journal of dental hygiene - american dental hygienists...

338 The Journal of Dental Hygiene Vol. 88 • No. 6 • December 2014

•AttentionDeficit/HyperactivityDisorderMedicationandDentalCariesinChildren

•NumbChinSyndrome:ASignalofUnderlyingConcern

•AQualitativeAnalysisofOralHealthCareNeedsinArkansasNursingFacilities:TheProfessionalRoleoftheDentalHygienist

•PerceptionsofKansasExtendedCarePermitDentalHygienists’ImpactonDentalCare

•EducationalDeficienciesRecognizedbyIndependentPracticeDentalHygienistsandtheirSuggestionsforChange

•AComparisonofDentalHygienists’SalariestoStateDentalSupervisionLevels

•ComparisonofCordedandCordlessHandpiecesonForearmMuscleActivity,ProcedureTimeandEaseofUseduringSimulatedToothPolishing

•ExplorationofCriticalThinkinginDentalHygieneEducation

Journalof

DentalHygiene

The AmericAn DenTAl hygienisTs’ AssociATion

December 2014 Volume 88 number 6

Vol. 88 • No. 6 • December 2014 The Journal of Dental Hygiene 339

Journal of Dental HygieneVOLUME88•NUMBER6•DECEMBER2014

CelesteM.Abraham,DDS,MSCynthiaC.Amyot,MSDH,EdDJoannaAsadoorian,AAS,BScD,MSc,PhDcandidateCarenM.Barnes,RDH,MSPhyllisL.Beemsterboer,RDH,MS,EdDStephanieBossenberger,RDH,MSLindaD.Boyd,RDH,RD,EdDKimberlyS.Bray,RDH,MSColleenBrickle,RDH,RF,EdDLorraineBrockmann,RDH,MSPatriciaRegenerCampbell,RDH,MSDanCaplan,DDS,PhDMarieCollins,EdD,RDHBarbaraH.Connolly,DPT,EdD,FAPTAMaryAnnCugini,RDH,MHPSusanJ.Daniel,BS,MSMicheleDarby,BSDH,MSDHJaniceDeWald,BSDH,DDS,MSSusanDuley,EdD,LPC,CEDS,RDH,EdSJacquelynM.Dylla,DPT,PTKathyEklund,RDH,MHPDeborahE.Fleming,RDH,MSJaneL.Forrest,BSDH,MS,EdDJacquelynL.Fried,RDH,MSMaryGeorge,RDH,BSDH,MEDKathyGeurink,RDH,MAJoanGluch,RDH,PhDMariaPernoGoldie,MS,RDHEllenB.Grimes,RDH,MA,MPA,EdDJoAnnR.Gurenlian,RDH,PhDAnneGwozdek,RDH,BA,MALindaL.Hanlon,RDH,PhD,BS,MedKittyHarkleroad,RDH,MSLisaF.HarperMallonee,BSDH,MPH,RD/LDHaroldA.Henson,RDH,MEDAliceM.Horowitz,PhDLauraJansenHowerton,RDH,MSOlgaA.C.Ibsen,RDH,MS

MaryJacks,MS,RDHHeatherJared,RDH,MS,BSWendyKerschbaum,BS,MA,MPHJanetKinney,RDH,MSSalmeLavigne,RDH,BA,MSDHJessicaY.Lee,DDS,MPH,PhDDeborahLyle,RDH,BS,MSDeborahS.Manne,RDH,RN,MSN,OCNAnnL.McCann,RDH,MS,PhDStacyMcCauley,RDH,MSGayleMcCombs,RDH,MSShannonMitchell,RDH,MSTanyaVillalpandoMitchell,RDH,MSTriciaMoore,EdDChristineNathe,RDH,MSJohannaOdrich,RDH,MS,PhD,MPHJodiOlmsted,RDH,BS,MS,EdS,PhDPamelaOverman,BS,MS,EdDVickieOverman,RDH,MedCeibPhillips,MPH,PhDMarjorieReveal,RDH,MS,MBAKathiR.Shepherd,RDH,MSDeanneShuman,BSDH,MS,PhDJudithSkeleton,RDH,Med,PhD,BSDHAnnEshenaurSpolarich,RDH,PhDRebeccaStolberg,RDH,BS,MSDHJulieSutton,RDH,MSSherylL.ErnestSyme,RDH,MSTerriTilliss,RDH,PhDLynnTolle,BSDH,MSMargaretWalsh,RDH,MS,MA,EdDPatWalters,RDH,BSDH,BSOBDonnaWarren-Morris,RDH,MeDCherylWestphal,RDH,MSKarenB.Williams,RDH,MS,PhDNancyWilliams,RDH,EdDPamelaZarkowski,BSDH,MPH,JD

EDITORIAL REVIEW BOARD

The Journal of Dental Hygiene is the refereed, scientificpublication of theAmericanDentalHygienists’ Association. Itpromotes the publication of original research related to theprofession,theeducation,andthepracticeofdentalhygiene.TheJournalsupportsthedevelopmentanddisseminationofadentalhygienebodyofknowledgethroughscientificinquiryinbasic,appliedandclinicalresearch.

STATEMENT OF PURPOSE

PleasesubmitmanuscriptsforpossiblepublicationintheJournal of Dental [email protected].

SUBMISSIONS

The Journal of Dental Hygieneispublishedbi-monthlyonlinebytheAmericanDentalHygienists’Association,444N.MichiganAvenue,Chicago, IL60611.Copyright2014by theAmericanDentalHygienists’ Association.Reproduction inwhole or partwithoutwrittenpermissionisprohibited.Subscriptionratesfornonmembersareoneyear,$60.

SUBSCRIPTIONS

EXECUTIVE DIRECTORAnnBattrell,RDH,BS,[email protected]

EDITOR–IN–CHIEFRebeccaS.Wilder,RDH,BS,[email protected]

EDITOR EMERITUSMaryAliceGaston,RDH,MS

COMMUNICATIONS [email protected]

STAFF [email protected]

LAYOUT/DESIGNJoshSnyder

PRESIDENTKelliSwansonJaecks,MA,RDH

PRESIDENT–ELECTJillRethman,RDH,BA

VICE PRESIDENTBettyA.Kabel,RDH,BS

TREASURERLouannM.Goodnough,RDH,BS

IMMEDIATE PAST PRESIDENTDeniseBowers,RDH,MSEd

2013 – 2014 ADHA OFFICERS


InsideJournal of Dental Hygiene

Vol.88•No.6•December2014

Features

Editorial

Research

342 AttentionDeficit/HyperactivityDisorderMedicationandDental Caries in Children SandraS.Rosenberg,RDH,MDH;SajeeshKumar,PhD;Nancy J.Williams,RDH,EdD

348 Numb Chin Syndrome: A Signal of Underlying Concern NormaJ.Chapa,RDH,BSDH

353 AQualitativeAnalysisofOralHealthCareNeedsinArkansas Nursing Facilities: The Professional Role of the Dental Hygienist VirginiaM.Hardgraves,RDH,MS;TanyaVillalpandoMitchell,RDH,MS; Carrie-CarterHanson,RDH,EdD;MelanieSimmer-BeckRDH,PhD

364 PerceptionsofKansasExtendedCarePermitDentalHygienists’ ImpactonDentalCare JuliaBrotzmanMyers,RDH,MS;CynthiaC.Gadbury-Amyot,MSDH, EdD;ChrisVanNess,PhD;TanyaVillalpandoMitchell,RDH,MS

373 EducationalDeficienciesRecognizedbyIndependentPractice Dental Hygienists and their Suggestions for Change CourtneyE.Vannah,MS,IPDH;MarthaMcComas,RDH,MS;Melanie Taverna,MS,RDH;BeatrizHicks,MA,RDH;RebeccaWright,MS,RDH

380 AComparisonofDentalHygienists’SalariestoStateDental SupervisionLevels AprilCatlett,RDH,BHSA,MDH,PhD

386 ComparisonofCordedandCordlessHandpiecesonForearm MuscleActivity,ProcedureTimeandEaseofUseduring Simulated Tooth Polishing GayleMcCombsRDH,MS;DanielM.Russell,PhD

394 ExplorationofCriticalThinkinginDentalHygieneEducation KimberlyS.Beistle,PhD,RDH,CDA;LouannBierleinPalmer,EdD

341 The Promise and Potential of a New Year RebeccaS.Wilder,RDH,BS,MS

Short Report

Review of the Literature


ThePromiseandPotentialofaNewYear

EditorialRebeccaS.Wilder,RDH,BS,MS

As2014quicklycomestoaclose,IwouldliketotakeamomenttoreflectonanotherexcitingandproductiveyearfortheJournalofDentalHygiene,aswell as look forward to the promise and po-tentialof2015.Thepastyearwasbusy,produc-tiveandfullofplansforpositivechangewiththeJournal.In2014,wecontinuedtoreceiveahighnumber of submissions from authors across theglobe, leading to somehighqualitymanuscriptsthathelpedreinforcetheneedfortransformationinourprofession.Duetoincreasingdemand,theJournal continues to publish bi-monthly, and isshowingno signs of slowing down.All of this ispossibleinparttoourpartnershipwithHighWirePress. This past year was our first full calendaryearpublishingtheJournalofDentalHygieneon-linewith theHighWire team,and theyhaveen-suredthatourpublicationcanbereadanywhereatanytime,andprovidingusthefreedomtoworkonadditionalcontent.

ThenextyearwillcontinuetobeabusytimefortheJournalofDentalHygiene,anditallstartsinFebruarywiththeaspecialsupplement–thePro-ceedingsfromthe3rdNorthAmerican/GlobalDen-talHygieneResearchConference.Thissupplementwillincludethemanywonderfulpresentationsanddiscussions that participants of this conferenceheardinOctoberofthisyear.Inadditiontoaspe-cialprintversion,therewillbeanexpandedonlineversionwhichwillincludeawealthofinformationthatresearcherswillfindinvaluable.

Shortly after this issue, a co-branded supple-ment,publishedbytheAmericanDentalHygien-ists’Association(ADHA)andtheJournalofDentalHygiene,will featureaWhitePaperauthoredbyADHAmembers. ThisWhite Paper will focus onthecurrentstateofdentalhygieneeducation,andprovidesawonderfulopportunity toseehowfarourprofessionhascome,andwhereitcangointhe future.

Finally,wearepleasedtoannouncethereturnofthespecialJournalofDentalHygieneCLLSup-plement.Thisprintsupplementwillbeavailabletoattendeesofthe92ndCenterforLifelongLearninginNashville,andwillhighlightthemostoutstand-ingresearchpublishedintheJournalofDentalHy-giene, includingourexpandingawardsprogram.The2014SigmaPhiAlphaJournalismAwardwin-nerswillbepublishedinthisissue.Inaddition,wewillonceagainoffertheJournalofDentalHygienesecondannualBestPaperAward,whichhighlightsthebestresearchpaperpublishedintheJournalofDentalHygieneduringtheprecedingyear.Anyresearchmanuscriptpublishedin2014iseligibletobeconsideredfortheaward.

An exciting change will be implemented forauthors and journal reviewers in 2015 with theadoptionoftheBenchPresssystemforallmanu-script submissions. This automated process willallowauthorstoeasilysubmitmanuscriptstotheJournal,andwillincreasethespeedatwhichman-uscriptsarereviewedandpublished.Itischangeslike these thatwill allow the Journal to stay onthe cutting edge and offer themost timely andimpactfulresearch.

Believeitornot,thisisjustthetipoftheice-berg.We havemanymore changes planned for2015,andIcannotwaittosharethemwithyou.As thedentalhygieneprofessionbegins itspro-cessoftransformation,sotoodoestheJournalofDentalHygiene.Here’stoaHappyNewYear,andtoanexcitingandwonderful roadahead for theJournal!

Sincerely,

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


Attention deficit/hyperactivity dis-order (ADHD) is the most commonbehavioral disorder in school-agedchildren today. According to Fried-lander,in2007,ADHDaffects4to9%ofchildrenintheU.S.1Prevalenceofthisneurologicdisorderhasbeenre-ported to be aswidespread as 2 to18%ofthepopulation.2 The charac-teristicfeaturesofADHDcanincludeexcessive motor activity, develop-mentally inappropriateactivity level,low frustration tolerance, impulsiv-ity,poororganizationalbehavior,dis-tractibility, and inability to sustainattentionandconcentration.1-9Sincemore children are being diagnosedwith ADHD today than ever before,causesand treatmentofdentalcar-iesinchildrenwithADHDareofgreatinteresttothedentalcommunityandtothepublic.

Studieshavebeenconductedthatsupport theanecdotal evidence thatchildren with ADHD have a signifi-cantly higher prevalence of dentalcariesthanchildrenwithoutADHD.2-

6Sincexerostomia (drymouth)hasbeen reported as a side-effect ofmethylphenidate,anddextroamphet-amine medications and non-stimu-lant medications such as serotoninreuptakemedicinesandtricyclicanti-depressantscommonlyusedtoman-agethesymptomsofADHD,itishypothesizedthatxerostomiamay contribute to ahigherprevalenceof dental caries.2,7-9 Saliva production, the body’snaturalprotectionsystemagainstdentalcaries,maybereducedbythesemedications.Areductioninsa-livaflowisconsideredtobeafactorindentalcariesrisk.10

Healthysalivaplaysmanyimportantfunctionsinthe prevention of dental caries. Reduction of sali-varyfloworchangesinthecompositionofthesa-

AttentionDeficit/HyperactivityDisorderMedicationandDentalCariesinChildrenSandraS.Rosenberg,RDH,MDH;SajeeshKumar,PhD;NancyJ.Williams,RDH,EdD

AbstractPurpose:Fewstudieshavebeenconductedtoinvestigatetheef-fects,ifany,ofspecificmedicationusedtomanagethesymptomsof attentiondeficit/hyperactivitydisorder (ADHD)asa risk fac-torfordentalcaries.Areportedside-effectofthemedicationisareductioninsaliva.Healthysalivahasbeenshowntoplaymanyimportantfunctionsinthepreventionofdentalcaries.ThefocusofthisreviewistodetermineifanyevidenceexiststoconfirmthatstimulantmedicationusedtotreatthesymptomsofADHDinchil-drenincreasestheriskofdentalcariesbyvirtueofitseffectonthereductionofsalivaryflow.Methods:AMEDLINEsearchwasconductedforrelevantstudies.Searchtermsusedweredentalcaries,attentiondeficit/hyperac-tivitydisorder,ADHD,pharmacologictreatmentofADHD,stimu-lantmedication,xerostomia,dry-mouthandsalivaflow.Publica-tiondatesrangedfrom2002to2012.Results: AlthoughdentalcariesprevalencehasbeenfoundtobehigherinchildrenwithADHD,decreasedsalivaryflowasaside-effectofpharmacologicaltreatmentdoesnotappeartoberespon-sible.Conclusion:Dentalcariesisamulti-factorialdiseaseprocess.ThemosteffectivemethodofreducingdentalcariesinADHDchildrenismorefrequentrecarevisitsfocusingonhomeplaqueremovalpracticesalongwithdietarycounselingtoreducetheconsumptionofcariogenicfoodsanddrinks.Thiscanonlybeaccomplishedwithinclusionoftheparent/guardianintheprocess.Keywords:attentiondeficit/hyperactivitydisorder,dentalcarries,medication,xerostomiaThisstudysupportstheNDHRApriorityarea,Clinical Dental Hy-giene Care: Investigatehowdentalhygienistsuseemergingsci-encetoreduceriskinsusceptiblepatients(riskreductionstrate-gies).

ReviewoftheLiterature

Introduction

liva caused bymedications in childrenwith ADHDmayhaveaneffecton the riskofdental caries.7-9 In search of contributing factors to higher cariesratesinchildrenwithADHD,researchershavealsoinvestigatedfactorssuchaspoororalhygiene,highconsumptionof sugar-containing foodsandbever-agesdemographics,lowIQ,lowsocioeconomicsta-tusofparents,dentalanxiety,andpathophysiologicchanges.2-9

Stimulant medications are effective in treatingADHDbecause theyenhance the releaseofdopa-


mine and norepinephrine,thereby allowing previouslyunder-stimulatedareasofthebrain to regain their normal functionality.1 In the case ofADHD, these normal func-tions are the suppression ofhyperactivity, impulsiveness,aggression and unusual dis-tractibility.1

Althoughmedicalmanage-ment brings about a 50 to75%reductioninsymptoms,a combination of pharmaco-logicalandbehavioraltherapyis generally more effectivethan either one alone.1 In2002, Wender reported thatstimulantmedicationisthemedicationofchoiceinthetreatmentofchildrenwithADHD.11TableIliststhenamesofsomeofthestimulantdrugsusedtotreat ADHD.Medications used to treat ADHD thatmay also cause xerostomia are antidepressants,suchasdesipramine,imipramineandbuporpionsoldasNorpramin®,Tofranil®andWellbutrin®.12,13

Thefocusofthisreviewistodetermineifstimu-lantmedicationusedtotreatthesymptomsofADHDinchildrenincreasestheriskofdentalcariesbyvir-tueofitseffectonthereductionofsalivaryflow.

Methods and MaterialsA PubMed/Medline search was performed using

the terms “ADHDmedications” and “dental caries”todiscoveraconnectionbetweenthetwo.Additionalsourceswerelocatedusingthesearchterms“atten-tion deficit/hyperactivity disorder,” “dental caries,”“xerostomiaanddentalcaries”and“salivaandden-talcaries.”Furtherinformationonpertinentarticleswas retrieved fromthe referencesectionsof thesearticles.EarlystudieswereincludedthattestedforacorrelationbetweenADHDanddentalcaries.2-6,8

Studieswerereviewedfordatarelevanttoacon-nectionbetweenxerogenicmedicationsusedtotreatsymptoms of ADHD and the risk of dental caries.Onlystudies thateither identifiedorexaminedtheprevalence of dental caries in children with ADHDand/orthosewhodiscussedand/orusedxerogenicmedicationasavariablewereincludedinthisreview.

StudiesConductedtoEstablishaRelationshipBetween ADHD and Dental Caries

Mostoftheearlyresearchconcerningdentalcar-iesandchildrenwithADHDhasbeenperformedwith

smallcasestudiestoconfirmtheanecdotalevidencethatchildrenwithADHDhaveasignificantlyhighercariesratethanchildrenwithoutADHD.BroadbentetalconductedaregressionanalysistodetermineifdentalcariesremainedhigherinchildrenwithADHDand toquantify the roleof confounding factors inany observed relationship between dental cariesandADHD.2Thisstudywasoneofthefirsttoaskthequestion,“HowmightADHDbeassociatedwithdentalcariesexperience?”2Fourpossibleexplana-tionswereoffered.Oneideawasthatcharacteristicsofthedisorderitselfmayleadtoalackofmotivationtomaintaingoodoralhygiene.AnotherpossibilitywasthatparentsofachildwithADHDmaybemorelikely to reward that childwith cariogenic treats.2 Thirdly,medicationsusedtotreatthesymptomsofADHDhavebeenreportedtohavethesideeffectofxerostomiawhichisoftenassociatedwithincreasedfrequencyofconsumptionofsoftdrinksandpooreroral hygiene.2Afourthsuggestionwasthatparents/guardiansofchildrenwithdevelopmentaldisorders(includingADHD)may report theunmetneed fororalhealthtreatmentthanparentsofchildrenwith-outdevelopmentaldisorders.

Usingquestionnairesanddental recordsof128case-controlled pairs (aged 11 to 13), cases andcontrolswerematchedonage, sex,ethnicityandsocio-economicstatus.Aftercontrollingforfluoridehistory, medical problems, diet and self-reportedoralhygiene,analysisshowedchildrenwithADHDhadnearly10timestheoddsofhavingahighde-cayed, missing or filled teeth (DMFT) score thanchildrenwhodidnothaveADHD.Noneoftheotherco-variants were significantly associated with theoutcome of higher caries in the ADHD group. OnthebasisoftheassociationbetweenmedicationforADHDandhighDMFT,itwassuggestedthattheremaybesomevalidity to the idea thatmedicationmightbeariskfactorforthehighrateofdentalcar-

GenericName BrandName AvailableasaGenericPrescription?

Amphetamine Adderall®AdderallXR®

YesYes

Dextroamphetamine Dexedrine Yes

Dexmethylphenidate Focalin®

FocalinXR®YesNo

Methylphenidate

Concerta®

Daytranapatch®

MetadateCD®

MetadateER®

Methylinoralsuspension®

Methylinchewabletablet®Ritalin®

RitalinLA®

RitalinSR®

YesNoNoYesYesNoYesYesYes

TableI:StimulantMedicationsUsedtoTreatADHDinChildren


ies.But,giventhatmedicationwasnotstudiedasapossibleriskfactorindentalcaries,thereisnosup-portingevidence for this conclusion.13 In fact, thelimitationsofthisstudywerethat,inadditiontoitssmallsamplesize, treatmentwithmedicationwasonlyusedasapositivediagnosisofADHDand9of14ofthesubjectswithADHDweremedicated.

Allothervariablesbeingconstant, theoutcomeof a studyof dental caries in childrenwithADHDcouldbeinfluencedbytheageofthechildrenwhichcorrelateswiththeeruptionsequence.Threeclini-calandretrospective,double-cohortstudies(2006,2007and2011)wereconductedbyBloomqvistetalusingsubjectsfromthesamepopulationpoolforall3studies.3-5All3studiestestedfordentalcariesexperience inchildrenwithADHDascomparedtochildrenwithoutADHDalongwithotherfactors.The2006studywhichtestedfororalhealth,dentalanxi-etyandbehavioralmanagementproblemsstudiedbothchildrenwithADHD(n=25)andchildrenwith-outADHD(n=58).Allofthechildrenwere11yearsof age.3AsignificantlyhigherrateofdentalcarieswasfoundintheADHDsubjects.TheADHDgroupwasnotfoundtohaveahigherdegreeofanxiety,buttheydidhavemorebehavioralmanagementprob-lemsthanthecontrolgroup.The2007studywhichtestedfordentalcariesandoralhealthbehaviordidnotfindasignificantdifferenceincariesprevalencebetweenagroupof13yearoldchildrenwithADHD(n=21) and control subjects (n=79).4 They did,however,findchildrenwithADHDhadpooreroralhealthbehavior than thecontrolgroup.The2011studyconsideredcariesexperienceandoralhygienestatusinagroupof17yearolds.5TheADHDgroupconsistedofmedicated(n=40)andnon-medicated(n=40)subjects.ResultsfoundsignificantlyhigherdecayratesintheADHDgroupalongwithpoororalhygiene and an increased consumption of sugaryfoods.

Itwaspostulatedthatthe lackofcariesamongthe 13 year old groupmay have been attributedto the shedding of deciduous teeth and the lackof time for caries development in the new denti-tion.4Anotherstudy,byChandraetal,foundasimi-lardifference.7Children,aged6to14yearsofagewithADHD(n=80)werefoundtoexperiencemorecaries (DMFT) in the primary dentition (p=0.002)thanchildrennotdiagnosedwithADHD.However,in the same study, no such difference (p=0.144)wasfoundinthepermanentdentition(DMFT).Thiswouldappear togive credence to the theory thatthenewlyerupted teethhadnotbeen in theoralenvironment a sufficient length of time for cariesto develop. These studieswould seem to supportthetheorythatchildrenwithADHDhaveatendencytowardahigherrateofcariesandgenerallypoorer

oralhygienethanchildrenwithoutADHD.However,moreresearchusingalargersamplesizeisneededtoconfirmthisfinding.

Studies Using Medication as aVariable in ADHD and Dental Caries

AlthoughmedicationhasbeenusedtodiagnosesubjectshavingADHD,fewstudieshavecontrolledfor medication as a risk factor in dental caries.Proper investigation of any relationship of xero-genicdrugsanddentalcariesamongADHDchildrenwouldrequireusingmedicationandsalivaproduc-tionasvariables.13

Across-sectionalstudytoexaminewhetherchil-drenwithADHDhadthesamecariesexperienceaschildrenwithoutADHDwasconductedinbyGroomsin 2005.7Salivaflowwasconsidered in thisstudytotestforxerostomiainchildrenwithADHD.Par-ticipantsrangedinagefrom6to10yearsold,andweredividedinto2groupsconsistingof38subjectseach (31boysand7girls).Onegroupwasdiag-nosedwithADHDandtakingmedication.Theothergroupwascomposedofhealthychildrenwhowerenot taking any medications. All 76 children werescreenedby1examinerfordecayed,missing,filledsurfaces(DMFS).Avisualexamwasconductedandsubjects’teethwerechartedfortheirpresence,car-ies,restorationsandsealants.Atthesamescreen-ing, the examiner collected a timed, quantitative,unstimulated,wholesalivasampleforeachpartici-pant.Theweightofthesalivawasmeasuredtothenearestone-hundredthofagram.Bothamedicalquestionnaireandaquestionnaireconcerningeachchild’soralhealthincludingdiet,oralhygiene,den-talcare,fluorideexposure,anddailyactivitieswascompletedbytheparent/guardian.

WithnodatayetavailableonDMFSforchildrenwith ADHD, researchers proposed that a two-foldincreaseinDMFSamongADHDchildrenwouldrep-resent a clinicallymeaningful elevation in caries.7 Results revealed that children in theADHDgrouphadstatisticallymoreenamelcariouslesionsintheprimarydentition (p=0.04)and significantlymoreenamelcariesinthepermanentdentition(p=0.01)thanthecontrolgroup.7Nodifferenceswereidenti-fiedinkeypreventivepracticessuchastoothbrush-ing, fluoride exposure and flossing and no differ-encesindietwerereportedbetweenADHDsubjectsand the control group. No significant differences(p=0.5)werefoundfortheamountofsaliva(0.5g)producedintheADHDgroupofsubjectstakingdif-ferenttypesofmedicationsandthoseinthecontrolgroup.Thesefindingsleadresearcherstoconcludesaliva flow is not significantly reduced in childrenprescribedmedications for ADHD.7 A limitation of


thisstudyisthatitdidnotperformaplaqueindex(PI)andthereforecouldnotdetermineiforalself-carecontributedtothehighercariesexperienceintheADHDgroup.

AlthoughthepreviousstudyfoundchildrenwithADHDdidnothaveasignificantreductioninsalivato cause xerostomia, it did not separate childrenwithADHDwhoweretreatedwithmedicationfromthosewiththedisorderwhowerenottreated.With-outcomparingthe2distinctgroupsofchildrenwithADHD, it isnotclear ifdentalcariesprevalence isrelatedtoADHDitselforthemedications.

