleaningagent.Patientsshouldalsobeeducatedaboutpropermethodsforstorageoftheoc-

clusaldevicewhennotinuse.

D

TableIII:ClinicalPracticeGuidelinesforRecallandMaintenanceofPatientswithTooth-BorneDentalRestorations(continued)

Note:Guidelines2A,2B,3Aand3Baresupportedbyreferences15through30

orstrong,whichwasnotappropriateforthisbase-lineCPG.53TheSORTmethoddividesthestrengthofrecommendationintothreecategories(A,BandC)butdoesnotallowextrapolationofhighercat-egoriesofevidencetolowercategories.54

Thisdocumentisintendedforhealthyadultpa-tients with tooth- or implant-borne restorations.Management of patients with mixed restorations(tooth-andimplant-borneremovableorfixedres-torations) inoneorboth jaws shouldencompassboth sets of proposed guidelines, appropriate totheclinicalsituation.Managementofpatientswithconditionssuchasbruxism,xerostomia,periodon-tal disease, peri-implant disease, or other condi-tionsareoutsidethescopeoftheseCPGs;howev-er,therecallandmaintenanceregimenguidelinesmade in thisdocumentwould likelybehelpful tothesepatients.Thisbaselinedocumentisintended

This document provides clinical practice guide-lines for patient recall regimen, professionalmaintenance regimen, and at-homemaintenanceregimenforpatientswithtooth-borneandimplant-borne restorations. The various guidelines weremade using the best level of evidencewheneveravailable. Guidelinesmade using expert opinion/consensus included the best possible analysis ofbestclinicalpractices,clinicalfeasibility,andrisk-benefit ratio for patients. A scientific panel ap-

concluSion

to improve patient care protocols, but is not in-tendedas a standardof care. TheoutlinedCPGsshould be supplemented with professional judg-ment and consideration of the unique needs andpreferencesofeachpatient.



1. Patientrecall

Patientswithimplant-bornerestorations(fixedorremovable)shouldbeadvisedtoobtainadentalprofessionalexamination

visitatleastevery6monthsasalifelongregimen.D

Patientscategorizedbythedentistashigherriskbasedonage,abilitytoperformoralselfcare,biologicalormechanicalcompli-cationsofremainingnaturalteeth,tooth-bornerestorationsorimplant-bornerestorationsshouldbeadvisedtoobtainadentalprofessionalexaminationmoreoftenthanevery6months,de-

pendingupontheclinicalsituation.

D

2A.

Professionalmain-tenance(Biologi-cal):Implant-borneremovableresto-rations(implant-supportedpartialremovabledentalprosthesesandimplant-supportedoverdenturepros-

theses)

Professionalbiologicalmaintenanceforpatientswithimplant-borneremovablerestorationsshouldincludeanextraoralandintraoralhealthanddentalexamination,oralhygieneinstruc-tions,hygieneinstructionsfortheprosthesesandoralhygieneintervention(cleaningofanynaturalteeth,tooth-bornerestora-tions,implant-bornerestorations,orimplantabutments).

A,C,D

Professionalsshouldusechlorhexidinegluconateastheoraltopi-calagentofchoicewhenantimicrobialeffectisneededclinically. A,C

Professionalsshouldusecleaninginstrumentscompatiblewiththetypeandmaterialoftheimplants,abutmentsandrestora-tions,andpoweredinstrumentssuchastheglycinepowderair

polishingsystem.A,C,D

Implant-supportedpartialremovabledentalprosthesesandimplant-supportedoverdentureprosthesesshouldbeprofession-allycleanedextraorallyusingprofessionallyacceptedmechanical

andchemicalcleaningmethods.D


at-homemaintenanceneeds.A,C,D

2B.

Professionalmain-tenance(Mechani-cal):Implant-borneremovableresto-rations(implant-supportedpartialremovabledentalprosthesesandimplant-supportedoverdenturepros-

theses)

Professionalmechanicalmaintenanceforpatientswithimplant-borneremovablerestorationsshouldincludeadetailedexamina-tionoftheprosthesis,intraandextraoralprostheticcomponents,andpatienteducationofforeseeableproblemsthatcouldimpair

optimalfunctionoftherestoration.

C,D

Professionalsshouldrecommendandperformadjustment,re-pair,replacement,orremakeofanyorallpartsoftheprosthesisandprostheticcomponentsthatcouldcompromisefunction.

C,D

2C.

Professionalmain-tenance(Biologi-cal):Implant-bornefixedrestorations(implant-supportedsinglecrowns,

partialfixeddentalprosthesesandimplant-supportedcompletearchfixed

prostheses)

Professionalbiologicalmaintenanceforpatientswithimplant-bornefixedrestorationsshouldincludeanextraoralandintraoralhealthanddentalexamination,oralhygieneinstructions,andoralhygieneintervention(cleaningofanynaturalteeth,tooth-bornerestorations,implant-bornerestorations,orimplantabutments).