In2011and2012,Hidasetalpublishedresultsof2individualstudiesthatfurtherinvestigatedhowsalivaaffectsdentalcariesbystudyingtheeffectofchildrenmedicated forsymptomsofADHDasop-posed to those notmedicated.8,9 In both studies,researchers separated subjects into 3 groups ac-cordingtotheirmedicationstatus.OnegrouphadADHDandnopharmacologicintervention,anothergrouphadADHDandwastreatedwithmethylphe-nidate,andthecontrolgroupconsistedofhealthynon-ADHD subjects taking nomedications. The 3groupsineachstudycontained31,30and30in-dividuals,respectively.Theaimofthe2011studywasto investigatetherelationshipbetweenADHDandtheprevalenceofcariesinchildren,adolescentsandyoungadultsbyfocusingonsalivaryqualityintermsofsalivaryflowrate,oralmucosalpH,PI,oralhygieneanddietarybehavior.8ItwashypothesizedthatchildrenmedicatedforADHDwouldhavelow-erunstimulatedsalivaryflowrates(anoutcomeofthemedicament)whichwouldresultinlowerbuffercapacityandhigherbacterialcountthanthosenottreated.8

Datawerecollected includingunstimulatedsali-vary flow rate, oralmucosal pH, PI, DMFT index,oralhygieneanddietarybehaviorwerecomparedbetween the 3 subject groups. It was found thatthe non-medicated ADHD group had the lowestmeanunstimulatedsalivaryflow(0.72ml/min)andthecontrolgrouphadthegreatest(1.13ml/min).ThemedicatedADHDgrouphad0.85m/min,whichwasnotsignificantlyhigherthatthenon-medicat-ed ADHD group. Both subject groups with ADHD(medicated and non-medicated) had significantlylower unstimulated salivary flow than the control(p=0.016).However,itwasnotedthatnoneofthechildreninanygrouphadverylowlevels(<0.1ml/min).9NosignificantcorrelationbetweenDMFTandunstimulated saliva flow was found among the 3groups.AlthoughPIscoresweresignificantlyhigh-er(p<0.05)inthe2ADHDgroupscombinedthanthecontrol,nosignificantcorrelationwasfoundbe-tweenDMFT/dmftandPI.Nosignificantdifferences

werefoundamongthegroupsfortheotherfactorsstudied.9

Reducedsalivaryflow impairsbufferingabilitiesandcreatesanoralenvironmentthatismoreacid-ic.8Mutansstreptococci(MS)andlactobacillus(LB),themajorcariespathogens,havebeenfoundtobehigher inpatientswithmoreconcentratedsaliva.8 WhilethepreviousstudyinvestigatedsalivaryflowandpHtoestablishalinkbetweenADHDandden-tal caries,8 the 2012 study looked at the compo-sitionofthesaliva, focusingonMSandLBlevels,salivarybuffercapacityandsalivaryflowratealongwithoralhygieneanddietin3groupsofchildren.9ItwashypothesizedthatlowersalivaryflowratesinmedicatedADHDchildren(anoutcomeoftheme-dicament)wouldresultinlowerbuffercapacityandhigher bacterial count.9

Threegroupsofchildren–ADHD1(withnophar-macological intervention, n=31), ADHD2 (medi-catedwithmethylphenidate,Ritalin®orConcerta®,n=30) and a healthy group (n=30). Each groupwas composedof childrenbetweenapproximately6and17yearsofage(meanage10.3+2.8years).Themainfindingof this studywas thatdespiteahigherPIintheADHDgroups,nosignificantdiffer-encesexistedinsalivarybuffercapacity(p=1.00),LB andMS counts (p=0.579), or theDMFT indexbetweenchildrenwithADHD(withorwithoutphar-macologicintervention)andthecontrolgroup.9Asreported inquestionnairesfromparents/guardiansofallsubjects,therewerenodifferencesindietandoralhealthbehaviorsbetweenthe3groups.Con-sumptionofsugarysodaswasassociatedwithhigh-erDMFTrates inall3groups(p=0.043).9Itwasnotedthatsignificantlyhigher(p=0.024) levelsofplaquewerefoundinthe2ADHDgroupscombinedcomparedwiththecontrolgroup.

DiscussionCurrent thought on the caries risk of children

medicated forADHD is due to the reported xero-geniceffectofthesemedications.Mostearlystud-ieswereconductedtosimplyevaluatethis theorybycomparingthecariesexperienceofchildrenwithADHDtothatofhealthychildren.Fewstudieshavebeen conducted to evaluate the effect of ADHDmedicationsondentalcariesinchildren.7-9

ResultsoftheGrooms7andHidas8,9studiessug-gestreducedsalivaflowfromADHDmedicationsisnot a factor in the rate of caries in childrenwithADHD.7-9 However, only the 2 Hidas studies havecompared medicated and non-medicated ADHDsubjects.8,9 The 2012 study provided preliminaryevidencethatchildrenmedicatedforsymptomsof


Conclusion

ADHDwerenotathigherriskforcariesthannon-medicated ADHD children due to the side effectof themedication reducing theamountof saliva.9 However,duetothesmallsamplesizeofbothstud-ies,moreresearchisneeded.

AlthoughdentalcariesprevalencehasbeenfoundtobehigherinchildrenwithADHD,2,3,5,7,9decreasedsalivary flow as a side-effect of pharmacologicaltreatmentdoesnotappear tobe responsible.8,9 IthasbeensuggestedchildrenwithADHDmaybeun-able to perform regular routine activity like toothbrushinginaneffectivemannerwhichmayleadtoimproperoralhygienepracticesduetotheirsymp-tomsofinattention,hyperactivityandimpulsivity.12 According to the studies, pharmacologic interven-tionshouldnotbediscontinuedbasedonafearofitcontributingtodentalcaries.Medicationisanef-fectiveandessentialpartofthemanagementofbe-havioralsymptomsassociatedwithADHD.Aslongasthemedicationiswelltoleratedbythechildandeffectiveincontrollingsymptoms,pharmacotherapyshouldgohand-in-handwithbehavioraltherapy.

Ithasbeenpostulatedthatthechild’sperceptionof xerostomiamay increase the desire for sugar-filledcandies,mintsandsodasbecausesugartem-porarilyincreasessalivaflow.12Theincreaseinsug-aralongwiththegeneralfindingofhigherlevelsofplaqueandpooreroralhygienepracticesmayhaveaneffectonthehigherprevalenceofdentalcariesinchildrenwithADHD.2Quantitative,objectivedataregardingthecapacityofmedicationstoinducexe-rostomiaareusuallybasedonpatientreportinclini-caldrugtrials.14

Theflow rateof salivavariesgreatly fromper-sontopersonandxerostomiaisasubjectivesensa-tionthatmaynotberelatedtoanactualreductionin salivaryflow.15 Theexperienceof drymouth isusuallyconsideredtobeminorwhenevaluatingthesideeffectsofamedicationandisoftenlistedintheinformation sheet along with other side-effects.15

Investigationstoevaluatetheactualflowrateofsa-livaarecomplex,expensiveandrarelyperformed.15

KnowingthatchildrendiagnosedwithADHDmayhaveahigherriskofdentalcaries2,3,5,7,9andaten-dencytowardhigherplaqueformation,1,4,5,8,9prac-ticingdentistsanddentalhygienistsneedtobeas-sertiveinrecommendingshorterintervalsbetweenrecare visits as well as nutritional counseling toincludeanon-cariogenicdietalongwithadditionalpreventivemeasuressuchas topicalfluorideandincreasedparentalmonitoring of the child’s dailyoralhygienepractices.Althoughdecreasedsalivaryflow as a side-effect of pharmalogical treatmentdoesnotappeartoberesponsiblefortheincreaseindentalcaries inchildrenwithADHD,7-9 the role of saliva in the caries process still needs furtherstudy.

Sandra S. Rosenberg, RDH, MDH, is an Adjunct Professor at Sanford Brown College. Sajeesh Ku-mar, PhD, is an Executive Director, Institute for Health Outcomes and Policy, Chair- PhD program, Associate Professor, Department of Health Infor-matics & Information Management at UTHSC-Mem-phis. Nancy J.Williams, RDH, EdD, is a professor and graduate program director in the Department of Dental Hygiene at UTHSC.

Sodascontainingsugarandseveraltypesofacidprovideacompounded threat fordental cariesbyintroducingrefinedcarbohydratesintotheoralenvi-ronmentandsignificantlyreducingtheoralpH.16Itisimportanttonotethatevenartificiallysweetenedsodascontain thesameamountofacidassugar-sweetened sodas.16 The presence of sugar is notthe only threat. Cariogenic oral bacteria thrive inanacidicenvironment.16Saliva’snormalpH is6.5to 7.5. ThepH required for enamel demineraliza-tionis4.5to5.5.16AcanofsodahasapHlevelofbetween2.7and3.5.16Perhapsthebestmethodofpreventing dental caries in childrenwith ADHD istoencouragebothchildrenandparentstolimittheconsumptionofcariogenicfoodanddrinks.Parents/caregiversshouldbeencouragedtonothavethemavailableandnotusethemforbehavioralrewards.

Vol. 88 • No. 6 •December2014TheJournalofDentalHygiene 347

1. Friedlander AH, Yagiela JA, Mahler ME, RubinR. The pathophysiology,medicalmanagementand dental implications of adult attention-def-icit/hyperactivity disorder. J Am Dent Assoc. 2007:138(4):475-482.

2. BroadbentJM,AyersKM,ThomsonWM.Isat-tention-deficithyperactivitydisorderariskfac-torfordentalcaries?Acase-controlstudy.Car-ies Res.2004:38(1):29-33.

3. BlomqvistM,HolmbergK,FernellE,EkU,Dahl-löfG.Oralhealth,dentalanxiety,andbehaviormanagement problems in children with atten-tion deficit hyperactivity disorder. Euro J Oral Sci.2006:114(5):385-390.

4. BlomqvistM,HolmbergK,FernellE,EkU,Dahl-löfG.Dentalcariesandhealthbehaviorinchil-drenwithattentiondeficithyperactivitydisorder.Euro J Oral Sci.2007:115(3):186-189.

5. BlomqvistM,AhadiS,FernellE,EkU,DahllöfG.Dentalcariesinadolescentswithattentiondeficithyperactivity disorder: a population-based fol-low-upstudy.Euro J Oral Sci.2011:119(5):381-385.

6. ChandraP,AnandakrishnaL,RayP.Cariesexpe-rienceandoralhygienestatusofchildrensuffer-ingfromattentiondeficithyperactivitydisorder.J Clin Pediatr Dent.2009;34(1):25-29.

7. GroomsMT,KeelsMA,RobertsMW,McIverFT.Cariesexperienceassociatedwithattention-def-icit/hyperactivity disorder. J Clin Pediatr Dent. 2005;30(1):3-7.

8. HidasA,NoyAF, BirmanN, et al.Oral healthstatus, salivary flow rate and salivary qualityinchildren,adolescentsandyoungadultswithADHD. Arch Oral Biol.2011:38(1):29-33.

9. HidasA,BirmanN,NoyAF,etal.Salivarybacte-riaandoralhealthstatusinmedicatedandnon-medicatedchildrenandadolescentswithatten-tiondeficithyperactivitydisorder (ADHD).Clin Oral Investig.2013;17(8):1863-1867.

10. StookeyGK.Theeffectofsalivaondentalcar-ies.J Am Dent Assoc.2008;139Suppl:11S-17S.

11. WenderPH.ADHD:Attention-DeficitHyperactiv-ityDisorderinChildrenandAdults.OxfordUni-versityPress:NewYork.2000.

12. KohlboeckG,HeitmuellerD,NeumannC,etal.Is there a relationship between hyperactivity/inattentionsymptomsandpoororalhealth?Re-sultsfromtheGINIplusandLISAplusstudy.Clin Oral Investig.2013;17(5):1329-1338

13. RindalDB,RushWA,PetersD,MaupoméG.An-tidepressant xerogenicmedications and resto-ration rates.Community Dent Oral Epidemiol. 2005:33(1):74-80.

14. Maupome G. Diverse components of the oralenvironment in attention-deficit hyperactivitydisorder (ADHD) make it difficult to establishwhetherADHDisariskfactorfordentalcaries.J Evid Based Dent Pract.2005:5(1):39-40.

15. William Wrigley Jr. Company. Dry Mouth andSalivary Flow. Drymouth.info [Internet]. 2013March [cited 2014 January] Available from:http://www.drymouth.info/practitioner/salivar-yFlow.asp

16. BardowA,NyvadB,NauntofteB.Relationshipsbetween medication intake, complaints of drymouth,salivaryflowrateandcomposition,andtherateoftoothdemineralization insitu.Arch Oral Biol.2011:46(5):413-423.

References


The prickling sensation of an ap-pendage that “fell asleep” and thenumbness that is experienced withdentalanesthesiaarenotlifethreat-ening. Numbness that occurs withnoexplanationanddoesnotresolvequicklymayindicatethepresenceofa serious underlying condition, es-pecially if itoccurs in themandible.The medical literature reveals thatchinnumbnessmaybeindicativeofamoreseriousunderlyingcondition,especiallyifcancerorthetreatmentofradiationorchemotherapypreced-ednumbness.

NumbChinSyndrome:ASignalofUnderlyingConcernNormaJ.Chapa,RDH,BSDH

AbstractPurpose:Thepurposeofthisarticleistopresentacasestudyof a patientwith chin numbness and to review its relation-ship, through research, to possible underlying diseases andconditions.Mentalnerveneuropathy,betterknownasnumbchin syndrome, is a rare condition. Research suggests thatthereareahighnumberofcaseswherenumbchinsyndromerunsparallelwithprogressionorrelapsesofmetastaticcancer.Clinicalpresentationofnumbchinsyndromeischaracterizedbypatientcomplaintsoflocalizednumbnesstothemandible.Sincethissyndromehasbeenassociatedwithseriouscondi-tionssuchasdiabetes,multiplesclerosesandmetastaticdis-ease,patientswhopresentwithsignsandreportunexplainedsymptomsofnumbnessshouldbeexaminedthoroughly.Den-tal professionalswho encounter patientswith this symptomshould refer them for furthermedical evaluation canpoten-tiallysavelives.Keywords:mentalnerveneuropathy,numbchinsyndrome,chinnumbness,breastcancer,metastaticcancerThisstudysupportstheNDHRApriorityarea,Clinical Dental Hygiene Care: Investigatehowdentalhygienistsidentifypa-tientswhoareat-riskfororal/systemicdisease.

ShortReport

Introduction

Case StudyInSeptemberof2011,a39year

old female, non-smoker and raredrinker presented to the Universityof Texas School of Dentistry for anadultprophylaxis.Thepatientcom-plainedoflocalizednumbnesstoherlower left quadrant with slight discomfort, whichshe had experienced for approximately 2 weeks.She reported that she had been diagnosed withhigh-gradesarcomainherleftbreastthepreviousyearandhadbeen treatedwith radiation therapyand chemotherapy, but she ultimately underwentaradicalmastectomyinJanuary2011.Areviewofher chart revealedno report of any symptoms inthe head and neck during her previous two den-talvisitssince2007.Noremarkablefindingswerenotedoneither themedicalhistoryor intra/extraoral exams. The patient’s last visit to the dentalschoolwas inJuly2010.Hertreatmentplancon-sistedofanadultprophylaxisforhermaxillaryarchwithlocalizedscalingandrootplaning(SRP)forhermandible.ThelocalizedSRPwaspreformedandthepatientwas scheduled to come back to completetreatmentbutneverreturned.

AttheSeptember2011appointment,significantfindings in her intra/extra-oral exam consisted ofpalpable lymph nodes across the left side of themandiblewithnumbnessaffectingthelipandchin,tendernessintheregionoftooth#20,andredness

with inflammation thatwas consistentwithgingi-vitis.Todiagnosetheetiologyofhernumbness,apartialfullmouthseriesofradiographsweretaken.Nodistinguishablecariouslesionsorapicallesionswerenoted;however,tooth#19hadastainlesssteelrestorationconsistentwithahistoryofendodontictreatment(Figure1).Toruleoutotherpathologicconditions,anoralpathologistorderedapanoramicimage,whichwasinterpretedbyadentalradiolo-gist.Theradiographrevealednosignsoftraumaorothersourcestoexplaintheetiologyofthenumb-ness. Idiopathicosteosclerosis in therightsideofthemandiblewaspresent(Figure2).Aprophylaxiswasperformedandona3weekfollow-upvisit,hergingivaltissuehealthimprovedbuthersymptomsstill persisted. Recommending she should consultwithheroncologist,hertreatingphysicianfoundnoevidenceofanyrecurringmalignancy.

Whenthepatientreturnedtotheclinic5monthslater,additionalradiographsweretakenandinter-preted by an oral pathologist revealing a “moth-eaten” radiolucent lesion of apical resorptionaround tooth #18 (Figures 3, 4). The area wasswollenandteeth#18and#19weretendertoper-


cussion. Further testing included apulp vitality test to tooth#18withabiopsytothesurroundingbone.ACone Beam Computed Tomographyscanwasalsorecommendedtoruleoutmetastatic disease and intraos-seousmalignancy.Originaldifferen-tial diagnoses included acute apicalabscess and subacute osteomyelitisbutafterabiopsythedifferentialdi-agnoses expanded to myofibroma,lipoma, adenoma, adenocarcinoma,lymphomaandsarcoma.Ultimately,thelesionwasdescribedasamalig-nant spindle tumorcompatiblewithmyofibroblastic sarcoma. The pa-tientwasreferredtoalocalhospitalfor treatment, which included sur-gery to remove themass, affectedtissues,andallportionsofdiseasedbonewithintheleftsideofmandible.However, the patient lived for ap-proximately1yearaftersurgery,dy-ing19monthsaftertheonsetofchinnumbness.

MentalNerveNeuropathy/Numb Chin Syndrome

Mental nerve neuropathy, betterknown as numb chin syndrome, isarareconditionwithoneofthefirstdocumentedcasesreportedintheearly1800sbyCharlesBellinapatientwithbreastcancer.1,2Sincethen, studies have reported a positive correlationlinkingneuropathiesofthementalnervetometa-staticcancers.Themostnotablearerecurrentcan-cers in the breast, lung and prostate, as well asleukemia and lymphoma; however, the strongestrelationshipwithnumbchinsyndromehasbeenwithbreastcancerandlymphoma.1-4Researchindicatesahighnumberof instanceswherechinnumbnessrunsparallelwiththeprogressionoforrelapsesinthe aforementioned cancers. A systematic reviewbyGalán-Giletalreported136documentednumbchinsyndromecasesshowingthatnumbchinsyn-dromehasthegreatestcorrelationwithbreastcan-cer(40.4%)followedbylymphoma(20.5%).3Thisrelationship isof importance todentistrybecausetheoralcavityisoftensensitivetointernalchangesandwilldisplaysignsofanobscuresystemicdis-easelongbeforeitisdiscovered.Itisimportantforclinicianstobethoroughwhenreviewingapatient’smedicalhistoryandwhiledoinganintra/extraoralexam.Onestudyfoundthatin47%ofcaseswherenumbchinsyndromewasdetected,thesyndromeprecededthediagnosisofmalignancyandin30%ofthecasesexamined,neuropathiesprecededre-

lapses of malignancies.5 Unfortunately, in the in-stanceswherenumbchinsyndromewasdetectedandassociatedwith cancer, the survival ratewaspoor. Statistics reveal that life-expectancy is lessthan12months fromthedateofdiagnosis.2,5-7 Itis critical for dental professionals to be cognizantandacknowledgepossiblesymptomsofnumbchinsyndrome in patients, especially for thosewith ahistoryofcancer.

Clinical Presentation

Numbchinsyndromenormallypresentsasunilat-eralnumbnessalongthelipandchinwithpatientsdescribingeffects feelingsimilar to localanesthe-sia.2,7,8Thefunctionsofthelipandtongue,suchasmovementandtaste,mayappearnormal.9,10 Diag-nosticdentalradiographsmaynotindicateanetio-logic source.6,10 In circumstanceswhere a patientreportssymptomsofnumbnesswithoutanidenti-fiable source, a referral to a specialist for furthermedicalexaminationshouldbeconsidered.

Patient Considerations and Diagnostic Tests

Thereareseveralfactorstoconsiderifnumbchin

Top:Lowerleftpremolar(left)andmolarview(right)Bottom:Enlargedviewoflowerleftmolar

Figure1:PeriapicalsFromPartialFullMouthSeriesonthePatient’sInitialComplaintsofNumbness


syndromeissuspected.Innumerouscasestudies,diagnostic dental radiographs found no correla-tiontotheetiologicpathologyofthesymptomstoparaesthesia.InacasereportbyRybaetal,a58yearoldedentulousmaledescribedanabruptonsetoflocalizednumbnesstothelowerleftsideofhismandible.7Althoughnosignificantabnormalitiesindentalradiographsororalexaminationwerefound,neurological testsexposeddisturbances in the in-feriorandmentalnerve,andbloodtestsrevealedsignsofwidespreadmetastaticdisease.7Inanotherreport,a56yearoldwomanwhopresentedwitha 3month cough, shortness of breath and bonepain, indicated a tingling sensation in the lowerright region of her mouth. No tangible abnormali-tieswithinthelymphnodesorneurologicevidenceweredescribed.However,aComputedTomography(CT)scandiscoveredamass inthepatient’s lungalongwithmultiplelivermetastasesandbonemar-rowinvolvement.RadiographsofthecervicalareaandtheCTscanof themandiblerevealednode-fectswithineitherregion.5 Inrespecttoothercasesreviewedforthisarticle,thepatients’initialdentalradiographsweretheleastusefulindetermininganearly diagnosis, cases that presented radiolucentlesionswereinlaterstagesofanalreadymanifest-ingdisease.

Prescriptionsaremeanttotreatcommondentalproblems;however,whenantibioticsandmedica-tions have limited or no effect in treating numb-

ness, clinicians should view this lack of responseasasignofurgency.2,8,11Thiswasthecaseofa37yearoldmalewithnopriorsymptomswhoexperi-encedpaininthelowerjawafteranadultprophy-laxis.Thepatientwastreatedwitherythromycinfor5days,whichfailedtoalleviatewhatwasthoughttobeadentalinfection.Findingsfromhismagneticresonance imaging(MRI)werewithinnormal lim-

Figure2:PanoramicRadiographTakenonaFollow-UpVisitExhibitingIdiopathicOsteo-sclerosisontheOpposingSide(NotedinRed)

Idiopathicosteosclerosisnotedinred.Nopathologyfornumbnessnotedfortheleftside.

Figure3:PeriapicalTaken5MonthsafterFigure 1

Moth-eatenbordersandapicalrootresorptionaffectingandsurroundingtooth#18


NumbChinSyndromeLinks

Non-Dental Related

MetastaticorRecurrentCancer

BreastLungProstateLymphomaLeukemia

SystemicDisease MultipleSclerosisDiabetes

Other

BenigntumorsRadiotherapyOsteomyelitisAbscess

Dental Related IatrogenicTrauma

ExtractionsMandibularsurgeryImplantsIllfittingdentures

TableI:NamesofConditionsandDiseasesWithLinkstoNumbChinSyndrome

Pleasenotethatmetastaticandrecurrentcancerofthebreastranksthehighestfollowedbylymphoma

Figure4:AnEnlargedSection of the Pre-Surgical Panoramic Radiograph, Taken 5MonthsafterInitialComplaintsofNumbness

Affectedareanotedinredcircle

its;however,thisconditionpersistedandlater,af-terhedevelopeda fever,blood testsandabonemarrowbiopsyverified that theunderlyingcondi-tionwaslymphoma.2Inanothercase,a48yearoldfemalewithdiabeteswasseenbyherphysiciantotreathersymptomsofnumbnessandtinglingtothelowerrightsideofherlipandchin.Prednisonewasprescribedtorelievehersymptoms,bothofwhichreturnedaboutamonthlater.Thewoman’sneuro-logicalexamandMRIappearednormalbutbloodtestsandabonemarrowbiopsyrevealedlympho-ma.2 These cases illustratewhyadditional testingandevaluationareessentialforproperdiagnosis.

Other Diagnostic Tests

Bloodandneurologicaltestsareusefulindetect-ingunderlying conditionsanddiseasesassociatedwithnumbchinsyndrome.2,5-7,11,12Usefuldiagnostictools areMRI andCT scans,with CT scansmostwidelyused.1,4,5,8,9,11-13Anadditionaltestreferencedinstudiesisthetouchandpaintestwhichisrela-tivelysimpletoexecutewithanexplorerorsmallbrushonthesofttissues.Thetesthelpstodiagnosetheextentofmanifestingnumbnessbycomparingtheaffectedregiontoanon-affectedarea.10 Anoth-ernotabletestisthetechnetiumTc99mmethylenediphosphonatebonescan,whichusesaradioactiveintravenousimagingagenttolocatethesitesofpos-siblelesions.10Ofnote,inallofthecasesreviewedinthispaper,acombinationoftestswereusedtodetermineadiagnosis.Becauseneuropathieshavethe tendency to imitate toothpain,multiple testsmayberecommendedtoformanaccuratediagno-sis.8Amisdiagnosiscouldcauseadangerousdelayinsuitabletreatment.

Differential Diagnosis and OtherPossible Causes to Numbness

Typicalsourcesofparesthesiaornumbnessfre-quentlyhavedentalorigins.Theseinclude,butarenotlimitedto,iatrogeniccausessuchastraumatothemandible, damage to the nerve from extrac-tions,mandibular surgery, ill-fitting dentures andimplants.8,9Inthesecases,theaforementionedarelikelytocauseinjuriestothenervesoftheramusand cause hypoesthesia. Other causesmay arisefrom benign tumors, radiotherapy, bone infection(osteomyelitis) and dental abscesses partly duetoinfectionimposingorcompressingonthenerve(TableI).7-9

Chronic systemic disorders such as diabetes ordemyelinatingdisorderssuchasmultiplesclerosiscanleadtoneuropathiesandnervedamage.Pos-siblesourcesofnervedamageindiabetesincludehighbloodglucoselevels,abnormalbloodfatlevels

and inflammation caused by the autoimmune re-sponse.14 Similar findings of chin numbness havealsobeenassociatedwithmultiplesclerosis.Thesecranialnervepalsiesinvolveseveralcranialnerves(CN), including CN III (Oculomotor), CN VI (Ab-ducens)andCNV(Trigeminal),not limitedtothemandibularnervealone.13

ConclusionHealth care professionals who encounter pa-

tientsreportingchinnumbnessshouldnotunder-estimatethesignificanceofthissymptom.Becausemany dental professionals are unaware of numbchinsyndromeandits linkstoseriousunderlying


1. Colella G, Giudice A, Siniscalchi G, Falcone U,GuastafierroS.Chinnumbness:asymptomthatshouldnotbeunderestimated:areviewof12cas-es.Amer J Med Sci.2009;337(6):407-410.

2. FaltasB,PhatakP,ShamR.Mentalnerveneurop-athy:frequentlyoverlookedclinicalsignofhema-tologicmalignancies.Am J Med.2011;124(1):e1-e2.

3. Galán Gil S, Peñarrocha Diago M, PeñarrochaDiago M. Malignant mental nerve neuropathy:systematicreview.Med Oral Patol Oral Cir Bucal. 2008;13(10):e616-e621.

4. Turner-IannacciA,MozaffariE,StooplerET.Mentalnerveneuropathy:casereportandreview.CJEM. 2003;5(4):259-262.

5. Laurencet FM, Anchisi S, Tullen E, Dietrich PY.Mentalneuropathy: reportoffivecasesandre-view of the literature. Crit Rev Oncol Hematol. 2000;34(1):71-79.

6. Baskaran RK, Krishnamoorthy, Smith M. Numbchin syndrome - a reflectionof systemicmalig-nancy. World J Surg Oncol.2006;4:52.

7. Ryba F, Rice S, Hutchison IL. Numb chin syn-drome: an ominous clinical sign. Br Dent J. 2010;208(7):283-285.

8. DivyaKS,MoranNA,AtkinPA.Numbchinsyn-drome:acaseseriesanddiscussion.Br Dent J. 2010;208(4):157-160.

9. Bar-ZivJ,SlaskyBS.CTimagingofmentalnerveneuropathy:thenumbchinsyndrome.AJR Am J Roentgenol.1997;168(2):371-376.

10. YoshiokaI,ShiibaS,TanakaT,etal.Theimpor-tance of clinical features and computed tomo-graphicfindingsinnumbchinsyndrome:areportoftwocases.J Am Dent Assoc.2009;140(5):550-554.

11. RayA,SkouraT,SchererW.Numbchinsyndrome:dentaltreatmentimplications.N Y State Dent J. 2011;77(2):28-29.

12. López-CortésLE,VeraJA,MerinoLdeL,CastellanoAD,CidonchaB,Gálvez-AcebalJ.Numbchinsyn-drome:awarningsignofaggressiveb-cellmalig-nancy. Leuk Res.2011;35(9):e177-e178.

13. KhandaghiR,AramiMA.“Numbchin”asthefirstandsolepresentingsignofmultiplesclerosis.Arch Iran Med.2005;8(1):60-62.

14. National InstituteofDiabetesandDigestiveandKidneyDiseases.Diabeticneuropathies:thenervedamageofdiabetes.NationalInstitutesofHealth.2009.

References

AcknowledgmentsAspecialexpressionofthankstoDonnaWarren-

Morris,herguidanceandmentorshiphelpedfacili-tate the article. Also, a notable extension of ap-preciationandrecognitiontoJefferyChen,MarceyMcLawchlin,andKimAnhThiNguyen-Garrett forallthehardworkthatwasput intocollectingthematerialsthatledtoproducingthismanuscript.

systemicconditions,unnecessarydentaltreatmentmay be recommendedwith little or no improve-ment.Apatient’smedicalhistoryprovestobeanessential part of everyvisit.Dental professionalsshould further investigate patients who presentsymptomsofchinnumbness,especiallywhencan-cerorthetreatmentofcancerwaseverapartoftheirhistory.Unexplainednumbnessisnotanor-malsymptom,andconsultationwithothermedi-calexpertsmayprovideneededanswers.Havingthe ability to recognize numb chin syndrome, ormentalnerveneuropathy,asapossibleindicatortoseriousdiseaseisimportantforthehealthandthepotentialsurvivalofapatient.

Norma J. Chapa, RDH, BSDH is a clinical hygien-ist in a general private practice in Southeast Texas that also specializes in oral pathology.


Olderadultsarethefastestgrow-ing population segment in the U.S.according to the 2010 U.S. cen-sus.1Data from theCenter forDis-ease Control (CDC) National Healthand Nutrition Examination Survey(NHANES) indicate older adults intheU.S.arelivinglongerandexpe-riencingasignificantdeclineineden-tulismresultinginmoreteethbeingexposedtodentaldisease.2 National and Arkansas statistics related todecliningtoothlossareillustratedinFigure 1.3

Retentionofteeththroughoutthelifespanisdesirable;however,dentalcareandmaintenancebecomemorecomplexandpresentadditionalchal-lenges in long-term care (LTC) andassisted living facilities.4,5 Nursingfacilities are definedby the level ofcaretheyprovide.Thehighest levelof care is provided through skillednursing facilities referred toas LTC.Assisted Living facilities encompassany facility that provides personalcareservicestothreeormoreadultresidentsandincludeLevelsIandII.ResidentsofLevel I facilitiesdonothaveseriousmedicalconditionswhileLevelIIfacilitiesacceptresidentsthatmeetthelow-estlevelofcareandmusthaveanurseoncontract.6

TheSurgeonGeneral’sReport identifiedfrailel-dersandnursinghomeresidentsamongthepopu-lationsmostvulnerabletopoordentalcare.7 Aging populationshavefewerfinancialresourcesandof-tendonotretaindentalinsuranceuponretirement.8 Elderly individualsare facedwithavarietyofagerelatedfunctionaldisabilitiesdirectlyandindirectlyaffecting their oral health.9-16Aprimaryconcernistheassociationbetweenpoororalhealthandaspira-

AQualitativeAnalysisofOralHealthCareNeedsinArkansasNursingFacilities:TheProfessionalRoleoftheDentalHygienistVirginiaM.Hardgraves,RDH,MS;TanyaVillalpandoMitchell,RDH,MS;Carrie-CarterHanson,RDH,EdD;MelanieSimmer-BeckRDH,PhD

AbstractPurpose:Fraileldersandnursinghomeresidentsarevulnerabletopoororalhealthandfrequentlylackaccesstodentalcare.ThepurposeofthisstudywastodeterminewhyresidentsinArkansasskillednursingfacilitieshavelimitedaccesstooralhealthcare.Methods: This study utilized qualitative research methodology.Datawascollectedfromoralhealthcarepersonnelthroughopen-endedresponsesinawrittensurvey(n=23)andthroughtelephoneinterviews(n=21).Theinvestigatorsappliedtheconstantcompara-tivemethodtoanalyzeandunitizethedataandultimatelyreachconsensus.Results: Data analysis resulted in consensus on 2 emergentthemes:policyandaccess.Conclusion: This qualitative case study suggestsaccess tooralhealthcareforresidentslivinginbothlong-termcare(LTC)andas-sistedlivingIandIIfacilitiesinArkansasisaffectedbypublicandfacilitypoliciesandaccesstooralhealthcareasafunctionofthepatient’shealthstatusandavailabilityoforalhealthcareproviders.AccessforresidentsresidinginassistedlivingIandIIfacilitiesisalsolimitedbytheresidents’inabilitytoassumeresponsibilityforaccessingoralhealthcare.Theoutcomesfromthisstudymayservetoinformpolicymakersandadvocatesforaccesstooralhealthcareastheydevelopnewpoliciestoaddressthisgrowingneed.Keywords:accesstocare,assistedliving,dentalhygiene,elderly,longtermcare,nursinghome,olderadult,oralhealthThisstudysupportstheNDHRApriorityarea,HealthServicesRe-search: Identifyhowpublicpoliciesimpactthedelivery,utilization,andaccesstooralhealthcareservices.

Research

Introduction

tionpneumonia.Aspirationpneumoniaaccountsforthemajorityofadmissionstohospitalsfromnursinghomesand is the leadingcauseofdeath innurs-ing home populations.15,16 Inadequate oral healthanddisabilitystatusarefurtherrelatedtopoororalhealth related quality of life, thus increasing theneedforaccesstooralhealthcare.15,17-21Researchclearlydocumentstheinadequacyoforalcarepro-videdinLTCfacilities.12-14,22-29

ImprovingoralhealthforolderadultsbyreducingtheincidenceofuntreateddecayandperiodontitisisamongthehealthobjectivesoutlinedinHealthy


People 2020.29 Arkansans are typical-ly behind in oral health care status asevidencedbyearningagradeof “F”onthe Oral Health America Report Card.22 Screenings of residents in LTC facilitiesin Arkansas revealed that virtually allresidents(99.9%)hadahistoryofdentalcariesorperiodontaldisease.30

ThestateofArkansas,throughits2011OralHealthPlan,addressedthisdispar-itybysettinggoalsforincreasingaccesstooralcareandpassingSenateBill42,creatingacollaborativecarepermitpro-gram for dental hygienists.31 The main purposeofthelegislativechangewastoalleviate oral health care disparities byexpanding the scope of dental hygienepractice.Similarworkforcemodelshavebeenimplementedinotherstates.32 The Arkansascollaborativecarepermitprogramcanaidinhelpingtopreservethenaturaldentitionof theelderlypopulationanddecreasedentalmorbidityofvulnerable elders living in LTC and assisted livingfacilities.Threekeycomponentsofthispopulation’soralhealthneedsinclude:regularoralassessment,preventiveoralhygienecareandprovisionofdentaltreatment.23

Itisimportanttoassessdentalneedsofresidentsinnursingfacilitiesinanefforttobetterprovideoralhealthcare.Thepurposeofthisstudywastode-terminewhy residents inArkansas skillednursingfacilitieshavelimitedaccesstooralhealthcare.

Methods and MaterialsInstitutionalreviewboardresearchprotocolwas

approvedbytheUniversityofMissouri-KansasCity.Thisstudyusedaqualitativeresearchdesignwithdescriptive statistics. The study was initially de-signedtocapturequantitativeandqualitativedatausingavalidatedsurveyinstrumentthatidentifiedcurrentissuesinmeetingoralhealthneedsofnurs-ing facility residents.28 A question delineating thetypeoffacility(LTCorassistedliving)andopenend-edquestionsaboutdentalhygienistsprovidingoralcarewereaddedtothesurvey.PapercopiesofthesurveyandfollowuppostcardsweremailedtooralhealthcarepersonnelinArkansasnursingfacilities(n=311).Theoralhealthcarepersonnelwerede-finedasthestaffmembermostinvolvedwithoralhealthcareinArkansasnursingfacilitiesandinclud-edDirectorsofNursing,registerednurses,certifiednursing assistants (CNA) andhealth andwellnesscoordinators.Administratorswhoreceivedtheinitialsurvey and cover lettermade this determination.Thesurveywasalsodistributedelectronicallytoall

registeredArkansasHealthCareAssociationmem-bers(n=306)inaweeklymembers’newsletter.

Collectively,23surveysrepresenting14countieswerereturned.Theresponseratewaslow(7.4%),so a quantitative analysis, as originally planned,wasnotimplemented.Fourresearchersseparatelyanalyzedtheopenendedresponsesusingthecon-stantcomparativemethodsdescribedbyLincolnetal.33Datawasunitizedbydeconstructingtheopenresponsesandidentifyingkeythemes.TableIliststhe descriptive and interpretive codes that wereused.Asthemesemerged,theunitizeddatawerereviewedandcomparedtoreflectanddescribespe-cificthemes.

In order to increase the response rate the pri-mary investigator conducted telephone interviewswithoralhealthcarepersonnelworkinginfacilitieslocatedinzipcodeswherethemailedsurveyswerenot returned.Apurposeful sampling strategywasusedtotargetfacilities(15LTCs,3assisted livingIand3assisted living II) foracombined totalof21interviews.Facilitieswerelocatedin13countiesequallydistributedacrossthestate.

Unstructured,open-endedquestionswereaskedtoinvestigatewhyresidentsinArkansasnursingfa-cilitieshavelimitedaccesstooralhealthcare.Theprimary investigatorbeganeach interviewasking:“Fromyourperspective,whatarethegreatestneedsandbarrierstoprovidingoralcareforresidentsofyour facility?”Questionswereaskeduntil nonewinformationemerged.Theprimaryinvestigatortookdetailednotestocapturetheessenceofeachcon-versation.33Four investigatorsseparatelyanalyzedinterviewnotesandreachedconsensusidentifyingkeythemes.Descriptivenumericalfrequencieswere

Figure1:National/ArkansasCompleteToothLoss,AdultsAge65orOlderWhoHaveLostAllTheirNaturalTeeth

60

50

40

30

20

10

0

Percent

1999 2002 2004 2006 2008Year

National

Arkansas


ResultsTable II summarizes the key

themesthatemergedfromthesur-vey’sopen-endedquestionsand in-terview responses. Collectively, 133units of data were analyzed. Theemergent themes included policy(77%)andaccess(23%).Policywasdefinedastherulesandregulationsinplace thatdirect theprovisionofhealth care in LTCandassisted liv-ing facilities.AccesswasdefinedasmakingoralhealthcareavailableforbothLTCandassistedlivingfacilities.

Within the theme of policy, 4representative interpretive codesemerged. The areas of particularinterest include regulations (12%),education (12%), infrastructure(44%) and personnel (8%). Ama-jorityoforalhealthcarepersonnel’sexpressed not having appropriateinfrastructure (44%) for the provi-sionoforalhealth carewithin theirfacilities.Oralhealthcarepersonnel’sdiscussed a lack of dental equipment, providers,moneyandtime,allofwhichimpactedthedeliveryof care.

Themajorityof facilityoralhealthcareperson-nel’s reported not having space dedicated to oral

Theme InterpretiveCodes RepresentativeDescriptiveCodes

Policy

Regulations

• [NREG]NotRegulated• [HREG]HighlyRegulated• [PPW]Lotsofpaperwork/RedTape• [NDA]Nodentalassessments• [QA]Quarterlyassessments

Education

• [LED]Lack/needoralhealtheduca-tion

• [EDMREQ]Educationnotrequired• [DVD]DVDprovidedforeducation• [LP] Lowpriority among residentsandstaff

• [POHS] Poor oral hygiene amongstaff

• [ED] More education needed forstaff

Infrastructure

• [NONS]Noonsitedentalequipment• [VOCP]Varietyoforalcareprovid-ers

• [NDDS]Nodentalpersonnel• [HAVEDENT]HaveDentistonstaff• [HTVR]Highturnoverrate• [FIN]Lackofmoney/finances/reim-bursement

• [TB]Toobusy/demandingenviron-ment

• [ONBFP]DirectorofNursingBurn-outespeciallyinforprofit

• [RSHIP]Need for staff to developrelationshipwith residents toben-efitbothcaretakerandresident

Personnel• [PATT]Positiveattitudes• [NRC]Noreturncall• [NATT]Negativeattitudes

Access

PatientHealthStatus

• [NATT]Naturalteeth• [DENP]Difficultywithdementiapa-tients

• [UNCoop]Uncooperative• [CPAIN]Consequenceofpain• [WL]Weightloss

Provisionofcare• [RDHOK]TreatmentbyaRDHisOK• [MTB] Mechanical toothbrushesneeded

ResidentResponsibility

• [GSHIP]Guardianship• [RRFDC] Resident Responsible forDentalCare

TableI:EmergentCategoryandRepresentativeInter-pretiveandDescriptiveCodesforInterviewAnalysis

trackedandtotaledwithincategoriesand calculated as an overall totalpercentage.

Several approaches were em-ployedtoestablishvalidityandreli-ability of the findings as suggestedand described by Creswell.34 Trian-gulation was achieved by collectingandanalyzingdatafrom2separatesourcesandbycomparingthepres-entfindingswithpublishedliterature.Between the 2 sources of informa-tion, 23 of Arkansas’ 75 countieswererepresented.Usingdescriptionstoconveyfindingsprovidingasenseof shared experiences was accom-plished by including original quotesin the results. Peer debriefing wasusedwithinthequalitativestudyfordescribingresultsforothercarepro-viders,governmentofficialsorfami-liesreviewingresultstoenhanceac-curacy.

health care. One oral health care personnel ex-pressed: “Residents staying in a familiar environ-mentmight increasecooperationmaking it easiertoprovidecare.”Anotheroralhealthcareperson-nelcommentedaboutthelackofdentalpersonnel(8%):“Weneeddentistswhoarewillingtocomedo


LongTermCareFrequencies(Percent) AssistedLivingFrequencies(Percent) CombinedLong

TermCareandAssistedLivingRe-sponses(n=133)

Theme InterpretiveCodes

SurveyOpenEndResponses(n=17)

InterviewResponses(n=77)

TotalLongTermCareResponses(n=94)

SurveyOpenEndResponses(n=13)

InterviewResponses(n=26)

Total AssistedLiving

Responses(n=39)

Policy

Regulations 1(6%) 3(4%) 4(4%) 4(31%) 8(31%) 12(31%) 16(12%)Education - 14(18%) 14(15%) - 2(8%) 2(5%) 16(12%)

Infrastructure 7(41%) 40(52%) 47(50%) 4(31%) 8(31%) 12(31%) 59(44%)Personnel - 7(9%) 7(7%) - 4(15%) 4(10%) 11(8%)

Total 8(47%) 64(83%) 72(77%) 8(62%) 22(85%) 30(77%) 102(77%)

Access

PatientHealthStatus - 10(13%) 10(11%) - 1(4%) 1(3%) 11(8%)

Provisionofcare 9(53%) 3(4%) 12(13%) - 3(12%) 3(8%) 15(11%)

ResidentialResponsibility - - - 5(38%) - 5(13%) 5(4%)

Total 9(53%) 13(17%) 22(23%) 5(38%) 4(15%) 9(23%) 31(23%)

Table II:SummaryofEmergentThemeswithRepresentative InterpretiveCodes forLongTermCareandAssistedLivingFacilitiesforSurveyOpenEndResponsesandIn-terviewResponses

assessmentsonresidentsatthefacility.”Additionalcommentsincluded:“ItwouldhelpifafamiliarCNAorfamilymemberwasinvolvedduringcare.”

Residentswithinthesefacilitiesmaybeinsured,uninsuredorunderinsured;thusallresidentslivinginthesamefacilitydonothavethesamefinancialresources. This variability requires theoral healthcare personnel to understand multiple plans andknowhow to navigate each system.Respondentsstated:“Ourmobiledentalservicescannotprovideemergencycareandonlypeopleonthe‘offsetplan’usuallygetservices,”“Familiescannotafforddentalcare”and“This isaruralareawith lotsofpeoplewith no money.” Thematically, these statementssupportissuesassociatedwithinfrastructure(44%)andregulation(12%)practices.

Anoralhealthcarepersonnelwithextensiveex-periencedescribedademandingworkenvironment:“There is a prevalence of OHCP (oral health carepersonnel)burnoutespecially inthefor-profitset-ting.OHCPstafffrequentlywork14hourdays.Oralcare isoftensacrificedas it isnotvisible,provid-ingOHCPsashortcuttosurvivingtheday.”Theoralhealthcarepersonnelfurtherdiscussescurrentat-tempts by nursing homes to implement a culturechangewhenshedescribed:“Thischangeistofo-cusnotjustontheelder,butontheeldercaregiver;topromote relationshipsbetweeneldersandstaffbypromotingconsistentassignmentsinwhichtheCNAwouldworkwiththesamepersonorgroupof

elders.”Thisfindingdescribedthethemeoflackofpersonnel(8%)andtheimportanceofstaffprovid-ingqualitycareforresidentsbeingserved.

Throughout the interviewsoralhealthcareper-sonnel’s at assisted living facilities discussed theneedforbetteroralhealtheducationamongperson-nel:“Educatingstaffaboutoralcareisnotrequiredasnursingstaff isprimarily responsible for takingmedicationtotheresidentandremindingthemtotakeit,”and:“Oralcareisnotregulatedbutwedoprovide some in-service education related to oralcare.”Theamountoforalhealtheducationprovidedtostaffrangedfromnonetooccasionalandwasin-consistent between facilities. Thematically, issuesassociatedwithstaffeducation(12%)andperson-nel(8%)havesignificantimpactsoncareprovision.

Lack of finances was a commonly cited barrierfor accessing care services. One oral health carepersonnelrecalledaresidenthavingtochoosebe-tweenaccessingdentalcareandpurchasingmedi-cation.Theoralhealthcarepersonnelreported:“He‘chosehismedicine.’”Thesestatementssupportedtheconsiderationsthematicallyassociatedwithin-frastructure(44%).

Concernsregardinglackofregulationsweresig-nificantlyhigherforassisted livingfacilities(31%)thanforLTCfacilities(4%).Surveyresponsesandinterviews with oral health care personnel in LTCfacilities revealed concerns that facilitieshave too


many regulations and toomuch red tape hinder-ingprovisionof oral health care.Conversely, sur-veyresponsesandinterviewswithoralhealthcarepersonnelinassistedlivingfacilitiesexpresseddif-ficultiesbecauseofthelackofregulations.Assistedlivingfacilitiesarenotregulatedandthereforearenot required to provide oral care assessments ortreatment. “We do not have dental assessments.The resident is responsible formaking dental ap-pointments.” These statements support concernsthematicallyassociatedwithregulations(31%).

Within the theme of access, 3 representativeinterpretive codes emerged: patient health status(8%),provisionof care (11%)and residential re-sponsibility(4%).TheoralhealthcarepersonnelatLTC facilities expressed access being impacted bypatienthealthstatus(11%).Thisdidnotappeartobeaconcernforassistedlivingfacilities(3%).

Anumberoforalhealthcarepersonnelexpressedchallenges when working with patients who havedementia resulting in the following quotes: “Theyareuncooperativeanddon’tunderstandwhatyouaretryingtodoandmayeventhinkthatthetooth-brushfeelsfunny.”Additionalconcernswererelatedto residents being unable to articulate their ownneedsdue tocognitive impairment: “Theyareof-tenuncooperative,withoutitbeingtheirownfault-theydon’tunderstandwhatyouaretryingtodoforthem.”Anotherdescribedconcernthatanunderly-ingdentalproblemcouldcausebehavioralproblemsstating:“Theycannottellyouwhereithurts.”Thesecomments address concerns thematically associ-atedwithpatienthealthstatus(8%)andprovisionofcare(11%).

Repeatedconcernswereexpressedaboutweightlossasaresultofthelackofaccesstooralhealthcare:“Manyoftheresidentshaveill-fittingdenturesthat discourage proper eating and cause weightloss,”and:“Itisimportanttoimproveoralcareinordertoavoidlosingweight.”Anotherstated:“They(residents)justdon’tcareabouttakingcareoftheirteeth.”Thesecommentssupportconcernsthemati-callyrelatedtopatienthealthstatus(8%)andpro-visionofcare(11%).

Theoralhealthcarepersonnelatassistedlivingfacilitiesexpressedaccessbeingimpactedbyresi-dentialresponsibility(13%).ThiswasnotaconcernforLTCfacilities(0%).Thefollowingquoteprovidesarichdescriptionofthismatter:“Eitherthefamilymemberorlegalguardiansmakealldecisionsabouttheiroralcareandareresponsibleformakingdentalappointments.”

Bothtypesoffacilitiesexpressedthataccessis

influencedbytheprovisionofcare(LTC13%,assist-edliving8%).Whenaskedwhetherornottheoralhealthcarepersonnelwouldbereceptivetohavinga dental hygienist serve as the primary oral careprovider,oralhealthcarepersonnelweregenerallysupportiveofthisoralhealthcareprovidermodel.Thefollowingquoterepresentsresponsesrelatedtotheprovisionofcareandopennesstodentalhygien-istshavingdirectaccesstopatientswithoutdirectsupervision:“Iseemoreresidentsthaninthepastwiththeirnaturalteethandcouldseethebenefitofhavingadentalhygienistprovideoralcare.”

DiscussionLimitations

Limitationsareinherentinqualitativeresearch.The investigator inqualitativeresearch isconsid-eredtobethesurveyinstrument.35Potentialbiasexistsas the investigator’spersonalopinionsandexperiencesareinvolvedintheprocess.Research-ersconferredthattherecouldbeoverlappingcodeswithinestablishedcategories.Limitedsamplesizeandpossiblegeographicbiasareacknowledgedtobelimitationsofthisstudy.Further,thevarietyoforalhealthcarepersonnelcouldhaveprovidedin-consistencies.Theopinionofacaretakerwhohasonlyworkedintheenvironmentfor2weeksisnotcomparabletoaregisterednursewith30yearsofexperience.Theinvestigatorsofthepresentstudyattempted to control for these limitations by us-ingwellestablishedqualitativeresearchmethods;nevertheless,findingscannotbegeneralized.34

Reachingthetargetpopulationofthisstudywasproblematic.Similarexperienceshavehistoricallybeen reported in other studies involving nursingfacilities.28,36,37Interviewswithindustryexpertsac-knowledgedthatthenursinghomestaffpopulationis hard to reach, citing a demanding work envi-ronment, lack of email access and high turnoverrate.AreportfromanArkansasresearchershoweddifficultyacquiringinformedconsentanddifficultyaccessingtheArkansasnursinghomepopulationinarecentstudy.38

Financial Needs and Barriers

Residents of LTC and assisted living facilitieshaveavarietyofpublicandprivatedental insur-anceplans.Oralhealthcarepersonnelinthepres-entstudyvoiceddifficultiesleveragingthenuancesoftheseplans.Oftenoralhealthcarepersonneldonot have the knowledge and time to assist resi-dentsinusingtheresourcesthatareavailable.Itisunlikelythatthiswillchangeinthenearfuture.Dentalcarecoveragepriortoandfollowingtheim-


plementationof theAffordableCareAct (ACA) isprovided primarily for children. Provisions of theACAexcludemandatorydentalcoverageforadultsdeferring provisions to states.39,40 In Arkansas,olderadultscoveredbybothMedicareandMedic-aidareselectivelyprovideddentalcareunder“lifethreateningconditions”only(OfficeofOralHealth,personalcommunication,2014).

As in similar studies, financial concerns of theresidentorfamilywereconsideredtobeanimpor-tantbarrierforbothLTCandassistedlivingfacili-ties.ThosedependinguponMedicaidandMedicareassistancearelimitedandencounterasignificantamountofpaperworktoattainneededassistance,addingtothedemandsofnursingstaffandfami-lies.Thisburdenresultsintreatmentdelays,pro-longedpainandsufferingandoverallreducedqual-ity of life.15,19,20

Educational Needs and Barriers

Thepresentstudyrevealedoralhealthcareper-sonnel felt more oral health education would bebeneficial. This findingmirrors conclusionsmadebytheInstituteofMedicineinthe2011report“Im-provingAccesstoOralHealthCareforVulnerableand Underserved Populations.”41 The literature isrepletewithstudiesdetailingthelowpriorityoforalhealthbynon-dentalhealthcareprofessionals.41-45 In response to these shortcomings, theCommit-teeonOralHealthAccesstoServicesdevelopedacoresetoforalhealthcompetenciesandcurriculafornon-dentalhealthcareprofessionalstoimprovetheirabilitytopromoteoralhealthanddiseasepre-vention.41 A national initiative knownas theOralHealthNursingEducationandPracticewasestab-lishedtoaddressthisconcern.46,47Animportantaimofthisinitiativeistouseinter-professionalteamsacrossthehealthcaresystemtoimproveoralcareprovisions.Nursesareonthefrontlinewithregardtoprovidingoralhealthcare.Withadequateedu-cationandtraininginoralhealthcare,thenursingworkforcehasthepotentialtoimproveaccessandqualityoforalhealthcare.Educationandtrainingaboutactivitiesofdailylivingcouldincorporateoralhealthcarepracticesalongwithbathing,toiletinganddressing.Oralhealthoutcomescouldbe im-provedusinganinterdisciplinaryapproachtocare.