A,C,D

Professionalsshouldusechlorhexidinegluconateastheoraltopi-calagentofchoicewhenantimicrobialeffectisneededclinically. A,C

Professionalsshouldusecleaninginstrumentscompatiblewiththetypeandmaterialoftheimplants,abutments,andrestora-tions,andpoweredinstrumentssuchastheglycinepowderair

polishingsystem.A,C,D

Inpatientswithimplant-supportedfixedprostheses,thedeci-siontoremovetheprosthesisforbiologicalmaintenanceshouldbebasedonthepatient’sdemonstratedinabilitytoperform

adequateoralhygiene.Theprosthesiscontoursshouldbereas-sessedtofacilitateat-homemaintenance.

D

Professionalsshouldconsiderusingnewprostheticscrewswhenanimplant-bornerestorationisremovedandreplacedforprofes-

sionalbiologicalmaintenance.D

TableIV:ClinicalPracticeGuidelinesforRecallandMaintenanceofPatientswithImplant-BorneDentalRestorations

Guidelines2A,2B,2C,2D,3Aand3Baresupportedbyreferences31through50



2D.

Professionalmain-tenance(Mechani-cal):Implant-bornefixedrestorations(implant-supportedsinglecrowns,

partialfixeddentalprostheses,andimplant-supportedcompletearchfixed

prostheses)

Professionalmechanicalmaintenanceforpatientswithimplant-bornefixedrestorationsshouldincludeadetailedexaminationoftheprosthesis,prostheticcomponents,andpatienteducationaboutanyforeseeableproblemsthatcouldcompromisefunction.

C,D

Professionalsshouldrecommendandperformadjustment,repair,replacement,orremakeofanyorallpartsoftheprosthesisandprostheticcomponentsthatcouldimpairpatient’soptimalfunction.

C,D

Professionalsshouldconsiderusingnewprostheticscrewswhenanimplant-bornerestorationisremovedandreplacedforprofes-

sionalmechanicalmaintenance.D

Whenclinicalsignsindicatetheneedforanocclusaldevice,pro-fessionalsshouldeducatethepatientandfabricateanocclusal

devicetoprotectimplant-bornefixedrestorations.D

Professionalmaintenanceoftheocclusaldeviceshouldincludehygieneinstructions,detailedexaminationoftheocclusaldevice,andpatienteducationaboutanyforeseeableproblemsthatcouldimpairoptimalfunctionwiththeocclusaldevice.Theocclusaldeviceshouldbeprofessionallycleanedextraorallyusingprofes-

sionallyacceptedmechanicalandchemicalmethods.

D

Patientswithmultipleandcomplexrestorationsonexistingteethshouldbeadvisedtouseoraltopicalagentssuchastoothpastecontaining5000ppmfluorideortoothpastewith0.3%triclosan,andtoaddsupplementalshort-termuseofchlorhexidinegluco-

natewhenindicated.

A,C,D

Patientsprescribedwithocclusaldevicesshouldbeeducatedtoweartheocclusaldeviceduringsleep. D

3A.

At-homemainte-nance:Implant-borneremov-ablerestorations(implant-supportedpartialremovabledentalprostheses,andimplant-sup-portedoverdenture

prostheses)

Patientswithimplant-supportedpartialremovabledentalpros-thesesshouldbeeducatedaboutbrushingexistingnaturalteethandrestorationstwicedaily,andtheuseoforalhygieneaidssuchasdentalfloss,waterflossers,airflossers,interdental

cleaners,andelectrictoothbrushes.

C,D

Patientswithimplant-borneremovablerestorationsshouldbeadvisedtocleantheirintraoralimplantcomponentsatleasttwicedaily,usingasoftbrushandtheprofessionallyrecommended

oraltopicalagent.D

Patientswithimplant-borneremovablerestorationsshouldbeadvisedtocleantheirprosthesisatleasttwicedailyusingasoftbrushwithaprofessionalrecommendeddenture-cleaningagent.

D

Patientswithimplant-bornepartialorcompleteremovableresto-rationsshouldbeadvisedtoremovetherestorationwhilesleep-ing.Theremovedprosthesisshouldbestoredinaprescribed

cleaningsolution.D

3B.

At-homemainte-nance:Implant-bornefixedrestorations

(implant-supportedsinglecrowns,

partialfixeddentalprosthesesandimplant-supportedcompletearchfixed

prostheses)

Patientswithimplant-bornefixedrestorationsshouldbeedu-catedaboutbrushingtwicedaily,andtheuseoforalhygieneaidssuchasdentalfloss,waterflossers,airflossers,interdental

cleanersandelectrictoothbrushes.C,D

Patientswithmultipleandcompleximplant-bornefixedresto-rations,shouldbeadvisedtouseoraltopicalagentssuchastoothpastecontaining0.3%triclosanandtoaddsupplementalshort-termuseofchlorhexidinegluconatewhenindicated.

A,C,D

Patientsprescribedwithocclusaldevicesshouldbeadvisedtoweartheocclusaldeviceduringsleep. D

Patientsprescribedwithocclusaldevicesshouldbeeducatedaboutcleaningtheirocclusaldevicebeforeandafteruse,withasoftbrushandtheprescribedcleaningagent.Patientsshouldalsobeeducatedaboutpropermethodsforstorageoftheoc-

clusaldevicewhennotinuse.

D

TableIV:ClinicalPracticeGuidelinesforRecallandMaintenanceofPatientswithImplant-BorneDentalRestorations(continued)

Guidelines2A,2B,2C,2D,3Aand3Baresupportedbyreferences31through50


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