EarlierIntervention

AssistedLivingfacilitiesarethefastestgrowingsegmentofthenursingcarecontinuum,48withthetypicalassistedlivingresidentbeingmuchlikethenursingfacilitypatientofthepastwithahighbur-denoffunctionalimpairmentandrelatedillness.49

Researchconcerningoralcareprovisioncenterson

highly regulated LTC facilities. Limited attentionisgiventounregulatedassistedlivingfacilities.AcomprehensivereportfundedbytheStateofFlor-idaHealthCareAdministrationrevealedagenerallackoforalcareduringtheperiodafterretirementand before entering a nursing facility.50 Resultsfromthecurrentstudyindicateassistedlivingresi-dentsare less likely tohaveadental exam thanLTCresidents.Residentsofassistedlivingdidnotreceiveassistancewithoralhygieneandadentalplanwasnotrequired.Downstreammedicalcostscouldbereducedbyincreasingaccesstooralcareatthiscriticaljuncturebypreventingdiseaseanditsassociatedcomorbidity.

Policy

TheInstituteofMedicine’slongitudinallandmarkstudycitednumerousrecommendationsforpolicyreformincludingtheestablishmentofaunifiedsetofitemsanddefinitionsforassessingallresidentsinnursingfacilitiesinthenation.51Concernsaboutpoor quality of care and the rights of residentswithinthenursinghomeledtoagovernmentman-dateknownasthe1987OmnibusBudgetRecon-ciliationAct(OBRA)whichprovidesasetofstan-dards fornursinghomesknownas theminimumdata set.52,53 Regulations, such asminimumdataset, are inplace today inanattempt to improveandmonitorthequalityofcareprovidedinLTC,53 yetmanyLTCresidentshaveinadequateaccesstooral care.11,18TheinadequacyoftheminimumdatasethasbeenreportedbyastudyofIowanursinghomesinwhichitwasdeterminedthattheuseoftheoral,nutritionalanddentalsectionsofthemini-mumdata setareoftennotuseful andnotusedasintendedintheidentificationofdentalneeds.25

These regulations need to be updated to reflectthechangingneedsofolderadults,whoarelivinglongerandretainingtheirteeth,sotheyhaveim-provedoralcare.

InadditiontoOBRAregulations,Arkansas,asinmoststates,requirethatfacilitiesestablishawrit-tencooperativeagreementwithanadvisingden-tistordentalservicewhichincludesaprovisiontoparticipateannuallyinastafforalhygienepoliciesandpracticesdevelopmentprogram.54ConclusionsfromstudiesofbothLTCandassistedlivingfacili-tiesindicatethatoralhealthpoliciesandpracticesvary,andthatdentalinvolvementinpolicycreationand in providing consultation and service is lim-ited.28,36ThecurrentstudysupportsthesefindingsasevidencedbyLTCsreportingannualpolicyde-velopmentprogramswithinconsistentamountsofin-serviceeducation.Oralhealthcarepersonnelinassisted living seemed receptive but stated theywerenotrequiredtoprovideanydentalcareother


thantransportingtheresidenttoadentistifneces-sary.Lackoftimeandfunding,aswellasanoveralllowpriorityseemstoprevail.

Lackofon-sitedentalequipmentandunwilling-ness of specialty and general dentists to providecareatnursing facilitiesweretwoof theprimarybarriers that emerged during this study. Further,timeconstraintsofnursingstaffpresentedasig-nificantbarriermakingoralpreventivecarealowpriority in this study and previous studies.28,36,55 Theoralhealthcarepersonnelinthepresentstudyexpressedaneed toprovidemoredental servic-eswithinthe familiarenvironmentof thenursinghomeandwiththeassistanceofaconsistentcare-giverorfamilymember.Thischangewouldaddressidentified concerns suchas inability to communi-cate, lack of cooperation, dementia and weightloss.Multiplestudiesreportsimilarneedsandbar-riers.15,56,57

Interestingly, the Arkansas state penitentiaryemploys a dental hygienist in an on-site dentalclinicraisingquestionsabouttheparityofpoliciesand infrastructure inplaceforprovidingoralcarewithin the state. This inequality is further illus-tratedinthe2011ArkansasreportcardpublishedbythePEWCenterontheStateswherechildren’s’oralhealthimprovedfroma“F”in2010toa“C”in2012.58InfrastructureinArkansashasbeenmodi-fiedtoprovideaccesstooralhealthcareformanydifferentpopulations;however,olderadultsarebe-ingoverlooked.A recentsurveyof theburdenoforal disease in Arkansas has found demographicinequitiesinolderadultsespeciallywithregardtoeducation,raceandgender.59Updatingregulationsandpoliciestorequireindividualizedcareplansde-velopedbyadentalprofessionalshouldbeinplaceandavailableforallindividuals.

The Role of the Dental Hygienist

Theuseofnon-dentalprofessionals toconductassessments isneededto improveaccess.An in-terdisciplinaryteamapproach,thatincludesdentalprofessionalsisnecessarytomoreaccuratelyiden-tifyoralhealthcareneedsandthereforefacilitatethedevelopmentand implementationofeffectiveoralhealthcareplansandeducationalprograms.Implementation using an interdisciplinary modelwillbechallenging.Thepresentstudyunderscoresthisdisconnectinresponsetoreportsoffrequentturnoveroffacilityemployeesandavarietyofpro-viderswith an inconsistent degree of oral healthknowledge.Oneoralhealthcarepersonnelstatedthatmanyofthecaregiversdonothavegoodoralcarethemselvesandoftendonotfeelitisaprior-ityforresidents.Educatingstaffmemberstovalue

theirownoralcareaswellasresidentsisimportantto increase the overall awareness of quality oralcare.Dentalhygienistscouldaidinincreasingtheconfidenceof thecaregiver inprovidingoralcareandreducesomeofthestressassociatedwithcar-ing foruncooperative residents.Basedon insightfromoralhealthcarepersonnel,dentalhygienistscouldbeusedto increaseretentionbyalleviatingsomeofthedemandingworkloadoftheoralhealthcarepersonnel.Results froma recentpilot studyconductedinArkansasdemonstrateshowhandsonsupportfromadentalhealthchampionworkingincollaborationwith oral health care personnel canhaveapositive impactontheoralhealthofresi-dentsinLTCsettings.60

Thepresentstudysuggeststhatoralhealthcarepersonnelareoverallreceptivetotheuseofdentalhygienistsinprovidingcareintheirfacilities;how-ever,no current involvementexists.This circum-stanceisaprobleminArkansasbecauseoflimita-tionspreventingdental hygienists fromprovidingoralcareandthesmallnumberofdentiststreatingresidentswithinthefacilitiesdespitetheapparentneed.In2011thedentalpracticeactinArkansaswasmodifiedtoallowthemanopportunitytoat-tain a Collaborative Care Permit enabling dentalhygieniststoprovideneededoralcaretopopula-tions that lackaccess.Thepermit,whichmirrorsother states’workforcemodels, is just beginningtobeimplementedinArkansas.Thepossibilityofincreasingaccesstocare inArkansasthroughdi-rectaccess todentalhygienepreventiveservicesas outlined by the Collaborative Practice Permitpromisestoalleviatesomeofthedisparitiesinoralhealthcareandisaresponsetothestate’seffortsto increaseaccess tocarebasedonneeds foundin oral health care reports.30 This model of carehas demonstrated success in Louisiana. Testimo-nyfromFolsedescribeshisgeriatricmodelofcarewhichuseshygieniststocompletefacilityminimumdatasetitemsandprovidetreatment.61Hestates:

“Withoutgeneralsupervisionwhichfullyenablesa hygienist’s abilities, I would not have a viablepreventionmodelortheabilitytoprovidemypa-tientsaccesstocomprehensivecare.Workingwithhygienistshasincreasedtheentrypointsofmypa-tientsintothedentaldeliverysystem.Thisisawin-ningmodelformypatients.”61

Future Research

Replication of this study in other stateswouldbebeneficial to improvegeneralizability. Inordertoachieveanacceptablesurveyresponse, futureresearchwiththistargetpopulationshouldexplorewaystoconnectwithoralhealthcarepersonnel“in


ConclusionThis qualitative case study suggests access to

oralhealthcareforresidentslivinginbothLTCandassistedlivingIandIIfacilitiesinArkansasisaf-fectedbypublicandfacilitypoliciesandaccesstooralhealthcareasafunctionofthepatient’shealthstatusandavailabilityoforalhealthcareproviders.AccessforresidentsresidinginassistedlivingIandIIfacilities isalsolimitedbytheresidents’ability

person”insettingssuchasprofessionalmeetings.Inpersoncontactwassuggestedbyoralhealthcarepersonneldueto lackoftime,andlackofaccesstoelectronicorregularmailwithintheirworkplace.Investigatorsmaywanttoofferincentivesforsur-veyparticipation.Amixedmethods approach in-corporatingbeforeandafterfocusinterviewsalongwithasurveycouldalsostrengthenandenrichthisstudy type. Additional suggestions for future re-searcharetoassesstheperceptionsoforalhealthcarepersonnelastotheirownoralcarepracticesandbeliefsandtoinvestigatedentistsanddentalhygienists inArkansastodeterminetheir interestin,orexperienceswithprovidingcarethroughtheuseofaCollaborativeCarePermit.

AcknowledgmentsWearegrateful for research support fromThe

UniversityofMissouriKansasCityResearchSup-portCommittee.TheauthorsalsothankDr.EdwardGbur at the University of Arkansas Fayettevilleforhishelpwithstatisticalanalysis,theArkansasHealth Care Association for their assistance withtheelectronicsurveyandBarbaraSmithforuseofthesurveyinstrument.

toassumeresponsibility foraccessingoralhealthcare.Theoutcomesfromthisstudymayservetoinformpolicymakers andadvocates for access tooralhealthcareastheydevelopnewapproachestoaddressthisgrowingneed.

Virginia M. Hardgraves, RDH, MS, is an Instruc-tor of Dental Hygiene at the University of Arkan-sas-Fort Smith. Tanya Villalpando Mitchell, RDH, MS, is an Associate Professor and Director, Gradu-ate Studies; Carrie-Carter Hanson, RDH, EdD, is an Assistant Clinical Professor; Melanie Simmer-Beck RDH, PhD, is an Associate Professor. All are at the University of Missouri-Kansas City.

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23. ChalmersJM,EttingerRL.PublichealthissuesingeriatricdentistryintheUnitedStates.Dent Clin N Am.2008;52(2):423-446,vii-viii.

24. EskildsenM,PriceT.NursinghomecareintheUSA.Geriatr Gerontol Int.2009;9(1):1-6.

25. EttingerRL,O’TooleC,WarrenJ,LevyS,HandJS.Nursingdirectors’perceptionsofthedentalcomponents of theminimun data set (MDS).Spec Care Dentist.2000;20(1):23-27.

26. FitzpatrickJ.Oralhealthcareneedsofdepen-dent older people: responsibilities of nursesandcarestaff.J Advanc Nurs.2003;2(6):1325-1332.

27.AdultOralHealthAssessmentExecutiveSum-mary.MissouriDepartmentofHealthandSe-nior Services [Internet]. 2009 [cited 2014December 15]. Available from: http://health.mo.gov/living/families/oralhealth/pdf/Adult_Oral_Health_Assessment_Executive_Summa-ry.pdf

28. Smith BJ, Ghezzi EM, ManzMC, Markova CP.Oralhealthcareaccessandadequacy inalter-nativelong-termcarefacilities.Spec Care Den-tist.2010;30(3):85-94.

29. Healthy People 2020. U.S. Department ofHealthandHumanServices.2013.

30. Oralhealth inArkansas report.Oralhealth inArkansasOfficeofOralHealth[Internet].[cit-ed2012July27].Availablefrom:http://www.healthy.arkansas.gov/programsServices/oral-health/Documents/OralHealthArkansas.pdf

31. ArkansasDepartmentofHealth.ArkansasOralHealthPlan2012-2015.ArkansasDepartmentof Health. 2011.


32. Workforce models and advanced practice.AmericanDentalHygienists’Association[Inter-net].2014[cited2014January14].Availablefrom:http://www.adha.org/workforce-models-apdh

33. LincolnY,GubaEG.Naturalistic Inquiry.New-buryPark,CA:Sage.1985.

34. Cresswell JW. Research design qualitative,quantitative and mixed methods approaches.ThousandOaks,CA:Sage.2009.

35. PattonMQ.Qualitativeresearchandevaluationmethods.Thirded.ThousandOaksCA:Sage.2002.

36. Smith BJ, Ghezzi EM, ManzMC, Markova CP.Perceptionsoforalhealthadequacyandaccessin Michigan nursing facilities. Gerodontology. 2008;25(2):89-98.

37.PyleMA,JasineviciusTR,SawyerDR,MadsenJ.Nursinghomeexecutivedirectors’perceptionof oral care in long-term care facilities.Spec Care Dent.2005;25(2):111-117.

38. Amerine C. An intervention to improve oralhealthofresidentsoflongtermcarefacilities.IdahoStateUniversity[Internet].2011[cited2014 December 15]. Available from: http://www.isu.edu/dentalhy/graduate-students.sht-ml

39. Edelstein B. Engaging the U.S. Congress intheoralhealthofspecial-needsadults:lessonsfrom pediatric oral health policy. Spec Care Dent.2013;33(4):198-203.

40. U.S. Senate Committee on Health EducationLabor andPensions.Dental crisis inAmerica:theneedtoexpandaccess.U.S.Senate.2012.

41. InstituteofMedicine.Improvingaccesstooralhealth care for vulnerable and underservedpopulations.InstituteofMedicine.2011.

42. U.S.DepartmentofHealthandHumanServic-es.OralhealthinAmericaareportoftheSur-geonGeneral.U.S.DepartmentofHealthandHuman Services, National Institute of DetnalandCraniofacialResearch,NationalInstituteofHealth. 2000.

43. InstituteofMedicine.AdvancingoralhealthinAmerica.InstituteofMedicine.2011.

44. ClemmensDA,KerrAR.Improvingoralhealthinwomen’nurses’calltoaction.Am J Maternal/Child Nurs.2008;33(1):10-14.

45. MooreK.OralhealthprogressinKansas.Kans Nurse.2004;79(10):8-10.

46. DolceMC,HaberJ,ShelleyD.Oralhealthnurs-ingeducationandpracticeprogram.Nurs Res Pract.2012;2012:149673.

47.Oral health nursing education and practice.NewYorkUniversityCollegeofNursing[Inter-net].2014[cited2014January16].Availablefrom:http://www.ohnep.org/about

48. Spellman BC. Trends in residential long-termcare:useofnursinghomesandassistedlivingand characteristics of facilities and residents.U.S.DepartmentofHealthandHumanServic-es.2002.

49. Briesacher B, Stuart B, Doshi J. MedicationusebyMedicarebeneficiarieslivinginnursinghomes and assisted living facilities. U.S. De-partmentofhealthandHumanServicesOfficeof Disability, U.S. Department of Health andHumanServices.2009.

50. WhitmanLA,WhitmanJ.Improvingdentalandoralcareservicesfornursingfacilityresidents.TRECS Institute [Internet]. 2006 [cited 2014December 15]. Available from: http://www.thetrecsinstitute.org/downloads/DentalCare.pdf

51. Committee onNursingHomeRegulation. Im-proving thequalityof care innursinghomes.Institute of Medicine [Internet]. 1986 [cited2014 December 15]. Available from: http://www.iom.edu/Reports/1986/Improving-the-Quality-of-Care-in-Nursing-Homes.aspx

52. Morris JN, Hawes C, Fries BE, et al. Design-ing the national resident assessment in-strument for nursing homes. Gerontologist. 1990;30(3):293-307.

53. Turnham H. OBRA Summary. North CarolinaPASRR[Internet].2001[cited2014December15].Available from:http://www.ncmust.com/doclib/OBRA87summary.pdf

54. OfficeofLongTermCare-Overview.ArkansasDepartmentofHealthandHumanServicesOf-ficeofLongTermCare[Internet].2011[cited2012July1].Availablefrom:http://humanser-vices.arkansas.gov/dms/Pages/oltcHome.aspx


55. Nunez B, Chalmers J, Warren J, Ettinger RL,Qian F. Opinions on the provision of dentalcare inIowanursinghomes.Spec Care Dent. 2011;31(1):33-40.

56. Johnson TE, Lange BM. Preferences for andinfluences on oral heath prevention: percep-tionsofdirectorsofnursing.Special Care Dent. 1999;19(4):173-180.

57.MartinKU,MartinJO.Meeting theoralhealthneeds of institutionalized elderly. Dysphagia. 1992;7(2):73-80.

58. PewCharitableTrusts.50statefactsheet-Ar-kansas.PewCharitableTrusts.2013.

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Access to care continues todrawsignificant concern and discussionamongthedentalcommunityandso-cialwelfareadvocates.Sinceitsinitialreleaseintheyear2000,OralHealthinAmerica:AReportoftheSurgeonGeneral has stimulated interest inthe oral health disparities presentintheU.S.1TheCentersforDiseaseControl and Prevention released aprogressreportfortheHealthyPeo-ple 2010 initiative, a renewable 10year agenda for improving the na-tion’s health. Results indicated thatdespite numerous program imple-mentations,littleornoprogresshasoccurredtowardsthegoalsofreduc-ingortreatingtoothdecayinages6to44, reducingcomplete tooth lossinthe65to74yearoldpopulation,andincreasingearlydetectionoforalandpharyngealcancer.2

Nearly one-third of U.S. citizenslackaccesstobasicpreventiveden-tal health care services,mainly re-sultant from dental care costs anduneven geographic distribution ofdentalproviders.3Kansashasalarg-erruralpopulation,37%,incompari-sontothenationalaverageof21%.4 Eighty-nineoutof105countiesareclassified as rural, concentrated inthe western part of the state, withfewer than 40 persons per squaremile.5Furthermore,86%ofthetotalKansascounties lackadequateden-tal care services and are federallydesignatedasdentalhealthprofessional shortageareas(Figure1).6

In2009,theKansasBureauofOralHealthWork-forceAssessmentreportedtheaverageageofKan-sasdentists(n=1,334)was50yearsold.7Amajor-ityofdentistsworkinginruralareasplantoretirein

PerceptionsofKansasExtendedCarePermitDentalHygienists’ImpactonDentalCareJuliaBrotzmanMyers,RDH,MS;CynthiaC.Gadbury-Amyot,MSDH,EdD;ChrisVanNess,PhD;TanyaVillalpandoMitchell,RDH,MS

AbstractPurpose:In2003,Kansasaddressedtheiraccesstooralhealthcareneedswithamendedstatedentalpracticeactforregistereddentalhygienists.TheExtendedCarePermits(ECP)I,IIandIIIhaveexpandedthedentalhygienescopeofpractice,allowingden-talhygieniststoprovideoralcaretoKansansindifferentsettingsbeyondthedentaloffice.Thepurpoaseofthisstudywastoexam-inetheperceptionsofKansasECPdentalhygienistsonchangetooralcareinKansas.Methods:AquestionnairewasmailedtoallECPdentalhygienists(n=158)registeredwiththeKansasDentalBoard.Questionswereopen-ended,close-endedandLikertscale.Informationwassoughtregardingdemographics,areasofemployment,workrelatedac-tivitiesandimpacttooralhealthcare.StudyexclusionsincludedECPprovidersnolongerpracticinginKansas,practicemorethan50%inanotherstateornolongerpracticedentalhygieneatall.Results: Atotalof69surveyswerereturned,with9surveysex-cludedforexclusioncriteria.Mostrespondents(92%)agreedtheECPisasolutiontooralhealthcareaccessissuesinKansas.Bar-rierstoutilizingtheirpermits fully included:difficulty locatingasponsoringdentist(12%),locatingstartupfinances(22%),lim-itedworkspace(14%)anddifficultywithfacilityadministrators(39%).Manyrespondents(62%)agreedtheproposedregistereddental practitionerwould improveaccess tooral health care toKansans.Conclusion:TheExtendedCarePermitprovidersinKansasap-peartobesatisfiedwiththeircurrentemploymentsituationsandfeeloralhealthcarehas improvedfortheirpatientsservedbuttheyareunabletoutilizetheirpermitsfullyforvariousreasons.Keywords:dentalhygienist,accesstocare,extendedcareper-mit,dentalworkforceThisstudysupportstheNDHRApriorityarea,Health Promotion/DiseasePrevention:Identify,describeandexplainmechanismsthatpromoteaccesstooralhealthcare,e.g.,financial,physical,transportation.

Research

Introduction

thenext6to10years,thusprojectingadecreasedsupplyofKansasdentistsby2045.8

The University of Missouri-Kansas City (UMKC)DentalSchoolisthenearestdentalinstitutionoffer-ingeducationofdentists,borderingtheKansasandMissouri state line, and would seemingly provideanabundanceofdentalgraduates for the region.


However,manyoftheinstitution’sdentalgraduateshavechosentobegintheirdentalpracticesoutsideofKansasaddingthedilemmaofaprojectedshort-ageofdentistsinthestate.9Thereare5dentalhy-giene academic programs in Kansas, and 2 addi-tionalprogramsarelocatedinMissourionthestatelineborder.Oftheselocations,onlyoneislocatedin ruralwesternKansas.Anoverwhelmingmajor-ityofKansasdentistsandregisteredKansasdentalhygienistsareconcentrated in largermetropolitanareaslocatedintheeasternhalfofthestate.5,10Itislogicaltoassumenewgraduatesfromtheseden-talhygieneprogramswillcontinuetoseekemploy-ment in largeKansasmetropolitanareasandnotlesspopulatedruralareasofKansas.

KansasAddressesAccesstoCare

Kansashasstruggledwiththeiroralhealthdis-parityandhasfocusedonhowtoprovidepreven-tivecaretothoseindisadvantagedorunderservedareas.Initially,Kansasaddressedthisin1998withadentalassistantmodel,termedscalingassistants.Tracking their impact to preventive oral care forthe underserved population is difficult since scal-ingassistantsareonlyrequiredtoregisterwiththeKansasDentalBoardaftercompletionofapprovedcourses.Theyarenotrequiredtomaintainanyli-censureorregistration,makingthelocationoftheirpracticeandthepopulationsservedspeculative.

Mitchell et al conducteda studyexamining theperceptions ofKansasdental hygienists and scal-ingassistants,thenconductedafollowupstudy5years later.10,11 Findingswere that themajorityofscalingassistantswereworkinginmetropolitanar-easandnotpracticingintheruralandunderservedareasthusnotaddressingtheworkforceneedsfortheunderservedKansaspopulationaswastheorig-inal intent.11

Kansashas since soughtadditionalways to in-creasetheoralhealthcareworkforcetomeettheneeds of its citizens. In 2003, theKansasDentalBoard amended the dental practice act and ex-panded thedentalhygiene scopeofpracticewiththeExtendedCarePermit I (ECP I) thuscreatinganalternativepracticemodelfordentalhygienists.Thisworkforcemodelworksincollaborationwithasponsoringdentist,providingpreventiveservicestotargetedpopulations.12

In2007,thedentalpracticeactfurtherexpand-edthescopeofdentalhygienepracticebycreatingtheECPIIworkforcemodel,allowingforagreaterrangeoflocationsandpopulationsforECPproviderstoaddresspreventiveoralhealthcareneeds(TableI).AllECPprovidersarerequiredtomaintainregis-

trationwiththeKansasDentalBoardwhichservesto track theactualnumberofprovidersand theirprimaryworklocations.12

In 2011, Delinger et al conducted a study ex-aminingtheexperiencesofECPproviders.13Resultssupported the positive impact on preventive oralhealthcareinKansastothetargetedpopulations.Barrierswereencountered,includinglocatingstartup funding, lack of support from facility adminis-tratorsandevendentists.Inspiteofvariouschal-lenges,thesedentalhygienistshaveagreatentre-preneurialspirit,havedevelopedasolidnetworkofsupport and have foundways to sustain the ECPpractice.

Adramaticincreaseinthenumberofpatientcon-tactsinsafetynetclinics,amainhubformanyECPproviders, was noted, rising from approximately5,000patient contacts in2007 toover30,000 in2010.13ManyofthepatientsservedbyECPprovid-erswouldnothaveaccesstopreventivecarefromanyothersource.Intheabsenceofsafetynetden-talclinics,individualsinoralpainmayseekcareintheirlocalhospitalemergencyroom.14

Thefinancial burdenofdental relatedERvisitscannotbeunderestimated.Kansas reportedmorethan 17,500 dental-related visits to emergencycarefacilities in2010.7From2006to2009,therewasanationwide16%overallincreaseinemergen-cyroomvisitsthatresultedinaprimarydiagnosisofpreventabledentalconditions;somemetropoli-tan areas reporting at least 20% where patientsvisited multiple times for the same condition.14,15 Mosttreatmentinvolvesaprescriptionforantibiot-icsandpainmedicationswhichfailtoaddressthecore of the dental need.16 It has been estimated

Figure 1: Kansas Department of HealthandEnvironmentBureauofLocalandRu-ralHealthDentalHPSAs

AsofOctober7,2011


ECPI ECPII ECPIIIPopulationServed

• Lowincomechildren• Adultsinprison• Federallyqualifiedhealthcenters

• Localhealthdepartment

• SameasECPI• Personsoverage65• Specialhealthcareneedspopulation

• SameasECPIandECPII

Requirements • Atleast1200clinicalhours,orDentalhygieneinstructionofatleast2yearsintheprevious3years

• MaintainCPRcertification• Dentistsponsorshipwithsignedagreement

• Maintainprofessionalliabil-ityinsurance

• Atleast1800clinicalhours,orDentalhygieneinstructionofatleast2yearsintheprevious3years

• Sixadditionaltraininghours,specificforcareofspecialneedspatients

• Completeminimumof6hourscontinuingeducationinareaofspecialneedscareevery2years

• Dentistsponsorshipwithsignedagreement


• Atleast2000clinicalhours,orDentalhygieneinstructionofatleast3yearsintheprevious4years

• Completionof18hourKSDentalBoardapprovedcourse

• MaintainCPRcertification• Dentistsponsorshipwithsignedagreement


ScopeofPractice

• Prophylaxis,fluorideap-plication,patienteducationandassessments

• SameasECPI• Removalofoverhangres-torationsandperiodontaldressings,administerlocalblockandinfiltrationan-esthesiaandnitrousoxide(undergeneralsupervi-sion)

• SameasECPIandECPII• Identifydecay,removewithhandinstrumentandplacetemporaryfilling,glassionomerorotherpalliativematerial

• Dentureadjustments,softrelines

• SmoothsharpteethwithslowspeedhandpieceSimpleextractionsofde-ciduousteethApplicationoftopical,localandblockanesthetic

LocationofPractice

• Schools,healthdepart-ments,correctionalfacili-ties

• HeadStartprograms

• SameasECPI• Adultcarehomes,hospi-tallong-termunits,stateinstitutions,homeboundpatients

• SameasECPIandECPII

TableI:KansasExtendedCarePermitIandIIRegulations

Source:KansasDentalBoard

thathospitaldentaltreatmentisnearly10%moreexpensivethanthecostofpreventivedentalcareinaprivatepracticedentalsetting.14Formanystateswhoalreadyhavestrainedbudgets,thequestisontoidentifycost-effectivealternativestoprovideac-cesstodentalcarebeyondtheemergencyroom.

TheFutureofKansasOralCareProviders

Kansas is seeking to continue the positive im-pact of the ECP providers on oral health care tounderservedpopulations.In2012,Kansaslegisla-tion expanding thedental hygiene scopeof prac-ticefurtherwiththeECPIII(TableI).17Proposition

foranewmodel,theregistereddentalpractitioner,wasintroducedbutdidnotpassKansaslegislationin2012duetostrongoppositionfromtheKansasDentalAssociation.Thismidleveldentalworkforcemodel was proposed to be an advanced degreedental hygienist, similar to Minnesota’s AdvancedDentalTherapist.18

TheapprovalfortheECPIIIin2012andthein-creasingdrivefortheRDPshowastrongdesirebyKansastoaddresswhatremainstobeadilemma:there aremany individuals who are lacking ade-quatedentalcare.WithgeographicbarriersinruralwesternKansasandtheprojectedshortageofden-


tistsinthenextdecade,thequestistoincorporateaworkforcemodelthatismosteffectivetoprovidedentalservicestothepopulationsinneedorutilizeacombinationofmodelstobestprovideaccesstodentalcare.

Since2008,therehasbeennearly33%increaseinthenumberofECPprovidersregisteredwiththeKansasDentalBoard,withatotalof158ECPpro-viders as of 2011.19 Yet evenwith the steady in-creaseofECPproviderssincethelegislationpassedin2003,therecontinuestoberuralpopulationsinKansaswhostill lackaccess tooralhealthcare.20 Delinger’s 2011 study provided encouraging evi-denceoftheECP’spositiveimpactforschool-agedchildren,elderlyandspecialneedspatients.13 The Kansas ECPmodel closely resembles the LimitedAccessPermitdentalhygienistsinOregon,servingsimilarpopulationsandlocationsofpracticeandarewell received by the patients they serve and thecollaborating dentists with whom they work withdocumentedsuccess.21

Becauseofthequalitativestudydesignused inDelinger’sresearch,onlya limitednumberofECPproviderswerestudied.13Thepurposeofthisstudy,therefore,was toexplore theentirepopulationofECPprovidersregardingperceptionsoftheirposi-tiveimpacttooralcareinKansas.

Methods and MaterialsSubjects/Population

AllKansasdentalhygienistswhowereregisteredwith theKansasDentalBoard ashavingobtainedeitheranECPIand/orECPIIpermitwere invitedtoparticipate.Atthetimeofthisstudy,therewere158dentalhygienistswithsuchpermits,thereforeatotalof158surveysweremailedtoeligiblepartici-pants.Inordertoachievethemaximumresponserate,thesurveysweremailedinpaperformatwitha4week responseperiod.22 The followinggroupswereexcludedfromthestudy:dentalhygienistsnolongerpracticing,dentalhygienistsnolongerprac-ticinginKansasanddentalhygienistswhopracticedmorethan50%oftheir time inanotherstate.Alloftheparticipantswereaskedtoreturnthesurveyunansweredinapostageprovidedenvelope.

Instrumentation and Measurement

AsurveyinstrumentdevelopedbyMitchelletalexaminingworkforceissuesinKansaswasmodifiedforuseinthisstudy.10Thequestionnaireconsistedof 3 sections with open-ended, close-ended andrank-scaledquestions.Respondentswereaskedtowriteexplanationsandcommentsontheopen-end-

edquestionsandonclose-endeddichotomousyesornoquestions.

Demographicinformationwascollected,includingtheeducationlevelofthedentalhygienistsandthecountyandpracticesettingofthegroups.Percep-tions from survey participants regarding the pro-posedECPIIIandtheregistereddentalpractitionerwerealsorequested.

Apilottestonaconveniencesampleof10dentalhygienistsanddentalhygieneeducatorswascon-ductedpriortotheinitialmailingtodeterminevalid-ityofthesurvey.Thefinalquestionnaire,coverlet-terandresearchdesignwasapprovedbytheSocialSciencesInstitutionalReviewBoardatUMKC.

Data Collection

Surveysweremailedinthesummerof2012toatotalof158participants.Eachdentalhygienistwasaskedtocompletethesurveyandreturn it intheself-addressed, stampedenvelopeprovided in theinitialmailing.Toensureanonymityandconfidenti-ality,nocodingremarksorlabelingofanysurveyin-strumentwasused.Toencourageoptimalresponserates,afollow-uppostcardwasmailed2weeksaf-tertheinitialmailing.Thedatacollectionperiodwasatotalof4weeks.

ResultsDatawereanalyzedutilizingSPSSversion19.Of

the158surveysmailed,69werereturned,yieldinga44%responserate.Ninesurveyswerenotinclud-edduetotheexclusioncriteria.Theremaining60surveys(39%)wereutilizedfordataanalysis.

Demographics

ThetargetpopulationwasKansasECPproviders.TableIIdescribesthedemographicinformation,in-cludingtotalyearsofhygienepractice.TheresponseoverlaptothequestionofpracticelocationpriortoobtainingtheirECPmaybeduetopreviousdentalhygieneactivityinmultiplesettings.

AreasofEmployment

TheECPprovidersreportedutilizingtheirpermitsinavarietyofsettings.NearlyhalfofECPrespon-dents(46%)indicatedworkingin4ormoredifferentlocations.Manyoftheseincludeddifferentschoolsand HeadStart centers. Other locations includedsafetynetfacilities,hospitals,WICcenters,specialneeds clinic, volunteer services, nursing homes,dentalclinicswithoutafulltimedentist,homelessshelters and health departments. Several respon-


dents indicated the importance oftheirabilitytogotothepatientstoprovide care instead of having thepatientcometothem,allowing“chil-drenwithlimitedresourcestoremaininschoolandbeseen.Thebarrierssuchastransportation,timeoffworkhavebeeneliminatedforpreventivecare.”

ECP-RelatedWorkActivity

The respondents reported spend-ing1to60hoursperweekperform-ingECPrelatedactivities,asreport-ed in Table II. Some respondentsreported having an ECP permit butwerenotusingitforworkrelatedpur-poses(35%,n=19).ReasonsfornotactivelyusingtheECPpermitswerevaried.Somewereunabletolocateasponsoringdentistorlackedsupportfrom local dentists in their commu-nity.Othersexpressedaninterestinutilizing theirpermitonapart-timebasisandwereunabletofindaloca-tion or opportunity in which to useit,stating“Theclinicwasclosedbe-cause there was no more budget.”Findingtimeoutsideofafulltimepri-vatepracticeschedulewasalimitingfactorforsomeECPpermitholders:“Noparttimeopportunities.Federalgrants not renewed.” The physicalstrain of transporting the equip-mentwasalso cited as anobstacletofulluseoftheECPpermitaswasthefrustrationoflimitedfundingandclinic closures due to budget cutsthateliminatedanemploymenthubforECPproviders.

PerceptionsofImpacttoCare

Overall, most participants weresatisfied with their current positionasanECPprovider(70%,n=42).TheECP appears to be providingdentalcare to many underserved popula-tions in Kansas. Nearly half on re-spondents(48%,n=28)agreedtheywereabletousetheirECPtothefull-estextent.ThosewhofelttheywereabletoutilizetheirECPfullyalsohadthe most perceived support fromtheir sponsoring dentist (r=0.438,p<0.05).

TotalRespondents Number Valid

PercentageAge

25 to 3435 to 4445 to 5455 to 66

5814102113

24%17.1%36.2%22.2%

GenderFemaleMale

58571

98.3%1.7%

DentalHygieneEducationAssociateDegreeBachelor’sDegreeMaster’sDegree

5832233

55.2%39.7%5.2%

YearsofActiveDentalHygienePractice

1to5years6to10years11to15years16to20years21to25years26+

58

81186619

13.8%19%13.8%10.3%10.3%32.8%

PriorLocationofDentalHygienePractice

PrivatePracticePublicHealthDentalHygieneEduca-tionalInstitution

58

54113

93.1%19%5.2%

NumberofLocationsforECPDentalHygienePractice

1234+

60

148019

34.1%19.5%

046.3%

NumberofHoursforWeeklyECPActivityLessthan1

1 to 1011 to 2021 to 3031 to 4041 to 5051 to 60

55

211493701

38.1%25.4%16.3%5.4%12.7%

01.0%

ECPRelatedWorkActivityPreventiveScalingFluorideApplicationOralHygieneInstructionPatientAssessmentOther DDS DelegatedActivities

3838383633

55.1%55.1%55.1%52.2%47.8%

Table II:Demographic andpractice characteristics oftheKansasECPdentalhygienerespondents(n=60)

*Valid percentage does not include non-responses; percentages calcu-latedfromtotalresponsesforeachquestion.


Conversely,manyECPrespondentsfelttheywerenotutilizing thepermit to its fullestextent (52%,n=30).Manycitedbarriers,asseeninTableIII,in-cludinga“toorestrictivescopeofpractice”fortheECP, “billing cannot be done directly to a hygien-ist,”“lackofequipmenttotraveltonursinghomes”and“objectionsfromthedentistsinmyarea.”WhenaskediftheirsponsoringdentistsfelttheECPwasasolutiontomanpowerissuesinKansas,nearly22%(n=13)of theECPproviderssurveyed for this re-search indicated their sponsoring dentists felt theECPwasnotasolutiontomanpowerissuesinKan-sas. One respondent stated they “work full time,needthesteadyflowinincome,sponsoringdentistisnotsupportiveandisonlyoneI’vefound.”

Many respondents (62%, n=37) agreed theproposed registered dental practitioner would im-proveaccesstodentalcareinKansas,yetonly45%(n=24)wouldbeinterestedinpursuingthislicenseifavailable.Reasonsforthisincludedacareernear-ing retirement and the perceived lack of supportfrom“dentistswillingtohelpout.”Overhalf(52%)indicatedtheyplantousetheirECPfor10yearsorless.

Respondents strongly agreed their permits arepartofasolutiontoaccesstocareissuesinKansas(92%,n=55)andfelttheirpermitshaveapositiveimpactondentalcare(93%,n=54).Likewise,theyfeeldentalcarehasimprovedforthepatientstheyserve(71%,n=42).Onerespondentcommented:“I work in public health andwe target southeastKansas schools,HeadStart andWICwithourECPlicense.Thisisaverylowincomeareathatdoesnotgotothedentist.ECPallowsustogotothem.”Amajority(57%,n=33)ofrespondentsagreedtheirsponsoringdentistviewedtheECPasonesolutiontoaccesstodentalcareinKansas.

Response n* PercentDifficultylocatingstartupfinances

YesNo

1346

2278

Difficultylocatingsponsoringdentist

YesNo

751

12.187.9

Limitedspaceinworkfacility

YesNo

851

13.686.4

Obstacleswithfacilityadministrators

YesNo

2336

3961

Inadequatenumberofpatientsavailableforservices

YesNo

653

10.289.8

Otherbarriers YesNo

2336

3961

Table III: Perceived Barriers PreventingFullUtilizationoftheECP

DiscussionThisstudywasdesignedtoinvestigatetheper-

ceptionsofKansasECPproviders’positiveimpacttodentalcare.Alargemajorityofsurveyrespondents(93%,n=54)felttheECPhasincreasedaccesstodentalcare inKansas.Thisstudyechoesaprevi-ousstudyon thecritical roleand impact theECPhashadonreachingtargetedunderservedpopula-tions.13 Encouraging statements fromECP’swere:“provideservicestomanychildrenwhohaveneverseenadentist,”“providepreventiveservicessokidscanstayinschool,””nursinghomepatientsstayintheirarea”and“specialneedsdonothavetotrav-el.”

The dental benefit to Kansas children will pre-sumablycontinuetoincreasesinceKansaspassed

legislationfortheECPIIIin2012.TheECPIIIwillincrease the dental hygiene scope of practice forspeciallytrainedhygienistsandincludesprovisionstoplacetemporaryfillings,extractloosebabyteethandadjustdentures.12TheECPIIIhasgonebeyondapreventivescopeofpracticeandallowsforlimitedrestorativedentaltreatment.

All 3 ECP permits are designed to allowdentalhygieniststoreachpopulationswhoareunabletoreceivetraditionaldentalcareinaprivateoffice,yetthefundamentalfocusforeachpermitispreventivecare.ThelimitedrestorativecapacityoftheECPIIIhasbeentermeda“babystep”towardsprovidingdentalservicestotheunderservedandmanyorga-nizationsarestilladvocatingforamidleveldentalproviderinKansas.12,13Theregistereddentalprac-titionerwouldfillagapthatstillexists.Legislationforamidleveldentalproviderwithmorerestorativecapabilities, the,was introduced in2012andwasstronglyopposedbytheKansasDentalAssociation.

AlthoughtheECPisprovidingpreventivedentalservices,someof theECPproviderssurveyedfelttheirscopeofpracticewaslimitedwithstatementssuchas:“weseeseveralkidsinschoolsandtheycontinuetohaveuntreateddecaythatanregistereddental practitioner couldfix in the school setting,trulyremovingallbarrierstoaccess.ECPhelpsbutnosolutionsincealargepercentageofourpatientsneedmorethanjustpreventivecare.”

WhenaskedtoexplainiftheECPhasincreasedaccess to dental care in Kansas, one respondentcommented:“Ina limitedmanner,yes.Cleaningsandsealantsinschoolsarebeneficialbutthisisthetipoftheiceberg.”TheinabilityoftheECPtopro-viderestorativeserviceshasbeensuggestedpre-


Figure2:ECPRespondentsbyCountyandSafetyNetLocations(n=60;60/158=40%)

viously as an obstacle to providing complete oralhealth care in school children and nursing homeresidents.13 Painful and unhealthy oral conditionsarepresentinpatientsthatanECPprovidercannotprovideandadentistreferralmaybeseveralmilesfromthepatient’slocation.13

In2011,Simmer-Becketalreleasedareportde-scribingtheoutcomeoftheMilesofSmilesprogram,acollaborativeeffortbetweenUMKCSchoolofDen-tistry,theOlatheKansasSchooldistrict(insubur-banKansasCity)andKansasECPproviders.23Milesof Smiles utilizes portable dental equipment, ECPproviders,UMKCdentalhygienestudents(asanac-ademicservicelearningassignment)andvolunteerdentists to provide dental screenings, preventivedentaltreatmentandreferralsforrestorativeden-talneedsatlocalschoolsinOlathe.JohnsonCoun-ty,oneof themostdenselypopulated inKansas,hasonly1clinicforuninsuredlowincomepeople.Ofthe7Medicaiddentalproviderslisted,Simmer-Becketalidentifiedonly4thatwereacceptingnewMedicaidpatients.Uponendofschoolyearevalua-tions,only11%ofthechildrenwhowerereferredfordentalneedsactuallyreceiveddentalcare.Fur-therresearchwouldwarrantinvestigatingobstaclesinthetransitionprocessforthesechildren.23

TheMilesofSmilesprogramissuccessfullypro-viding hands-on experiences for dental hygienestudents, introducing them to the disparities thatexisteveninwealthysuburbanareasandprovidingthemwiththeopportunitytoexperiencefirsthandthedeliveryofcomprehensivepreventiveservicesinanelementaryschoolsetting.TheMilesofSmilesprogramalongwithotheracademicservicelearningcomponents in thedentalhygiene curriculumhasresultedinincreasingnumbersofstudentsmakingcareerchoicesinthepublichealthsector.24

Advocatingformorehygieniststoobtainanduti-lizetheirECPpermitswassuggestedbymorethanoneparticipantinthecurrentsurvey.However,con-cernwasnotedabouttheECPproviders’geographicpracticelocationtoremainin“areasofneed…afraidthatdistributionwillfollowsamepatterns”wascit-edbyarespondent.Mitchelletalfoundthatdentalhygienistsatthetimeweremainlylocatedinmet-ropolitanareasofKansasandnotinruralcommuni-ties.11

ThecurrentsurveyaskedtheECPproviderstoin-dicatethecountiesofpracticefortheirpermits.Fif-ty-eightoutof105Kansascountieswerelistedbytherespondentsandallarewithina1or2countyradiusofasafetynetclinicwhichprovidesoralcaretounderservedpopulationsregardlessofabilitytopay(Figure2).The60ECPprovidersinthisstudy

haveshowntohaveawidegeographicreachinthestateandareinareasofmostneedincludingcoun-tieswithdesignationsofhealthprofessionalshort-age areas, low income populations and Medicaideligible.6 This differs fromMitchell’s ECP researchwhich identifiedECP locationofpracticemainly inmetropolitan Kansas City and Wichita.10,11 Somecounties,mainlyinwesternKansas,werenotrep-resentedinthissurveybuttheindicationofECP’sgeographicexpansionisencouraging.

In theory, the ECP providers should be able toreachasmanytargetpopulationsasallowed.TheresultsofthissurveyindicatemanyECPprovidersperceivednumerousbarriersthatobstructedtheirabilitytoprovidecare.Difficultylocatingasponsor-ingdentistwasfoundinthisstudy.Similarly, lackofsupportfromsponsoringdentistshasbeennotedin past research.13 One respondent stated, “mostdentists inmy ruralareadon’tandwon’temployahygienist (Iwas toldmyassistantsscaleabovethegumsandIfinishin10minutes!).”OtherECPprovidersindicatedutilizingtheECPpermitbutare“limitedbymysponsoringDDS”and“notdoingverymanycleaningsduetoobjectionsfromthedentistsinmyarea.”Kansasdentistsalsoappeartobedi-vided in their supportor lack thereof for theECPprovidersasonerespondentdescribedanencoun-teredbarrier:“otherdentistsintheareawhodonothelpbutdonotsupportmysponsoringdentist.”Thedentalcommunityappearsdividedinthemostef-ficientpathwayandworkforcemodeltodeliveroralhealthcaretotheunderservedKansaspopulations.

Many intheKansasdentalcommunitycontinuetoseekinnovativepathwaysfordeliveryofdentalcaretounderservedpopulations.Althoughtheleg-islationforthemidlevelregistereddentalpractitio-nerwasnotpassedinearly2012,FortHaysUniver-sityisalreadycommittedtocreatinganeducationalprogram for midlevel practitioners.25 The KansasHouseBillthatcreatedthenewECPIIIalsoinclud-


ConclusionKansasECPprovidersreportedmakingaposi-

tive impact on the dental care to underservedpopulations.Theyaregenerallysatisfiedwiththe

edprovisions for increasing thenumberofdentalstudentseatsatUMKCSchoolofDentistryforKan-sas studentswith the intention of these studentsreturningtoruralKansastopracticeupongradua-tion.12ItisyetunknownifthisstrategywillindeedincreasethenumberofdentistsinruralKansas.

TheECPpermitsallowsopportunitiesforKansasdental hygienists to expand their dental hygieneservicesoutsideoftraditionaldentalsettings.Simi-lar to previous research, the ECP respondents tothissurveywereenthusiasticabouttheircontribu-tiontoimprovethedentalcaredisparityinKansasandtheirabilitytotaketheircareer inadifferentdirection.13 Over half of the respondents report-edagesover45and intendedtoutilize theirECPpermitsfor10yearsor less.Perhapsexposuretoservicelearningprojects,suchasUMKC’sMilesofSmiles,willencouragedentalhygienegraduatestopursuecareersinalternativesettings.

Limitationstothisstudyincludetheself-report-ing nature of survey research. Respondents mayhave varying interpretations of the scale-rankedquestionsandpotentialforinternalbiasispresent.TheECPIIIwasinitiatedintolegislationatthetimeofthedatacollectionforthisstudy.FutureresearchtodeterminetheECPproviders’impacttocarewiththeECPIIIwouldbewarranted.

AcknowledgmentsThe authors would like to thank the Rinehart

Foundation, UMKC Research Support CommitteeandUMKCWomen’sCouncilfortheirgenerousfi-nancialsupporttothisresearch.

current utilization of their ECPpermits andper-ceive the ECP to have increased access to den-talcareinKansas.Barrierswerenoted,includinglackofdentistsupport, limitedscopeofpracticefor preventive services only, and administrativeobstacles.TheECP III,withvery limited restor-ativecapacity,wasinitiatedimmediatelyuponthelaunchofthissurveythereforeitisyettobede-terminedifthiswillimpactthedeliveryofcaretoKansas populationswith limited or no access todentalcare.

Julia Brotzman Myers, RDH, MS, currently works in private practice in Overland Park, KS and mobile outreach dentistry to elementary schools. Cynthia C. Gadbury-Amyot, MSDH, EdD, is an As-sociate Dean and Professor, Instructional Technol-ogy and Faculty Development, University of Mis-souri-Kansas City. Christopher J. Van Ness, PhD, is a Research Assistant Professor and the Direc-tor of Assessment at the University of Missouri-Kansas City School of Dentistry. Tanya Villalpando Mitchell, RDH, MS, is an Associate Professor and Director of Graduate Studies at the University of Missouri-Kansas City School of Dentistry, Division of Dental Hygiene.

1. U.S.DepartmentofHealthandHumanServices.OralHealth inAmerica:ANationalCall toActiontoPromoteOralHealth.U.S.DepartmentofHealthandHumanServices,NationalInstituteofDentaland Craniofacial Research, National Institutes ofHealth. 2000.

2. HealthyPeople2020.U.S.DepartmentofHealthandHumanServices.2010.

3. Shaefer HL, Miller M. Improving Access to OralHealth Care Services AmongUnderserved Popu-lations intheU.S.:IsThereaRoleforMid-LevelDentalProviders?J Health Care Poor Underserved. 2011;22(3):740-744.

4. State & County QuickFacts: Kansas. U.S. Cen-sus [Internet]. 2010 [cited 2014 December 5].Available from: http://quickfacts.census.gov/qfd/states/20000.html

5. Kansas Department of Health and Environment.Rural Health Overview. Kansas Department ofHealth and Environment [Internet]. 2012 [cited2014December15].Availablefrom:http://www.kdheks.gov/olrh/RHOverview.htm

6. KansasDentalProject.WehaveaseriousprobleminKansas.KansasDental [Internet].2012[cited2014December15].Available from:http:/www.kansasdental.com

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7. Kansas2009OralHealthWorkforceAssessment.Kansas Department of Health and Environment[Internet]. 2009 [cited 2012 January 1]. Avail-able from: http://www.kdheks.gov/ohi/down-load/2009_Oral_Health_Workforce_Assessment.pdf

8. AllisonRA,BryanDJ.TheDecliningsupplyofden-talservicesinKansas:Implicationsforaccessandoptionsforreform.AreporttotheUnitedMethod-istHealthMinistryFundKHI/R05-1.KansasHealthInstitute.2005.

9. TiraD,PetersR,ReedM,KillipJ.AddressingDen-talworkforce issues inMissouriandKansas:oneschool’sinitiative.J Dent Ed.2003;67(8):902-908.

10. MitchellTV,PetersR,Gadbury-AmyotC,OvermanP,StoverL.Accesstocareandthealliedoralhealthcareworkforce inKansas:perceptionsofKansasdental hygienists and scalingdental assistants. J Dent Edu.2006;70(3):263-278.

11. MitchellTV,Gadbury-AmyotC,OvermanP,PetersR.TheimpactofKansasHouseBill2724:percep-tionsofKansasdentalhygienistsanddentalassis-tants.J Dent Hygiene.2003;77(IV):233-243.

12. KansasDentalBoard.KansasDentalPracticesAct.Statutes,regulationsandrelatedlawspertainingtodentistsanddentalhygienists.RevisedJan2012.KansasDentalBoard.2012.

13. Delinger J, Gadbury-Amyot CC, Mitchell TV,Wil-liamsKB.AQualitativeStudyoftheExtendedCarePermitDentalHygienists inKansas. J Dent Hyg. 2014;88(3):160-172.

14. ACostlyDentalDestination:Hospitalcaremeansstates pay dearly. Pew Center on the States[Internet]. 2012 [cited 2012 March 6]. Avail-able from: http://www.pewtrusts.org/~/media/Assets/2012/01/16/A-Costly-Dental-Destination.pdf

15. TheMinnesotaStory:Howadvocatessecuredthefirststatelawofitskindexpandingchildren’saccesstodentalcare.PewCenteron theStates[Inter-net].2010[cited2012January2].Availablefrom:http://www.pewtrusts.org/en/research-and-analy-sis/reports/2010/09/20/the-minnesota-story-how-advocates-secured-the-first-state-law-of-its-kind-expanding-childrens-access-to-dental-care

16. BathA.LackofdentalcoveragesendspatientstoERforpain.USATODAY[Internet].2012[cited2012January 19]. Available from: http://usatoday30.usatoday.com/news/health/healthcare/health/healthcare/story/2012-01-19/Lack-of-dental-cov-erage-sends-patients-to-ER-for-pain/52683018/1

17.Housecommitteeapprovesbilltoletdentalhygien-ists domore.KansasHealth Institute [Internet].2012 [cited 2012 February 17]. Available from:http://www.khi.org/news/2012/feb/13/commit-tee-approves-bill-let-dental-hygienists-do-m/

18. KansasActionforChildren[Internet].2011[cited2012January24].Availablefrom:http://www.kac.org/ftp/file/Briefs/2011brief_dental(3).pdf

19. Kansasdentalfactsandstats.KansasDentalBoard[Internet].2012[cited2012February1].Availablefrom: http://www.accesskansas.org/kdb/facts.html

20. KimminauK,WelleverA.MappingtheRuralKan-sasDentalWorkforce.UniversityofKansasMedicalCenter for Community Health Improvement [In-ternet].2011 [cited2012 January24].Availablefrom:http://www.kdheks.gov/ohi/download/Map-ping_the_Rural_Kansas_Dental_Workforce

21. BattrellA,Gadbury-AmyotC,OvermanP.Aqualita-tivestudyoflimitedaccesspermitdentalhygienistsinOregon.J Dent Edu.2008;72(3):329-343.

22. Hardigan, PC, Succar CT, Fleisher JM. An analy-sisofresponserateandeconomiccostsbetweenmail and web-based surveys among practicingdentists:arandomizedtrial.J Community Health. 2012;37(2):383-394.

23. Simmer-Beck M, Gadbury-Amyot C, Ferris H,VoelkerM,KeselyakN,EpleeH,ParkinsonJ,MarseB,GalemoreC.Extendingoralhealthcareservicesto underserved children through a school-basedcollaboration:Part1-Adescriptiveoverview.J Dent Hyg.2011;85(3):181-192.

24. Keselyak N, Simmer-Beck M, Gadbury-AmyotC. Extending oral health care services to under-servedchildrenthroughaschool-basedcollabora-tion:Part2-Thestudentexperience.J Dent Hyg. 2011;85(3):193-203.

25. FortHaysconsidersdentaldegree.FortHaysStateUniversity[Internet].2012[cited2012January24].Availablefrom:http://leader.fhsu.edu/?p=7236.


Access to dental care is a grow-ing problem in many areas of theU.S.Specifically,8outof16countiesin Maine are entirely designated asdentalshortageareas.Theremainingcountieshaveatleastsomelocalizedareas of dental shortage designa-tion.1DentalshortagesinMaineweredocumentedasearlyas1929whenitwasnotedthatdentistsservedonly20%ofcommunities.2InadditiontotheexistingdeficitofdentalservicesinMaine, largenumbersof dentistsareexpectedtoretireinthenext10yearswithtwiceasmanydentistsre-tiringasgraduating.3,4 Dental hygien-istspracticinginalternativesettings,therefore,haveauniqueopportunitytoincreaseaccesstocare.Thepur-poseofthisstudywastodeterminethe perceived level of preparednessMaine Independent Practice DentalHygienists (IPDHs) received fromtheirstandardundergraduatedentalhygieneeducation,andrecognizear-easnecessaryforfurthereducationinordertoexplorecareersbeyondtheprivatepracticedentalofficemodel.

In 1982, Rovin et al predictedwithin2decadestherewouldbenewforms of dental care deliverywhichwouldleadtoanincreaseinpatientaccess.5Inre-sponsetotheneedforgreateraccesstodentalcare,many states havemoved to allow dental hygien-iststoprovidecareindependentlyfromadentist.AstudybyFreedetalin1996foundthatIPDHprac-ticesappearedtoofferadvantagestounderservedpatientsbyincreasingaccesstocare.6

Colorado and Washington were the first statestoallowunsupervisedpracticeofdentalhygienistsduring the1980s.6AsofOctober2012,35states

EducationalDeficienciesRecognizedbyIndependentPracticeDentalHygienistsandtheirSuggestionsforChangeCourtneyE.Vannah,MS,IPDH;MarthaMcComas,RDH,MS;MelanieTaverna,MS,RDH;BeatrizHicks,MA,RDH;RebeccaWright,MS,RDH

AbstractPurpose:Thepurposeofthisstudywastodeterminetheper-ceivedlevelofpreparednessMaineIndependentPracticeDentalHygienists (IPDHs) received from their standardundergraduatedentalhygieneeducation,andrecognizeareasnecessaryforfur-therpreparation inorder toexplorecareersbeyondtheprivatepracticedentalmodel.Methods:Aconveniencesampleof6IPDHsparticipatedinasur-vey exploring their educational experience in public health andalternativepracticesettings.Thesurveyalsoaskedfortheirrec-ommendationstoadvancedentalhygieneeducationtomeettheneedsofthosewishingtopursuealternativepracticecareers.Results: Thisstudyfoundthatparticipantsfeltunderpreparedbytheirdentalhygieneeducationwithdeficitsinexposuretopublichealth,businessskillsnecessaryfor independentpractice,com-municationtrainingandunderstandingofsituationswhichrequirereferralfortreatmentbeyondtheIPDHscopeofpractice.Conclusion:Asthedentalhygieneprofessionevolves,dentalhy-gieneeducationmustaswell.TheIPDHparticipants’recommen-dationsfordentalhygieneprogramsincludeincreasedexposuretoalternativesettingsandunderservedpopulationsaswellaselec-tivecoursesforthosestudentsinterestedinalternativepracticeandbusinessownership.Keywords:dentalhygieneeducation,dentalpublichealth,inde-pendentpractice,alternativepracticeThisstudysupportstheNDHRApriorityarea,Professional Edu-cationandDevelopment:Evaluatetheextenttowhichcurrentdentalhygienecurriculapreparedentalhygieniststomeetthein-creasinglycomplexoralhealthneedsofthepublic.

Research

Introduction

allowsomeformofdirectaccesstodentalhygienecarewithoutspecificauthorizationofadentist.7In2008,MainepassedlegislationtoallowindependentpracticeofthedentalhygienistandmorerecentlytoallowIPDHstobereimburseddirectlybyMaineCare(Maine’snomenclatureforMedicaid)asacarepro-vider.SpecificinformationpertinenttoIndependentPracticeDentalHygiene intheStateofMainecanbefoundintheStateofMaineDentalPracticeAct,Licensing Statue for Independent Practice DentalHygienists-Title32,Chapter16,Subchapter3-B.


Feesforservicesindentalhygienepracticeswerefoundtobelowerthantheircounterpartsinprivatepracticedentaloffices.8InMaine,thecostofanap-pointmentatanIPDHpracticewasroughly<$100thanitsequivalentinadentalpractice.1Payingthedentalhygienistdirectlyratherthanaccessinghy-gienecarethroughadentistmakescaremoreaf-fordable.Moreaffordableservicesnotonlyincreas-esaccesstoMaineCarepatientsbutalsotheunderanduninsuredpopulation.

TheIPDHmodelofcaredelivery,alsocalledcol-laborativepractice,alternativepracticeorunsuper-visedpractice,wasdevelopedprimarilytoreachagreaternumberofpatients includingMedicaidpa-tients.9Yearsago,fewpeoplethoughtofthebusi-ness of dental hygiene as a career opportunity;however, it is now a rewarding career and thriv-ingbusinessformany.10AccordingtotheAmericanDental Hygienists’ Association (ADHA), dental hy-gieneeducationwas,historically,tailoredtodentalhygienistswhoplantoprovidecareinprivateprac-ticedentaloffices.ADHAsuggestschangesmustbemadetoadvancecurrentdentalhygienecurriculuminordertokeeppacewiththeevolvinghealthcaredeliverysystem.11

The American Dental Education Association’s(ADEA) Policy Statement: Recommendations andGuidelines forAcademicDental Institutions statesthateducation institutionsareencouraged topre-parestudentsforevolvingworkforcemodelswhichwillincludeinterdisciplinarycareandbeingpartofa health team.12AccordingtoADEA,dentalhygieneprogramsspecificallyshould:

“…preparegraduates fornewandemerging re-sponsibilities.Monitorandanticipatechangesinsu-pervisionrequirementswithinthestateandmodifythecurriculumandextramuralexperiencesofstu-dentssoas toprepare themtoprovidemoreex-tendedservicesinavarietyofpracticesettings.”12

TheADHArecommendsprogramsredefinecurri-culatomeetevolvingoralhealthneeds.Specifically,theirrecommendationsarethatdentalhygienepro-grams:

“Evaluate the dental hygiene curriculum andcreate newmodels for entry level programs thataddress: oral health needs, training programs incommunity-based, underserved areas, communityhealth and diseasemanagement, cultural compe-tence,needsofspecialgroups,healthservicesre-search,publicpolicydevelopment,evidence-basedresearchmethodologyandpractice,andcollabora-tivepracticemodels.”11

Some states, such as California, require dentalhygieniststotakeaneducationalcourseinadditiontotheireducationrequirementsforregisteredden-talhygienistlicensurepriortoreceivingtheirlicensetopracticeinalternativesettings.California’scourseis150hoursconsistingoftraininginmanagement,business, dental hygiene practice and medicallycomplexpatients.13 InMaine, there isnorequiredcoursebeyondtheregistereddentalhygienistlicen-sure education requirements necessary to obtainIPDHlicensure.Thisleavestheresponsibilityforad-ditional training necessary to succeed outside theprivatepracticesettinguptothedentalhygieniststoobtainontheirown.

Previously,multiplesurveyshavebeenconduct-ed asking alternative hygiene practitioners theirthoughts about additional education requirementspriortolicensing.AqualitativestudyofLimitedAc-cessPermit (LAP)dental hygienists inOregon re-ported that LAP dental hygienists feel additionalcoursework should include organizational struc-ture,billing,coding,prescriptionwritingandpublichealthdeliverysystems.14Similarly,astudyofColo-radoIPDHsreportedaccounting,computerscience,managementandmarketingcourseworkwouldbebeneficial to those dental hygienists interested inpracticingindependently.15

Beachetalsuggestssuccessfulindependentden-talhygienistswillbepractitionerswithastrongurgeforentrepreneurship.16Researchshowswhileonlyafewdentalhygienistsmaywanttoownapractice,manymoremaybeinterestedinworkinginthisen-vironment.8Independentdentalhygienistswillhaveto assume the risks and responsibilities for itemssuchasequipmentmalfunctionandrepair,runningabusiness,managingemployees,andthefinancialburdensofowningabusiness.16

Literature suggests dental hygienists practicingoutsidetheprivatepracticedentalofficewillneedskills beyond what the traditional dental hygieneeducationcurriculumprovides.Somestatesrequireadditionaltrainingpriortolicensureforalternativepractice, but for thosewhichdonot, it is unclearwhere the responsibility lies to ensure dental hy-gienistshaveadequatetraining.Althoughithasnotbeendeterminedthatitistheresponsibilityofbasicdentalhygieneeducationprogramstopreparestu-dentsforalternativepractice,itcanbeagreeduponthattheprofessionischanging.TheADHAandADEArecommendprogramsbegintoevolvetomeettheneedsofthechangingprofessionandthisstudywillprovidedentalhygieneprogramswithsuggestionstoenablecompliancewiththisrecommendation.


Methods and Materials

Asurveydesignapproachusingbothclosedandopen-endedquestionswasutilized.Thesurveywasdevelopedbytheresearcher,andwhilenotvalidat-ed,wasreviewedbyexpertsinthefieldofdentalhygiene education and curriculum development.Thesurveywasadministeredviatelephone.

A convenience sample of 6 practicing IPDHswasselected fromMaine. Inaneffort to capturethe most relevant information for today’s dentalhygiene curriculum, only themost recent gradu-ates actively practicing as IPDHs were selected;more specifically, thosewho graduated since thenewmillennium.Contactinformationwasobtainedthrough the Maine State Board of Dental Exam-iners. Through review of the Maine State Boardof Dental Examiners records, it was determinedthat6IPDHshadgraduatedsincetheyear2000.Participantswerereadastatement indicatingthevoluntarynatureofthesurveyandverbalconsentobtained. All 6 participants contacted agreed toparticipateandalthoughparticipantswereabletowithdraw at any time, all chose to complete thesurvey.

Questionsaddressedincluded:

1. WhataretheperceptionsofpracticingIPDHsinMaineabouttheireducationalpreparednessforalternativepracticeenvironments?

2. WhatrecommendationsdotheIPDHshaveforinclusionsindentalhygieneeducationtobet-ter prepare dental hygienists for alternativepracticesettings?

ThisstudywasreviewedandapprovedbytheUni-versityofTexasHealthScienceCenterSanAnto-nioInstitutionalReviewBoard(IRB).TheIRBalsoreviewedandapprovedthestatementreadtotheparticipants to obtain verbal consent and deter-mined that recordedconsentswerenot required.LikertScaledatawereanalyzedusingdescriptivestatisticsinMicrosoftExcel2007®.Themesevolvedfrom transcription of thenarrativeportion of thesurvey.

ResultsTheaverageageoftheparticipantswas36with

arangefrom26to51.Allparticipantsgraduatedfrom dental hygiene programs located in Maine.Graduationyearrangedfrom2001to2008.Threereceived anAssociate of Science degree and theother3 receivedaBachelorofSciencedegree indentalhygiene.Theparticipantshadbeenpractic-ing independently foranaverageof2yearswith

arangeof1to4years.Theprimarypopulationsbeing served were reported as: MaineCare, lowincome,uninsuredand, inonecase, residentsoflong-term care facilities. All the IPDH practicesrepresented in this study were located in a ru-ralsetting.Oftheparticipants,3usedtraditionalfixed dental equipment, the others usedmobile.Although theequipmentwas reportedasmobile,2ofthe3participantswhoreportedusingmobileequipment used it in a fixed location.All partici-pantswereownersoftheirpractice,andonly1re-portedhavingemployees.

Participantsrespondedto10questionsbasedona4pointLikertScale.Theresponsechoiceswere1=Strongly Disagree, 2=Somewhat Disagree,3=SomewhatAgree,4=StronglyAgree.Themostcommonresponsewas“SomewhatDisagree”andtheleastcommonresponsewas“StronglyAgree.”

The 10 Likert Scale questions can be groupedbytopicincludingexposuretopublichealth(ques-tions3,5,6,7),exposuretoalternativepracticeenvironments(questions2,9)andoverallpercep-tionsofpreparednessfortheparticipant’schosencareer path (questions 1, 4, 8, 10).When com-paringresponsestothetopics,theIPDHsreportedthelowestlevelofsatisfactionwiththeexposuretoalternativepracticesettingstheyreceivedintheireducation.Of the3 topics,none receivedoverallpositiveresponses(TableI).

Thefirstopen-endedquestionofthesurveywas:“Pleasedescribeyoureducationalexperienceswithalternative practice setting career opportunities.”Two responded that extramural internships wereanintegralpartoftheireducationalexposuretoal-ternativepracticesettings.Tworeportedtheironlyexposurewasintheclassroomthroughdiscussionin public/community health courses. One partici-pant described visits to local schools to performscreeningsas alternativepractice exposure. Fourstatedtheyreceivedinadequateexposuretoalter-nativepracticesettingsduringtheireducation.

The second open-ended questionwas: “Pleaseelaborateonyourlevelofinterestinpublichealthcareersduringyoureducationand,ifappropriate,how your education impacted that level of inter-est.”Mostsurveyparticipants felt theireducationimpactedtheir interest inpublichealthminimallyornoneatall.Variousreasonweregivensuchastheydidnothaveenoughpublichealthexposureintheireducationtomakeanimpact,theyalreadyhaddecidedonacareerinprivatepracticedentalofficespriortoenteringdentalhygieneschool,orprivatepracticewasportrayedasmoreappealing.Althoughtheirexposuretopublichealthwasmini-


SurveyQuestions QuestionTopic StronglyDisagree=1

SomewhatDisagree=2

SomewhatAgree=3

StronglyAgree=4

Q1.Iamsatisfiedwiththeprepared-nessIreceivedduringmydentalhy-gieneeducationprogramformychosencareerpath

Overallprepared-nessforchosencareerpath

1 3 2 0

Q2.IfeelasthoughIwasgivenampleopportunitytolearn,explore,andpiquemycuriosityaboutalternativedentalhygienecareersduringmydentalhy-gieneeducation

Exposuretoal-ternativepractice

settings2 3 1 0

Q3.Ifellasthoughtmylevelofinterestinpublichealthcareerswasimpactedinsomewaybymydentalhygieneeduca-tionproblem

ExposuretoPublicHealth 1 1 4 0

Q4.IfeelasthoughALLskillsneces-sarytomycurrentpracticechoicewereincludedinmyeducation


2 2 1 1

Q5.UpongraduationIfeltverywellinformedabouthowtomakeanimpactontheunderservedpopulationIwasinterestedinhelping


Q6.Mydentalhygieneeducationprogramhelpedbeidentifyandunder-servedpopulationIwasinterestedinhelping


Q7.Duringmydentalhygieneeduca-tion,Iwaswellinformedandmadeawareoftheunmetdentalneedsexist-inginmyownstate


Q8.IfeelasthoughIgainedadequateclinicalexperienceinalternativeprac-ticeenvironmentstopreparemeformychosencareerindentalhygieneduringmydentalhygieneeducation


1 3 1 1

Q9.Mydentalhygieneeducationexposedmetoavarietyofpracticeen-vironmentsavailabletomeasadentalhygienist

Exposuretoal-ternativepractice

settings2 2 0 2

Q10.Mydentalhygieneeducationpreparedmewellforpracticeenviron-mentsoutsideoftheprivatepracticedentaloffice


0 4 2 0

TableI:Respondents’FrequencyofAgreementorDisagreementtowardSurveyState-mentsQuestionandtheTopicsforEachQuestion

mal,2participantsweregreatlyimpactedbecausetheywereabletowitnesstheneedsofunderservedpatientsbeingmet.Theyfeltwitnessingachangethey couldmake first hand,wasmuchmore lifechangingthanreading it ina textevercouldbe.Theybothcreditedthisasakeymomentindefin-ingtheircareerchoices.

The final open-ended question was: “Pleaseexplainwhatyoufeelwouldhavebeenhelpful inyourdentalhygieneeducationthatcouldhavebet-terpreparedyou foryourcurrentcareerpracticechoice.”Ofthe6participants,4stressedthatbusi-ness training should be added to dental hygieneeducation to prepare students for independentpractice.Theystatedfinancial,legal,businessplan


DiscussionDental hygiene practice possibilities have

changed inMainewith the advent of IPDH. Stu-dentsinMainehavethiscareeroptionavailabletothem;however,theparticipantsinthissurveysug-gestalackofpreparationfromtheircurrentden-talhygienecurriculum.Theparticipantsdescribedtheiroveralldissatisfactionwithalternativecareerexperiencesduringtheirdentalhygieneeducation.Whiletheydidfeelpreparedbytheirbasicdentalhygiene program for traditional private practice,theydidnotfeelwellpreparedfortheirchosenca-reerpathasIPDHsandwerenotgivenampleop-portunitytoexplorealternativepracticesettings.

MainedoesnotrequireadditionaleducationpriortoIPDHlicensure;however,allparticipantsagreedfurthertrainingisnecessary.Somestatesrequiretrainingpriortoalternativepracticelicensure,butforthosewhodonot,wheredoestheresponsibilitylie?ADEAandADHAsuggestdentalhygienepro-gramsevolve tomeet thechangingneedsof theprofessionandthisincludespreparingstudentsforall opportunities available to them as dental hy-gienists.

Better preparation could be accomplished byaddingelectivecoursesandexperiencesdesignedto educate, inspire andmotivate the student in-terestedinalternativedentalhygienepractice.Ad-ditionalcoursesshould includebusiness,commu-nication,andadditional training identifyingneeds

creation and marketing were areas of owning abusinesstheywishedthey’dbeenbettertrainedin.Twoparticipantssaidcommunicationskillsshouldbeagreaterpartofdentalhygieneeducationpro-grams.Interpersonal,interprofessionalanddentalteamcommunicationskillswerenotedasimportantcomponents of a successful independent practicebusiness.One participant specified that empathyand compassion training is necessary because inalternativesettingsaclinicianismorelikelytoen-counterdifficultsituationsandbeingabletohandlethese with finesse would facilitate better patientcare.

One respondent felt strongly that a better un-derstandingof treatmentand referralprocedureswasnecessaryforthosedentalhygienistspractic-ing independently. When working alone, relyingonotherdentalprofessionalsintheofficetohelptreatmentplan,refer,andguidewouldnotbeanoption.Therefore,havingagoodunderstandingofwhentorefertoadentistformoretreatmentbe-yondthescopeoftheIPDHpracticeisnecessarytooptimizepatientcare.

which are beyond the dental hygiene scope ofpracticeforreferrals,aswellasincreasedexposuretoalternativepracticesettingsthroughextramuralinternshipopportunities.

When discussing exposure to alternative prac-tice settings, participants felt extramural intern-ships/experiences, and exposure through public/communityhealthclassdiscussionswerethemostimpactfulexperiencestheyengagedinduringtheireducation; yet this exposure was minimal. Thisstudydemonstratesanappreciationanddesirebystudentsinterestedinpublichealthdentalhygieneto have programs with curriculum that nurturesand grows the extramural internship experience.Oneparticipantsuggestedthatextramuralexperi-encesshouldincludeavarietyofpopulationsandnotbelimitedtochildrensothestudentmaygainabroaderunderstandingofthemultitudeofunder-servedpopulations.

Further suggestions for educational programsemerged during the open-ended questions. Al-though extramural internshipswere identified byrespondentstocreatethemostexposuretopublichealthpracticesettings,exposuretopublichealthsettings couldalsobeaccomplished in theclass-room.Studentscouldresearchvariousunderservedpopulations andways tomeet their needs.Oncestudents have identified a population of interest,theycouldcreateabusinessplanthatwouldpre-pare them for future career prospects. Speakerscouldbeinvitedintotheclassroomtodiscusstheirownpersonalexperiencesinalternativedentalhy-gienepositions.Thiswouldbringrealityandcreatehumanconnectiontoalternativepracticesettings.This would differ from the traditional communityhealthcoursebyemphasizingthecareeropportu-nity aspect of alternative settings as opposed tothepublichealthcomponent.

Participants felt elective courses should be of-feredtostudentsplanningtopracticeindependent-ly.Shadowingvariousdentistsandofficemanage-ment for one semester togainbetter knowledgeof all aspects of dentistry was suggested. If adentalhygieneschoolhasconnectionswithaden-talschool, thereshouldbeampleopportunity fordentalanddentalhygienestudentstocollaborate,integrateand learnfromeachother inamutual-ly beneficial classroom/clinical/long-term care orhospitalsetting.

A communications elective including skills forcommunicatingwithbothotherprofessionalsandpatientswasalso suggested.Oneparticipantde-scribedtheirjobduties“inthefield”asmorecom-municativethanclinical.Itwasreportedthatmore


ConclusionThis study demonstrated that participants did

not feel thecurrent levelofdentalhygieneedu-cational programs fully prepared them for theircareerchoice.Meetingtheneedsofstudentsnow

time is spent educating patients, caregivers andworkingwithotherhealthcareprofessionalsthanproviding clinical services. Therefore, having ad-vancedcommunicationtrainingwouldbeideal.

Participantsalsofeltelectivecourseworkinbusi-nesswouldgreatlybenefitthosewishingtoengageinentrepreneurialbusinessownership.Thiswouldalsobeanopportunityfor interprofessionaltrain-ingbyallowingdentalhygienestudentstopartici-pateinabusinesscoursewhichisgearedtowardthehealthcareprofessional.

Alimitationofthisstudywasthatrecentgradu-ateswiththemostcurrentinformationaboutstu-denteducationexperiencesarenoteligibleforIPDHlicensureuntilacquiringaminimumof2yearsofdentalhygieneexperience.Anotherlimitationwasthatonly6practicingIPDHsgraduatedsince2000.Althoughtheyallagreedtoparticipate,thenum-ber of responses was limited alongwith the op-portunity for randomselection. It should also benotedthat3oftheparticipantsgraduatedpriortoIPDH legislationpassing in theStateofMaine inMay2008.

Continued research using this survey can beusedtoexpandthenumberofparticipantsinMaineandextend tootherstateswithalternativeprac-ticelicensure.Expansionoftheresearchisimpor-tantasmore relevant informationwill surfaceasIPDHswhograduated following theenactmentofIPDH legislation are licensed.Additional researchshould be done to determinehow current dentalhygieneprogramsaremeetingthechangingneedsofMaine’sDentalHygienescopeofpractice.

AcknowledgmentsIwouldliketothankmyfamilyfortheirsupport,

understanding,andpatienceduringthisresearch.Manythanksgotomyco-authorsandtheIndepen-dentPracticeDentalHygienistswhoparticipatedinthissurvey.IwouldalsoliketothankTalineDadianInfante,EdD,RDH,forsparkingtheinitialinspira-tionforthisresearchthroughaclassproject.Shewillbesadlymissed.

includesthosestudentswhowillonedaypracticeindependentlyoutsidetheprivatedentalpractice,or in alternative settings. The responsibility topreparestudents forbusinessownershipand in-dependentpracticemaynotlieentirelywithinthebasicdentalhygienecurriculum,butasthefieldofdentalhygienechangessodramatically,thereis a responsibility for programs to adjust theirmethods toalignwith theseemergingpriorities.Thisstudyshallserveasthebeginningofthecon-versation,notthecompleteanswer,northeend.It does not provide all the answers, but it doesidentifyadeficitandbegintodiscussthechangesnecessarytomeettheneedsofgraduates.

Courtney E. Vannah, MS, IPDH, is a Visiting As-sistant Professor at the University of New England Portland, Maine and graduate of the University of Texas Health Science Center San Antonio. Martha J. McComas, RDH, MS, is a Clinical Assistant Pro-fessor in the Department of Periodontics and Oral Medicine, Division of Dental Hygiene, University of Michigan. Melanie V. Taverna MS, RDH, is an As-sistant Professor/Clinical Faculty, Department of Periodontics, Division of Dental Hygiene, Univer-sity of Texas Health Science Center San Antonio. Beatriz M. Hicks, MA, RDH, is a Clinical Associate Professor at the University of Texas Health Sci-ence Center San Antonio. Rebecca A. Wright MS, RDH is an Assistant Professor at the University of Texas Health Science Center San Antonio.


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5. RovinS,NashJ.Traditionalandemergingformsofdentalpractice cost, accessibility, andqual-ityfactors.Am J Public Health.1982;72(7):656-662.

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8. FreedJR,KushmanJE,PerryDA.Practicechar-acteristics of dental hygienists operating inde-pendently of dentist supervision. J Dent Hyg. 1996;70:194-205.

9. Reitz M, Jadeja R. The collaborative prac-tice of dental hygiene. Int J Dent Hygiene. 2004;2(1):36-39.

10. NaughtonDK.Thebusinessofdentalhygiene-Apracticeexperienceinnursinghomes.J Dent Hyg.2009;83(4):193-194.

11. Dentalhygienefocusonadvancingtheprofes-sion.AmericanDentalHygienistsAssociation[In-ternet].[cited2013January15].Availablefrom:http://www.adha.org/resources-docs/7263_Fo-cus_on_Advancing_Profession.pdf

12. ADEApolicystatements:Recommendationsandguidelinesforacademicdentalinstitutions(Withchangesapprovedbythe2012ADEAHouseofDelegates).J Dent Ed.2012;76(7):916-928.

13. MertzE,GlassmanP.Alternativedentalhygienein California: Past, present and future. J Calif Dent Assoc.2011;3(1):37-46.

14. Battrell AM, Gadbury-Amyot CC, OvermanPR. A qualitative study of limited access per-mit dental hygienists in Oregon. J Dent Ed. 2008;72(3):329-343.

15. AstrothBD,Cross-PolineGN.PilotstudyofsixColoradodentalhygieneindependentpractices.J Dent Hyg.1998;72(1):13-22.

16. BeachMM,ShulmanJD,JohnsG,etal.Assess-ing theviabilityof the independentpracticeofdentalhygiene-Abriefcommunication.J Public Health Dent.2007;67(4):250-254.

References


Dental hygiene supervision is de-finedasdirect,generalordirectaccessanddeterminedbystatepracticeactlaws.Althoughdifferent states allowavarietyofproceduresandpossiblelimitations ondental hygiene servic-es,theAcademyofGeneralDentistryand theAmericanDentalHygienists’Association define direct supervisionas“thedentistneedstobepresenttoprovideservices,”generalsupervisionas“thedentistneedstoauthorizepri-ortoservices,butneednotbepres-ent”anddirectaccessas“thedentalhygienist canprovideservicesasheor she determines appropriatewith-outspecificauthorization.”1,2Theden-talhygieneprofessiondoesnothavecommon national standards regard-ingpracticerestrictionsandthelevelofdentalsupervisionthatisrequiredtoprovidedentalcaretopatientspro-fessionally.Somestatesrequiredirectsupervisionbyadentist,whichman-datesthatadentist isontheprem-iseswhile dental hygienepreventivecare is being provided. Some statesrequire general supervision, whichrequires that the dentist authorizedental hygiene procedures. Generalsupervision,however, isdifferent foreach state and varies depending onstate practice act language. For in-stance,dentalhygienistsmaybelim-ited to a set number of days annu-allywithoutdentistsupervision.Thirtyfivestatesallowdentalhygieniststopracticeunder less restrictivesuper-vision laws.Unsuperviseddentalhy-gienecaregivenincertainsettingsoutsidethedentalofficeistermeddirectaccess.3Todate,therearenostudiesthathaveexaminedifthereisadifferenceinregistereddentalhygienecompensationoraveragesalaries. Therefore, this studyexamined the3dif-ferentlevelsofdentalsupervisionthatarerequiredwithintheU.S.

AComparisonofDentalHygienists’SalariestoStateDentalSupervisionLevelsAprilCatlett,RDH,BHSA,MDH,PhD

AbstractPurpose:Thepurposeofthisstudyistoevaluatetheeffectofdentalsupervisiononregistereddentalhygienists’salariesinthe50statesandDistrictofColumbiabycomparingtheaverageden-talhygienesalariesfromthelargestmetropolitancitywithineachstatefromMay2011,themostrecentvaliddata,inrelationtotherequiredlevelofdentalsupervision.Methods: A retrospective contrasted-group quasi-experimentaldesignanalysiswasconductedusingthemostcurrentmeandentalhygienesalariesforthelargestmetropolitancitywithineachstateandtheDistrictofColumbiawhichwasmatchedtotheappropri-atedentalsupervisionlevel.Inaddition,adentalassistingsalarycontrolgroupwasutilizedandcorrelatedtotheappropriatedentalhygienistsalaryinthesamemetropolitancityandstate.SampleswereobtainedfromtheU.S.DepartmentofLabor.Amultivariateanalysisofvariance(MANOVA)statisticalanalysiswasutilizedtoassesstherelationshipofthe5levelsofdentistsupervision,withtheregistereddentalhygienistsalaries.TheMANOVAanalysiswasalsoutilizedtoassessthecontrolgroup,dentalassistantsalaries.Results: Nostatisticallysignificantresultswerefoundamongthedentalsupervisionlevelsonthemeasuresofdentalhygienesala-riesanddentalassistantsalaries.Wilks’sΛ=0.81,F(8,90)=1.29,p=0.26.Analysesofvariances(ANOVA)onthedependentvari-ableswerealsoconductedasfollow-upteststotheMANOVA.Conclusion:Studyresultssuggestdentalhygienistswhoarere-quiredtohaveadentistonthepremisestocompleteanydentaltreatmentobtainsimilarsalariestothosedentalhygienistswhoareallowedtoworkinsomesettingsunsupervisedbyadentist.Therefore,dentalsupervisiondoesnotseemtohaveanimpactondentalhygienists’salaries.Keywords:dentalhygienesalaries,supervisionlevel,accesstodentalcare,autonomyThisstudysupportstheNDHRApriorityarea,Health Promotion/DiseasePrevention:Identify,describeandexplainmechanismsthatpromoteaccesstooralhealthcare,e.g.,financial,physical,transportation.

Research

Introduction

Methods and MaterialsThisresearchstudyutilizedaquasi-experimental

designwhichusedacontrast-groupasamethodtocontrol internal validity.4 Thisdesignallows regis-tereddentalhygieniststobeassignedasmembersofseparatecategoricalgroups(directlysupervised,generallysupervisedanddentalhygienistsallowed


directaccesstopatients).4ThemeandentalhygienesalariesforeachmetropolitancityandtheDistrictofColumbiawerematchedtotheappropriateden-talsupervisionlevelthatis legalforitsstate.Thedentalassistingsalarycontrolgroupswerecorre-latedtotheappropriatedentalhygienesalaryinthesamemetropolitancityandstate.Sincedatacouldnot be randomly assigned, a quasi-experimentaldesignwasusedwhichallows for theselectionofrandomsamplesfromthepopulationwhichishowthesampleswereobtainedbytheU.S.DepartmentofLabor(USDL).4,5

Inorder toaddressthedifferences in thestatelevels of dental supervision for dental hygienists,additional categories of the independent variablewereaddedtothestudy.Theresultsofthisadditionleadto5independentvariables,whichare:6

• DirectSupervision• DirectSupervisionwithsomeGeneralSupervi-sionproceduresallowed

• GeneralSupervision• Direct Access with some General Supervisionproceduresrequired

• DirectAccess

Thesupervisionlevelsforadentalprophylaxiswereplacedinanordinalscaleaccordingtothelevelofrequired dental supervision for dental hygienistsas determined in each state dental practice act.Mean salaries were selected from a metropolitancitywithineachstateandtheDistrictofColumbiain order to standardize the statistics since statescanhaveasubstantialvariationinsize,populationandnumberofruralareas.Inaddition,meandentalassistantsalariesfromthesamemetropolitancityandtheDistrictofColumbiawereusedasacontrolgroupsincedifferentareasoftheU.S.havediffer-entcostoflivinglevels.7

UsingSPSSsoftware,amultivariateanalysisofvariance(MANOVA)procedurewasusedtoassesstherelationshipoftheindependentvariables,whicharethe5levelsofdentalhygienesupervision,withadependentvariable,thedentalhygienists’salariesandthecontrolgroupofdentalassistants’salaries,byconductingbetween-subjectanalyses.8Inordertoreducethepossibilityofvariableerrors,there-search design included a parallel-forms techniquethat ensured that the datawas entered correctlywhichwascompletedbyperformingthetesttwiceonthesamevariablesandcorrelatingtheresultstoensureaccuracy.4

The sample of May 2011 registered dental hy-gienists’anddentalassistants’wageswereobtainedthroughtheUSDLStateOccupationalEmployment

andWageEstimates(OES)website.9Thestatemet-ropolitancitiesusedforeachsamplewerelocatedandobtainedfromtheUSDLwebsitebasedonpop-ulationsizeinordertoobtainsimilar-sizedcitiesforthestudy.Thelevelofrequireddentalhygienesu-pervisionforeachsamplestatewasobtainedfrom2chartsdevelopedbytheAmericanDentalHygien-ists’AssociationandtheAcademyofGeneralDen-tistry.1,2TheUSDLbiannuallymailstheOESsurveyto sampled employers, which measures employ-mentandwageratesevery6months inMayandNovember.9TheOESsurvey is fundedby theBu-reauofLaborStatistics(BLS),whichalsoprovidesthe procedures and technical support, while theStateWorkforceAgencycollectsmostofthedata.9 EachOESsurveyestimatesarebasedonresponsesfrom the previous 6 semiannual surveys that arecollectedovera3yeartimeframe.Theoverallna-tionalresponserateforthe6semiannualsurveysis73.3%foremploymentandwages.9

TheOESsurveyobtaineditssamplingfromstateunemployment insurancefiles for theUSDLStateOES.9TheOESsurveysampleisstratifiedbymetro-politanandnon-metropolitanareas,industries,andsize.9AccordingtotheUSDL,largeremployersandestablishments aremore likely to be selected forparticipationinthesurveythansmalleremployersandestablishments.9However, inthefieldofden-tistry,quotasamplingisnotavalidityfactor,since176,670(96%)ofalldentalhygienistsand296,810(92%)ofalldentalassistantsintheU.S.areem-ployedbyaself-employeddentistinadentaloffice.9

OESreceiveswagedatain12intervalsforeachoccupation.Sampledemployersareaskedtoreportthenumberofemployeespaidwithinaspecificwageintervalbybothhourlyratesandthecorrespondingannualrates.9Theannualrateiscalculatedbymul-tiplyingthehourlywagerateby2,080hours.9 The 6 surveysamplethatisobtainedforeachoccupationallows for theproduction of estimates at detailedlevelsofoccupationandlocation.Significantreduc-tionsinsamplingerrorsareobtainedbycombiningthe6surveysofdataforeachoccupationbyupdat-ingthe5previoussurveystothecurrentsurvey’sreference period according to the averagemove-mentofitsbroaderoccupationaldivision.9

Thereisapproximatelya20%non-responseratetotheOESsurveyevery6months.9Non-responsescanbeattributedtopeoplewhoareill,those“notfound”(whichcanincludepeoplewhohavemovedorwhoare inaccessible)and“refusals”(which in-clude people who refuse to cooperate or answerthe survey).9 Therefore, a “nearestneighbor” im-putationprocedureisusedtocreditmissingoccu-pationalemploymenttotalsandavariantofmean


MetropolitanCity,State EmploymentSizeofDentalHygienists

DentalHygienistsMeanSalary

SupervisionLevelforProphylaxis

Birmingham,Alabama 840 44,410 DAnchorage,Alaska 210 84,300 G/APhoenix,Arizona 2,200 80,470 G/ALittleRock,Arkansas 360 59,650 G/ALosAngeles,California 4,280 93,130 G/ADenver,Colorado 1,940 77,660 AHartford,Connecticut 940 77,090 G/ADover,Delaware 100 70,170 GDistrictofColumbia 2,700 90,500 GMiami,Florida 1,150 49,660 G/AAtlanta,Georgia 2,830 70,020 DHonolulu,Hawaii 770 66,500 D/GBoise,Idaho 630 68,420 GChicago,Illinois 5,620 62,250 GIndianapolis,Indiana 1,040 71,350 D/GDesMoines,Iowa 450 67,300 G/AWichita,Kansas 370 64,350 G/ALouisville,Kentucky 540 59,340 G/ABatonRouge,Louisiana 320 52,150 D/GPortland,Maine 440 74,260 G/ABaltimore,Maryland 1,200 73,940 GBoston,Massachusetts 4,310 78,510 G/ADetroit,Michigan 1,120 65,810 G/AMinneapolis,Minnesota 2,820 72,480 G/AJackson,Mississippi 230 47,910 DSaintLouis,Missouri 1,630 70,870 G/A

TableI:MeanDentalHygienistSalariesinMay2011andStateDentalSupervisionLev-elsforaDentalHygieneProphylaxis(PartI)

Note:TableIadaptedfromUSDL5andAmericanDentalHygienists’Association.2

imputationiscompletedtocreditmissingwagedis-tributions.9Thesampledemployersareweightedtorepresentallemployersofanoccupation foreachsurveyperiod.WeightsareadditionallyadjustedbytheratioofemploymenttotalsfromtheBLSQuar-terlyCensusofEmploymentandWagestoOESsur-veyemploymenttotalsbytheUSDL.9

Thisstudyexaminedthedentalhygieneandden-talassistantsalariesfromametropolitancitywithinall50statesandtheDistrictofColumbiafromthiscollectedUSDLdata.Eachsampleofdentalhygien-ists and dental assistants consisted of a samplelarger than30participants toensurevalidity.ThesmallestsamplesizeofdentalhygienistsanddentalassistantswerebothinCheyenne,Wyomingwithasamplesizeof80dentalhygienistsandasample

sizeof110dentalassistants(TableI).7 The number ofstateswithDirectSupervisionhad3samples,theDirect/GeneralSupervisionhad5samplesandtheDirectAccessSupervisionsamplesizecontained1sample.Thesesmallsamplesizescouldhaveaffect-edthestatisticaltestresults.AMANOVAwascon-ductedtodeterminetheeffectofdentalsupervisiononthe2dependentvariables,thedentalhygienists’anddentalassistants’salariesfor50metropolitancitieswithineachstateandtheDistrictofColumbia.

ResultsWith a 97.5% confidence level, non-significant

differenceswerefoundamongthedentalsupervi-sion levels on the 2 dependentmeasures, dentalhygienists’ and dental assistants’ salaries, Wilks’s


DiscussionThesestudyresultsshowthatasdentalhygien-

ists’ mean salary increased and decreased, thecontrol group (dental assistants’ mean salary)

MetropolitanCity,State EmploymentSizeofDentalHygienists

DentalHygienistsMeanSalary

SupervisionLevelforProphylaxis

Billings,Montana 200 68,930 G/AOmaha,Nebraska 380 68,280 G/ALasVegas,Nevada 850 87,110 G/AManchester,NewHampshire 110 76,850 G/ANewark,NewJersey 1,180 82,410 D/GAlbuquerque,NewMexico 510 73,560 G/ABuffalo,NewYork 1,120 51,450 GCharlotte,NorthCarolina 1,340 68,320 D/GFargo,NorthDakota 240 50,330 GCincinnati,Ohio 1,380 64,900 G/AOklahomaCity,Oklahoma 650 58,400 GPortland,Oregon 1,970 80,760 G/APittsburgh,Pennsylvania 1,840 52,660 G/AProvince,RhodeIsland 1,100 72,470 G/AColumbia,SouthCarolina 460 57,170 GSiouxFalls,SouthDakota 140 58,730 GMemphis,Tennessee 620 63,260 GDallas,Texas 2,910 74,530 G/ASaltLakeCity,Utah 950 67,800 GBurlington,Vermont 150 71,540 G/AVirginiaBeach,Virginia 930 73,310 G/ASeattle,Washington 2,660 94,000 G/ACharleston,WestVirginia 230 52,720 G/AMilwaukee,Wisconsin 1,300 60,550 G/ACheyenne,Wyoming 80 67,160 G

TableI:MeanDentalHygienistSalariesinMay2011andStateDentalSupervisionLev-elsforaDentalHygieneProphylaxis(PartII)

Note:TableIadaptedfromUSDL5andAmericanDentalHygienists’Association.2

Λ=0.81, F(8,90)=1.29, p=0.26. Analyses of vari-ances (ANOVA) on the dependent variables wereconductedas follow-up tests to theMANOVA.Us-ing the Dunnet-Bonferronimethods, each ANOVAwas tested at the 0.025 level. Post hoc tests didnotshowasignificantdifferencebetweenthedentalhygienists’salariesorthedentalassistants’salarieswithp>0.05.TableIIshowsthatthemeandentalhygienists’ salary increased and decreased corre-spondinglytothecontrolgroupofdentalassistantsalarymeans.

alsoincreasedanddecreased.Althoughthemeansalaries for dental hygienists increased as thelevelofdentalsupervisiondecreased, itappearstobeassociatedwiththecostoflivingsincethecontrolgroup’smeansalariesfordentalassistantsraised and lowered at a similar percentage rate(TableII).

EmploymentisdefinedbytheUSDLasthenum-berofworkerswhocanbeclassifiedasfull-timeorpart-timeemployees,includingworkersonpaidvacationoranyothertypeofpaidleave.9In2010,approximately 38% of dental hygienists workedfull time.5AccordingtotheUSDL,therewereap-proximately184,110dentalhygienistsemployedintheU.S.inMay2012,withthemajorityofthemworkinginmetropolitanareas.5Adistinctivefea-


ConclusionThisstudysuggeststhatthereisnosignificant

difference between compensation salaries be-tween dental hygienists who work under directsupervision,generalsupervisionordirectaccessstatepracticeacts.Practicalcontributionsforthisstudyincludeatentativeempiricalgeneralizationthatwillneedtobefurtherinvestigatedbyfuturestudies. This studymaybeof interest to dentalpersonnelandlawmakersintheU.S.whoarecon-cernedinhowdentalsupervisionlevelsmayaffectdentalhygienistcompensationsalaries.

April Catlett, RDH, BHSA, MDH, PhD, is the pro-gram chair of the Central Georgia Technical Col-lege Dental Hygiene Program.

SupervisionLevel NumberofStateswithSupervisionLevel

AverageDentalHygieneSalaries(Differencefrom

PreviousLevel)

AverageDentalAssistantSalaries(ControlGroup)

(DifferencefromPreviousLevel)

Direct 3 $54,113(N/A) $32,493(N/A)Direct/General 5 $68,146(+1.28%) $35,124(+1.08%)General 13 $64,583(-0.95%) $33,349(-0.95%)General/Access 28 $71,360(+1.10%) $35,468(+1.06%)DirectAccess 1 $77,660(+1.09%) $40,580(+1.14%)

TableII:SPSSMeanComparisons

ture of dental hygiene employment is a flexibleschedule.Morethanone-halfofalldentalhygien-istsworkparttimeforonlyafewdaysaweekandmany dental hygienistswork formore than onedentistweekly.5

When trying to determine a cause-and-effectrelationship between dental hygienists’ salariesand supervision levels,manyother factorsneedtobe taken intoconsideration.Forexample, re-cent legislationexpanding the roleofdentalhy-gienistsinseveralstatesmaybeincreasingdentalhygienesalariesintheseareas.Inaddition,therehas been a pronounced geographic shift in theAmerican population with southern andwesternstates increasing in population and the numberoforalhealthpersonnelwhichmaybeincreasingthe health care salaries in these areas.10 There has also been a recent increase in the numberof mobile and teledentistry services brought toareaswhere there is a need for dental servicesinunderservedareas in recentyearswhichmayalsobeaffectingdentalhygienesalaries.11Thesefactorsmaybecausingahigherdemandforreg-istereddentalhygienistswhichcanbeincreasingsalaries.11Similarly,astudyin1991involvingreg-isterednursesshowedthat increasingwages in-creasedthesupplyofindividualswhowereavail-ableinthelabormarket.11However,manydentalhygienists arenow choosing toworkpart-time.5 And with dental hygiene being predominantly afemaleprofessionsimilartonursing,thepresenceof childrenmaybedecreasing theprobabilityofworking full-time as a registered dental hygien-ist.11 All of these factors need to be taken intoconsiderationwhenlookingattherelationshipbe-tweendentalhygienesalaries,thelevelofdentalsupervision,andthemeandifferencesthatwere

assessed for analysis rather than a correlationanalysis.

The relationship between salaries and super-vision levelscannotbeexpressedbyauniversallawbecausenoteverycaseofachange inden-talsupervisionlevelwillbringaboutachangeindentalhygienesalary level.4Thesestudyresultscanonlysuggest that there isahighprobabilitythatalargepercentageofcasesinvestigatedledto these results because they are derived fromprobabilisticgeneralizations.4Themajorlimitationofprobabilisticgeneralizationsisthatconclusionsabout specific casescannotbedrawnwith com-pletecertainty.4Therefore,theseresultswillonlyprovideprobabilisticgeneralizationsandthereareotheraspectsofdentalsupervisionlevelsforden-talhygieniststhataremoreimportantsuchasac-cess to preventive dental care for the poor andunderservedpopulationswithintheU.S.thatarenotaddressedinthisstudy.4


1. Dental hygienist duties by state. Academyof General Dentistry [Internet]. 2012 [cited2013 February 11]. Available from: http://www.agd.org/files/webuser/website/advocacy/dentalhyg.-asst.pdfdocs/dental%20hygien-ist%20duties%20by%20state%20%282%29.pdf

2. Dentalhygienepracticeactoverview:Permittedfunctionsandsupervisionlevelsbystate.Amer-ican Dental Hygienists’ Association [Internet].2013[cited2013February10].Availablefrom:http://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf

3. Access tocarepositionpaper,2001.AmericanDentalHygienists’Association[Internet].2012[cited2013February11].Availablefromhttp://www.adha.org/profissues/access_to_care.htm

4. Frankfort-Nachmias C, Nachmias D. Researchdesigns:Cross-sectionalandquasi-experimen-taldesigns.In:Researchmethodsinthesocialsciences. 7th ed. New York: Worth. 2008. p.184-216.

5. United States Department of Labor. Work en-vironment:Dentalhygienists.Bureauof LaborStatistics.2012.

6. Burkholder G. Sample size analysis for quan-titative studies. Walden University [Internet].[cited 2013 February 10]. Available from:https://class.waldenu.edu/bbcswebdav/institu-tion/USW1/201310_01/XX_RSCH/RSCH_8200/Week%206/Resources/Resources/embedded/Sample_Size_Analysis.pdf

7. UnitedStatesDepartmentof Labor.May2011stateoccupationalemploymentandwageesti-mates.BureauofLaborStatistics.2012.

8. Green SB, Salkind NJ. One-way multivariateanalysisofvariance.In:UsingSPSSforWindowsand Macintosh: Analyzing and understandingdata.6thed.UpperSaddleRiver,NJ:Pearson.2011.p.222-231.

9. United States Department of Labor. Technicalnotes forMay2011OESestimates.BureauofLaborStatistics.2012.

10. MasonA.Demographicdividends:Thepast,thepresent,andthefuture.In:PopulationChange,LaborMarketsandSustainableGrowth:Towardsa New Economic Paradigm (Contributions toEconomic Analysis). United Kingdom: EmeraldGroupPublishingLimited.2007.p.75-98.

11. MahoneyCB.Thelaborsupplyofnurses:Aself-selection approach - University of Minnesotadoctoral dissertation. Open Library [Internet].1991[cited2013February11].Availablefrom:https://openlibrary.org/works/OL12268527W/THE_LABOR_SUPPLY_OF_NURSES_A_SELF-SE-LECTION_APPROACH

References


Musculoskeletal disorders (MSD)areasignificantproblemfortheden-tal profession.1,2 A high prevalence(64 to96%)ofdentalprofessionalsreport having musculoskeletal painordiscomfortina12monthperiod,indicating that much of these MSDare work related.3-7 General prac-tice dentists commonly experiencepainintheback(35to60%),wristsandhands(34to54%),neck(20to57%)andshoulders(21to53%).8-11 Dentalhygienistsoftendemonstratehigherprevalenceforthesesamere-gions:wristsandhands(64to70%),shoulder (60 to 68%), neck (54to 69%) and back (24 to 67%).4,6,8 Variationinthesereportedratesbe-tween studies may result from dif-ferent data collection techniques ordifferentoccupationalresponsibilitiesaroundtheworld.1,2Ofparticularfo-cusisthefindingofahighprevalenceof pain in the wrists and hands ofdental hygienists. Previous researchhas revealed that dental hygienistshaveoneofthegreatestrisksofde-velopingtheMSDcarpaltunnelsyn-drome (CTS) compared with otherprofessions,12with7to8.4%receiv-ingtheclinicaldiagnosisofCTSand44.2%displayingatleastonesymp-tomofCTS.4,13,14EvidenceshowsthatCTS and other MSD cause signifi-cantimpactondentalhygienistsandmay leadtoreducedproductivityorperformance, or even to decreasedworkinghoursandchangeofprofes-sion.5,13

Theincidenceandlocationofpainmatchfindingsofarecentstudywhichrecordedsignificantphysicalworkloadintheneck,shouldersandwrists/handsofdentalhygienistsperformingtheirregularduties.15

ComparisonofCordedandCordlessHandpiecesonForearmMuscleActivity,ProcedureTimeandEaseofUseduringSimulatedToothPolishingGayleMcCombsRDH,MS;DanielM.Russell,PhD

AbstractPurpose:Dentalprofessionalssufferfromahighprevalenceofwork-relatedmusculoskeletaldisorders(MSD).Dentalhygienistsinpar-ticularhaveahighprevalenceofpainintheforearmsandhands.Theobjectiveofthisstudywastocompare1cordlesshandpieceto2cordedhandpiecesduringsimulatedtoothpolishingintermsofthemuscleloads(recordedaselectromyography(EMG)activity),dura-tionofpolishingprocedure,anddentalhygienistopinionabouteaseofuse.Methods:EMGwasusedtoquantifymuscleelectricalactivityof4forearmmuscles during simulated dental polishingwith 2 cordedhandpieces(HP-AandHP-B)and1cordlesshandpiece(HP-C).Acon-veniencesampleof30dentalhygienists(23to57yearsofage)with1to20+yearsofclinicalpracticeexperiencecompletedthestudy.Eachparticipantspentapproximately5minutespolishing3predeter-minedteethineachofthe4quadrants.Thesequenceofthehand-pieceswasrandomlyassigned.Attheendofthestudy,participantscompletedasubjectiveenduserevaluationofhandpiecepreference.Results: Muscleactivitylevelsof10th,50thand90thpercentilesdidnotdiffersignificantlybetweenthe3handpiecestested(p>0.05).However, totalmuscleworkload (integrated EMG)was lowest forthecordlesshandpiece(HP-C),butthiswasonlysignificantly lessthanHP-A(p<0.05).Polishingusingthecordlesshandpiece(HP-C)(M=257seconds,SD=112seconds)tooksignificantlylesstimethaneithertheHP-Acorded(M=290seconds,SD=137seconds)orHP-Bcorded handpiece (M=290 seconds, SD=126 seconds) (p<0.05).Overall,50%ofthestudyparticipantspreferredthecordlesshand-piece,37%preferredHP-Aand13%preferredHP-B(p<0.05).Conclusion:Useofthecordlesshandpiecereducedthedurationofpolishing,whichinturnledtolesstotalmuscleactivity,butnotmuscleintensity.Overall,dentalhygienistspreferredthecordlesshandpiece.Keywords:ergonomics,cordlesshandpiece,musculoskeletaldisor-ders,MSD,EMGThisstudysupportstheNDHRApriorityarea,OccupationalHealthand Safety: Investigatetheimpactofexposuretoenvironmentalstressorsonthehealthofthedentalhygienist(aerosols,chemicals,latex,nitrousoxide,handpiece/instrumentnoise).

Research

Introduction

Holding instruments at a patient’smouth and farfromthedentalhygienist’sownbodyplaces largeforcemomentsattheshoulders,whileleaningtheheadortorsoawayfromaneutralpositionincreas-


Methods and MaterialsPracticing dental hygienists (n=30) of varying

agesand lengthofemploymentparticipated inaninstitutionalreviewboardapprovedcontrolledclini-caltrial.Participantswererecruitedbydistributionofaninvitationlettersenttolicenseddentalhygien-istsintheHamptonRoadsregion.Aninitialphonescreeningofinterestedindividualswasconductedtodetermineeligibility.Inordertocontrolforcertainlimitations, individuals with a dominant left handwere excluded, aswell as individualswith historyofsurgery,injuryordisabilityoftheworkinghand,wrist, forearm or shoulder, or diagnosis of CTS.Strenuousarmmuscleactivitysuchas tennisandchoppingwoodwereprohibitedfor2dayspriortodatacollectiontocontrolformusclestrains.Noat-temptwasmadetocontrolforvariationsinforearmmuscle size among participants. Each participantservedastheirowncontrol.Datawascollected inonevisit(lastingapproximately45minutes)attheDentalHygieneResearchCenteronthecampusofOldDominionUniversity.

Inasimulatedoralpolishingsetting,3lowspeedhandpieceswereevaluatedonforearmmuscleactiv-itythatreflectedloadorforceonthelowerportionofthearmandhand.Thehandpiecestestedwereasfollows:HP-A(corded),HP-B(corded)andHP-C(cordless)(Figure1).Themodelnames,handpiecemassesandgripdiametersarepresentedinTableI.

After informed consent was obtained and EMGequipmentwasconnected,eachindividualpolishedselectedteethusingall3handpieces,intheorderdetermined through simple randomization. Dentalchair-mounted typodonts (Kilgore International,Inc) equippedwith an artificial facewere used tosimulatetheoralcavity(Figure2).Foreachhand-pieceatypodont,dpaandprophypastewasprovid-ed.Eachtypodonthadartificialbrownstainplacedonthefacialandlingualsurfacesof3predeterminedteethineachquadrant(3,4,7,11,12,15,19,20,

es forcemoments at the neck and back, respec-tively.These forcemomentscanbeminimizedbyappropriatebodypostures.However,therepetitiveproceduresofhandscalingandtoothpolishingforapproximately21minutesofanaverage50minuteappointmentplacesalargeloadonthemusclesandtendons of thewrists and hands.16 Precisemove-mentsrequiredentalhygieniststoholdbodyposi-tionsandaccuratelycontrolthelocationandforceapplicationofdifferentinstruments.Ergonomicde-signimprovementstoinstrumentsholdthepromiseof reducing theworkloadonwristandhands,butresearchisneededtodeterminewhetherdentalin-strumentsachievethesegoals.

Currently,themostaccuratetechniquetoquanti-fymuscleworkloadofoperatingadentalinstrumentistorecordtheelectricalactivityofmusclesthroughelectromyography (EMG).15,17Electrodesplacedonthesurfaceof theskinoverthebellyofamuscledetectasummationoftheactionpotentials(smallvoltages produced when muscles are activated).The greater the voltage themore the underlyingmuscleisbeingactivatedtogenerateforce.Intensi-ty,durationandfrequencyofactivityareallimpor-tant considerations for the potential developmentofMSD.17RecordingEMGduringaprocedureallowstheintensityofmuscleworkloadtobedeterminedand the duration can also be readily measured.Thetotalmuscleactivityisdeterminedbyintensityx duration. By quantifying and comparing the in-tensity and duration of electrical activity betweendentaltoolswithdifferentdesigncharacteristics,re-searcherscandeterminewhich instrumentscausethegreatestorlowestmuscleload.Frequencyofaprocedurewouldbeexpected to remainconstant.Researchershavebeguntodeterminetherelevantergonomic factors in dental instruments by usingEMGtomeasureactivityofmusclesintheforearmwhichcontrolmovementsatthewrist,fingersandthumb.18Researchhasrevealedthatmirrors,whichare lightweightandhave soft andwiderdiameterhandles,reducemuscleloads.19Scalinginstrumentswithahandlediameterofatleast10mm,amassof15gorpossibly less,andaroundandtaperedshapeleadtothelowestactivityofmusclesoftheforearm.20,21However, there is stillmuch researchanddevelopmentofequipmentneededtoprovideoptimuminstrumentstominimizeworkrelatedMSDinthedentalprofession.

Oneergonomicconcerniswiththeuseofhand-piecesthatrequirehosesorcords.Hosesorcordsaddweighttoaninstrument.Theyalsocreatecorddragwhereadditionalresistancetomotionislikelyto increasemuscleworkloads.Whiledevelopmentoftheswivelhosemechanismhasgreatlyimprovedhandpiece ergonomics, the ideal handpiecewould

have the ability to easily rotate andmove effort-lesslywhileperformingthe intended function.Re-cent technological advances have allowed for thedevelopmentofcordlesshandpieces.Therefore,theobjectiveof thisstudywastocompare1cordlesshandpieceto2cordedhandpiecesduringsimulatedtooth polishing in terms of themuscle loads (re-cordedasEMGactivity),timeinvolvedtocompletestandard procedures and dental hygienist opinionabouteaseofuse.Studiessuchas thisprovideascientificapproachtodeterminingwhichergonomicfactorsreducemuscleloadsandhavethepotentialforreducingthe incidenceofworkrelatedMSDinthedentalprofession.


24,25,29,30).Thisexperimentalset-upprovidedasimulatedpolishingexperienceinallareasofthemouthandmaintainedconsistencyacrossthehand-piecestested.

Priortostudyinitiation,participantswerefamiliar-izedwithboththeEMGandpolishingequipment.Tostandardizepolishingprocedures,participantswereprovidedwithwrittenandoralinstructionsforneu-tralbodypositioningandwereinstructedtopolishallsurfacesofassignedteethutilizingtheirnormalpolishing procedures, thus applying typical pres-sureandtechniques.Eachindividualspentapprox-imately 5minutes polishingwith each handpiece,althoughnotimelimitswereplacedonparticipants.Tominimizetheeffectsoffatigue,participantswereallowedtorestfor1to2minutesinbetweenpolish-ingsequences.

Atthecompletionofthepolishingsessions,par-ticipantscompletedanevaluationofhandpiecedi-ametergrip,balance,maneuverability,weightandnoiselevel,utilizinga5-pointLikertscale(notcom-fortabletoverycomfortable),aswellasrespondedto5openedendedquestionsrelatedtohandpiecepreference.

Figure1:ExperimentalHandpieces

Fromlefttoright:CordedHP-A;CordedHP-B;CordlessHP-C(Dentsply,International,York,Penn.)

Figure2:SimulatedPolishingSetUp

Pictured:Mannequin,typodontandparticipantwithEMGelectrodesattachedtoskinover4musclesites forre-cordingelectricalactivityofmuscles.

HandpieceCode ModelName Corded/Cordless Mass(g) Diameter(mm)

HP–A MidwestRhino Corded 81(90°attachment) 22.7HP–B MidwestRDH Corded 77(motoronly) 23.3HP–C CordlessRDH Cordless 114 27.8

TableI:HandpieceSpecifications

DatasuppliedbyDentsply,International,York,Penn.

EMG Procedure

EMGwasusedtorecordtheelectricalactivityof4muscles(Figure2) involved inhighpinchforcesandstudiedinpreviousdentalresearch:flexordigi-torumsuperficialis, flexorpollicis longus, extensordigitorumcommunisandextensorcarpiradialisbre-vis.20,21Participantswashedtheirrightforearmwithregular soapandwarmwater to remove skinoilsandlotions.Thelocationforplacementoftheelec-trodeswasdeterminedusingstandardproceduresandthentheseareaswerewipedwithalcoholandallowedtodry.22NoraxondualAg/AgClsnapelec-trodes(Scottsdale,AZ),with1cmactiveareasand2cminter-electrodedistance,wereplacedoverthebellyofeachmuscleinparallelwiththedirectionofthemusclefibers.Agroundelectrodewasplacedonthe lateralepicondyleoftherightarm.Theactionpotentialsproducedbythemusclescreatevoltagesacrossthesurfaceelectrodeswhichflowalongcablestoatelemetryunitwhichthentransmitsthesignalat1,500HztoaNoraxonTeleMyo2400TG2wire-lessdataacquisitionsystem(Scottsdale,AZ).Thelocationoftheelectrodeswascheckedwithmusclefunctiontestsandchangesweremadeifnecessary.Theelectrodesandcablesbetween theelectrodes


ResultsThirtyfemalesubjectsbetweentheagesof23to

57years,withameanageof37.7years,completedthestudy.Allparticipantswereemployedatleast3fulldaysperweekandhadclinicalpracticeexperi-encebetween1to20+years:1to5years(30%),

andtelemetryunitwerefasteneddownwithnon-allergenictapetoavoid movement artifact. Oncethe EMG equipment was set upcorrectly,participantsperformedmaximum voluntary isometriccontractionsforeachmusclesep-arately,whichwererecordedfor3secondseach.Foreachhand-piece, EMG was recorded fromthebeginningtotheendofpol-ishing.The timeof theEMGre-cordwas the trial duration. Theraw EMG signals were rectifiedandfilteredusingasecondorderButterworthfilterwith10Hzhighpass cutoff frequency. The EMGwas integrated (area under thevoltage-time curve) to obtain ameasureof totalmuscleactivityacrossapolishingtrial.Datafromthepolishingtrialswasalsonor-malized by determining its per-centage of maximum voluntaryisometriccontractionsbeforede-termining the 10th,50thand90th percentile of the EMG signal foreachofthe3handpiecetrials.

Data Analysis

EMG measures, trial duration and quantitativesurveyresponseswereenteredintoSPSS19.EMGmeasuresandtrialdurationwereanalyzedusingre-peatedmeasuresmultivariateanalysisof variance(RMANOVA) with 3 levels of handpiece. Plannedsimplecontrastscomparedthecordlesshandpiecewith 2 corded handpieces. A chi-square test wasemployed to detect significant differences in pref-erencebetweenthehandpieces.Surveyratingsforhandpiecepropertiesofdiameter,balance,maneu-verabilityandweightwerecomparedbetweenthecordlessandthecordedhandpiecesusingWilcoxon

Muscle 10thpercentile 50thpercentile 90thpercentileHP-A HP-B HP-C HP-A HP-B HP-C HP-A HP-B HP-C

Flexordigitorumsuperficialis 7±5 7±5 7±5 13±8 13±8 13±8 25±17 24±17 24±15Flexorpollicislongus 12±6 11±6 11±6 20±10 19±9 20±9 32±17 32±19 32±16Extensordigitorumcommunis 10±4 10±3 10±4 17±5 17±5 17±6 27±8 26±8 27±8Extensorcarpiradialisbrevis 9±5 9±4 9±5 15±7 15±7 15±8 24±13 23±12 24±12

TableII:GroupMeanandStandardDeviationsfor10th,50thand90thPercentileLevelsofActivityfortheFlexorDigitorumSuperficialis,FlexorPollicisLongus,ExtensorDigitorumCom-munisandExtensorCarpiRadialisBrevisMusclesDuringPolishingWith3TypesofHandpiece

Valuesrepresentpercentageofmaximumvoluntaryisometriccontraction.Nosignificantdifferenceswerefoundinmuscleactivationbetweenthe3handpieces(p>0.05).

Figure3:IntegratedEMG(MeansandStandardDeviationEr-rorBars)ofthe4MuscleSitesforPolishingWiththe3Differ-entHandpieces(CordedHP–A,HP–BandCordlessHP–C)

IntegratedEMGistheareaundertherectifiedvoltage-time(V.s)curve,whichquantifiestotalmuscleactivity.The4musclesare:flexordigitorumsuperfi-cialis,flexorpollicislongus,extensordigitorumcommunisandextensorcarpiradialisbrevis.Thecordlesshandpiece(HP-C) resulted insignificantly lowerintegratedEMGfortheflexordigitorumsuperficialis,extensordigitorumcom-munisandextensorcarpiradialisbrevismuscles(p<0.05).

Muscles

FDS FPL EDC ECR

IntegratedEMG(V.s)

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0

HP-A

HP-B

HP-C

signed-ranktests.Thelevelofsignificancewassetatp<0.05.Openendedquestionsinthesurveyweretabulatedbyrecordingthefrequencyofoccurrenceacrosstheparticipants.


HandpieceCharacteristic HP–A(corded) HP–B(corded) HP–C(cordless)Gripdiameter 3.7±1.0 4.2±0.7 3.8±0.9Balance 3.1±1.1 4.0±0.7 3.6±1.1Maneuverability 3.4±1.1 4.1±0.8 4.0±0.9Weight 2.9±1.1 3.7±0.9 3.9±1.3

TableIII:MeanandStandardDeviationofSurveyHandpieceComfortRatingsforGripDiameter,Balance,ManeuverabilityandWeight

Ratingsareonascaleof1=notcomfortableto5=verycomfortable.Nosignificantdifferencesbetweenhandpieceswereobservedforgripdiameter,balanceandmaneuverability(p>0.05).WeightoftheHP–Cwasratedassignifi-cantlymorecomfortablethanHP–A(p<0.05).

HandpieceFeature HP–A(corded) HP–B(corded) HP–C(cordless)Weight/balance 4 1 2Maneuverability(lackofswivelhead) – – 3

Speed – – 2Noise 5 1 –Diameter/grip 2 – 4Cord 2 1 –

TableIV:ResultsfromQuestion3oftheSurvey-WhatWouldYouChangeaboutPre-ferredHandpiece?

Valuesindicatethenumberofresponsesfromparticipants.

HandpieceFeature HP–A(corded) HP–B(corded) HP–C(cordless)Weight/balance 5 2 6Maneuverability 4 2 3Speed 1 2 1Quiet – – 5Diameter/grip 5 2 1Swivelhead 2 – –CordlessHP – – 11Cordlessrheostat – – 1

TableV:ResultsfromQuestion2oftheSurvey-WhatDidYoulikeMostaboutYourPreferredHandpiece

Valuesindicatethenumberofresponsesfromparticipants.

6to10years(33%),11to15years(17%)and16+years(20%).Twenty-nineparticipantsreportedthattheyroutinelyconductedfull-mouthpolishing,while1 respondent reported that selectivepolishingwasprovided.

Muscleactivitylevels(10th,50thand90thpercen-tiles)didnotvarysignificantlybetweenthe3hand-piecesforanyofthemusclestested(p>0.05)(TableII).Meantotalactivity(integratedEMG)oftheflexordigitorumsuperficialis,flexorpollicislongus,exten-

sordigitorumcommunisandextensorcarpiradialisbrevismuscleswerelowerforthecordlessthanthecorded handpieces (Figure 3). RMANOVA indicatedsignificant effects for the flexor digitorum superfi-cialis and extensor digitorum communis muscles(p<0.05),butnottheflexorpollicislongus(p=0.18)andextensorcarpiradialisbrevis(p=0.08)muscles.SimpleplannedcontrastsrevealedthatthecordlesshandpieceledtosignificantlylesstotalactivitythanthecordedHP-Afortheflexordigitorumsuperficia-lis,extensordigitorumcommunisandextensorcarpi


DiscussionDentalprofessionalshaveahigh rateofMSD.1-7

Dentalhygienistsareespeciallysusceptible topaininthewristsandhands.4,6,8Whileergonomicallyap-propriateposturescanminimizeforcemomentsonthebody,thenatureofperformingrepetitivemove-ments, such as hand scaling and polishing, placeshighworkloadsonthemusclesandtendonsofthe

radialis brevismuscles (p<0.05), butnot theflex-orpollicislongus(p=0.06).TheeffectoforderwasassessedusingRMANOVAandBonferroniposthoctests.Onlytheextensordigitorumcommunismusclerevealedasignificantordereffect,withthethirdpro-cedureemployinggreater50thpercentileactivationthanthesecondtrial(p<0.05).

Onaverage,polishingusing the cordless (HP-C)handpiece(M=257seconds,SD=112seconds)tookover30secondslesstimethanwitheithertheHP-Acorded(M=290seconds,SD=137seconds)orHP-Bcorded (M=290 seconds, SD=126 seconds) hand-pieces. TheRMANOVA revealed a significant effectof handpiece on polishing duration (p<0.05) andsimple planned contrasts revealed that using thecordless handpiece led to statistically significantlyshorterpolishingtimesthanthe2cordedhandpiec-es (p<0.05). Therewere no significant differencesindurationbasedontheorderthehandpieceswereused(p>0.05).

HandpieceDesignandPreference

A chi-square analysis revealed significant differ-ences(p<0.05)inoverallhandpiecepreferenceswith50%(n=15)ofthestudyparticipantspreferringthecordlesshandpiece(HP-C),37%(n=11)preferringthecordedHP-Aand13%(n=5)preferringthecord-edHP-B.Thesurveyratingsfordiameter,balanceandmaneuverabilitywerenotsignificantlydifferentbe-tweenthecordlessandcordedhandpieces(p>0.05)(TableIII).However,theweightofthecordlessHP-CwasratedassignificantlymorecomfortablethantheHP-A (p<0.05) (Table III).Whenparticipantswereaskedwhattheywouldchangeabouttheirpreferredhandpiece, weight/balance, noise level, diameter/gripandcordwerecitedascommonfactors(TableIV).TableVrevealsthatrespondentslikedthecord-lesshandpiecebecauseitlackedacordandalsobe-causeitwaslightweight,balancedandquiet.Fifty-sevenpercentfeltthecordlesshandpieceproducedsufficientpowerthroughouttheprocedures.Subjec-tivecommentsbythedentalhygienistsemphasizedthefreedomofmovement, lackofcordresistance,lightweightandlownoiselevelofthecordlesshand-pieceasimportantfactorsindeterminingtheirpre-ferredexperimentalhandpiece.

forearmsandhands.Ergonomicallydesignedinstru-mentsofferthepossibilityofreducingtheworkloadandminimizingtheriskofdevelopingworkrelatedMSD. Workload on the muscles can be quantifiedthrough recording theelectrical activityofmuscles(EMG).15,17EMGresearchstudieshaveonlyjustbe-guntodeterminethecharacteristicsofdentalinstru-ments thatminimizemuscle workload.20,21 For the first time, this studyexaminedwhethera cordlesshandpiece,whichinprincipalcouldreducetheeffectsofcordpull,reducesintensityanddurationofmuscleactivityoftheforearmandhandduringdentalpolish-ingcomparedwithtwostandard,cordedhandpieces.

Polishing teeth with the cordless handpiece re-ducedtheduration,butnottheintensityofthemus-cularworkload comparedwith the2 cordedhand-pieces.TheEMGintensitydistributionremainedthesameacrosshandpiecesas revealedbyno signifi-cantchangestothe10th,50th or 90thpercentilelev-els ofmuscle activity.However, using the cordlesshandpiece reduced the integratedEMGof3outof4muscles,thatisthetotalwork(intensityxdura-tion).Thesefindingscanbeexplainedbythe,onav-erage,30secondreduction inpolishing timewhenusingthecordlesshandpiece(HP-C)comparedwiththe2cordedhandpieces(HP-AandHP-B).Thisdif-ferenceintimecannotbereadilyexplainedbyworsepolishingperformance.Itisimportanttorealizethat30secondsis20%oftheaveragepolishingtimeforonly12teeth,hencealargerreductionindurationwouldbeexpectedforpolishingalltheteeth,whichmostdentalhygieniststestedreportedtheydo.In-tensity,durationandfrequencyofactivityareallim-portant factors in the development of MSD.17 Thisresearchrevealsthatthecordlesshandpieceimpactstheworkloaddosebydecreasingduration,butnotintensity ofmuscle activity, andwould not changefrequency.Unfortunately,thedevelopmentofMSDismulti-factorialandvariesgreatlyacrossindividuals,thereforewecannotdefinitivelystatetheworkloaddose that avoidsMSD.15,17 Clearly, there is a needforfutureresearchtoestablishsafeworkloadsandclinicallymeaningfulchangesinworkloaddose.Untilthesefactorsaredetermineditremainsimportanttofindwaystoreduceworkloadduringactivities thathaveahighincidenceofMSD.

Thecordlesshandpiecewaspreferredmost(50%)bythedentalhygienistsinspiteofthefactthattheparticipantsweremorefamiliarwiththeotherhand-piecesandnonehadanypriorexperiencewiththenewcordlesshandpiece.Thelackofacord,weightandbalance,andlownoisewerelistedasthemainreasonsforpreferringtheHP-Chandpiece.Whiletheotherhandpiecesare lighterthanthecordless,thehoseaddstotheweightandcanimpactthebalanceof the device. The larger diameter of the cordless


ConclusionWithin the limitationsof thecurrentstudy, the

cordlesshandpiecedidnotinfluencemuscleinten-sity (p>0.05), but decreased the overall muscleworkload(p<0.05)byreducingpolishingduration(p<0.05). The cordless handpiece was preferredoverthecordedhandpiecesbythedentalhygien-istswhoparticipatedinthestudy(p<0.05).Futureresearch is needed to determine whether thesechangesimpactthedevelopmentofMSD.

Gayle McCombs RDH, MS, is a University Pro-fessor, Graduate Program Director and Director of Dental Hygiene Research Center in the School of Dental Hygiene, Old Dominion University. Daniel M. Russell, PhD, is an Assistant Professor in the School of Physical Therapy and Athletic Training at Old Dominion University.

handpiecetothecordedhandpiecesisunlikelytobethecauseofreducedtotalmuscleactivity,althoughsomedentalhygienistsdidprefer the largerdiam-eter.Allhandpiecestestedherehaddiametersgreat-er thanthecriterionof10mm, foundtominimizemuscleactivityduringapreviousEMGstudyofscal-ing instruments,20,21andhandpiecediameterwouldbeexpected to influencemuscleactivity levelsnotnecessarilythepolishingtime.Dentalhygienistslikeusingapolishingdevicewithoutacord,whichap-pearstotranslatetoshorterpolishingduration,butnotlowermuscleintensity.

Thisstudywasthefirsttoexaminewhetheracord-lesshandpiece influencedmuscleactivity,polishingdurationanddentalhygienistopinioncomparedwithcordedhandpieces.Thereareseverallimitationsthatimpacttheapplicabilityofthisresearch.The3hand-pieceswereprovidedbyonecompanyandvariedonseveralcharacteristicsinadditiontohowtheywerepowered.Futureresearchcouldexamineabroaderrangeofhandpiecestoseparatelyanalyzedifferentdeviceproperties.Dentalhygienistswere recruitedusingaconveniencesample,ratherthanbeingran-domlysampledfromthepopulation.Thereisalsoaneedtodevelopavalidquestionnaireforassessingdentalprofessionals’ opinionsofdental equipment.FurtherresearchisneededtoidentifytheworkloaddoseandindividualcharacteristicsthatleadtoMSDindentalhygienists.

Acknowledgments

Disclosure

Theauthorswould like to thankKyleKelleran,Amy Marsh, Maricel Navarro, Scott Sechrist andDebbieWilliamsfortheirassistancewithdatacol-lection.

ThisprojectwassupportedbyDentsplyProfessional.

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11. Leggat PA, SmithDR.Musculoskeletal disordersself-reportedbydentistsinQueensland,Australia.Aust Dent J.2006;51(4):324-327.

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13. OsbornJB,NewellKJ,RudneyJD,StoltenbergJL.CarpaltunnelsyndromeamongMinnesotadentalhygienists.J Dent Hyg.1990;64(2):79-85.

14. LissGM,JesinE,KusiakRA,WhiteP.Musculoskel-etal problems amongOntario dental hygienists.Am J Ind Med.1995;28(4):521-540.

15. ÅkessonI,BaloghI,HanssonGÅ.Physicalwork-loadinneck,shouldersandwrists/handsinden-tal hygienists during a work-day. Appl Ergon. 2012;43(4):803-811.

16. Guay AH. Commentary: Ergonomically relateddisorders in dental practice. J Am Dent Assoc. 1998;129(2):184-186.

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19. Simmer-BeckM1,BrayKK,BransonB,GlarosA,WeeksJ.Comparisonofmuscleactivityassociatedwithstructuraldifferencesindentalhygienemir-rors.J Dent Hyg.2006;80(1):8.

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22. DelagiEF,PerottoA,LazzettiJ,MorrisonD.Ana-tomic guide for the electromyographer. 2nd ed.Springfield,Ill.CharlesC.ThomasPublisher,Ltd.;1981.


Twenty-first century health careis dynamic and challenging. On adailybasis,healthcareprofessionalsmakedecisionswhichrequirecalcu-latedandstructuredthought,incor-porating the use of critical thinkingskills.1-3 As health care evolves toinclude evenmore complex patienttreatment options, increased phar-maceuticals and a diverse popula-tion,soshouldthemannerinwhichprofessionals are taught in educa-tional programs. Indeed, the Insti-tuteofMedicinehasconcludedthatall health care professionals shouldbe educated to deliver patient-cen-teredcareasmembersofan inter-disciplinary team, emphasizing evi-dencebasedpracticeutilizingcriticalthinking skills,quality improvementapproaches,andinformation.2

Historically,educationalprogramsfor health professionals, includingthe dental profession, have taughtstudentsbylectureandrotememo-rizationwiththegoaltopassthena-tional and state licensure exams.4-6 Asindicatedbynumerousresearch-ers indentaleducation,dentalpro-gramsoftenhaveovercrowdedcur-riculawhicharelockedintoaspecifictime frame, contain redundant ormarginally useful information, anddonotallow foruniqueeducationalexperiencestodevelopcriticalthink-ingskills.4-11Dentaleducationreformandcurricularchangehasbeenneededtoeducatestudentsusingthebestteachingmethodscurrentlyavailable.Thishasledtotherethinkingofpracticesinpost-secondarypreparationprogramsfordentalhygiene,alongwithanumberofotherprofessionalpreparationprogramsinhealthanddentalcare.5,12

Abundantliteraturealsosubstantiatestheneedfor inclusion of critical thinking skills in educa-

ExplorationofCriticalThinkinginDentalHygieneEducationKimberlyS.Beistle,PhD,RDH,CDA;LouannBierleinPalmer,EdD

AbstractPurpose:Thisqualitativestudyexplorestheperceptionsofdentalhygienefacultyregardingissuessurroundingcriticalthinkingskillsintegrationwithintheirassociatedegreedentalhygieneprograms.Methods:Twentyfacultyparticipatedinthestudy,asdrawnfrom11accreditedassociatedegreedentalhygieneprogramsinoneMid-weststate.Multiplesourcesofdatawerecollected,includingemailquestionnaires,individualfollow-upphoneinterviewsandartifacts.Interpretiveanalysiswasconducted.Results: Dataanalysisrevealedthatfacultygenerallyunderstoodcriticalthinking,butinterpretationsvaried.Mostdonotusevariedteachingstrategiestopromotecriticalthinkingskills,andfocusononeparticularstrategy–thatofcasestudies.Theparticipantsiden-tifiedtheneedforalliedhealth-focusedfacultydevelopmentoppor-tunities,andnotedthatcalibrationofinstructionwasneeded.De-spitechallenges,facultyfeltresponsibleforteachingcriticalthinkingskills,andidentifiedtheneedfortimetobuildcriticalthinkingskillsinto the curriculum.Conclusion:ThisstudywasconductedinresponsetotheAmeri-canDentalEducationAssociationCommissiononChangeandIn-novation’schallengefordentalhygieneeducatorstocomprehendtheirownknowledgeontheconceptofcriticalthinkingrelatedtoresearch-basedpedagogicalapproachestoteachingandlearning.Findingsrevealedastrongdesireamongthedentalhygienefacultyinthisstudytoincorporatecriticalthinkingintotheirwork.Theywant todowhat theybelieve is theright thing,but theiractualknowledgeofthedefinitionalandapplicationtheoriesaboutcriticalthinkingisstillintheearlystagesofdevelopment.Regularandtar-getedfacultydevelopmentopportunitiesareneeded.Keywords:criticalthinking,curriculum,teachingstrategies,dentalhygieneThisstudysupportstheNDHRApriorityarea,Professional Educa-tionandDevelopment:Investigatetheextenttowhichnewre-searchfindingsareincorporatedintothedentalhygienecurriculum.

Research

Introduction

tion.13-21 Inaddition,alliedhealthprograms, suchas dental hygiene education, must provide evi-denceofmeetingaccreditationstandardswhichin-dicategraduatesarecompetentintheuseofcriti-cal thinking and problem-solving skills related tocomprehensivecareofpatients.22-24

Specifically,ifthepreservationofdentistryasalearnedprofessionwithsustainablevitalityinedu-cationandresearch is tocontinue, there isacall


forseriouscurricularchangeandinnovationinboththeclassroomandclinicalsettingfordentaleduca-tion.6,10,12 Dental education commissions, such astheCommissiononDentalAccreditation,theAmer-icanDentalAssociationCouncilonDentalEducationandLicensureandtheJointCommissiononNation-alDentalExaminers,haveunanimouslyrecognizedthe need to change dental curricula as a part ofimproving the nation’s oral health.22 The Ameri-can Dental Education Association Commission onChangeandInnovationsuggeststhatchangingsci-ence,technology,anddiseasepatternswill trans-formoralhealthcaredeliverygreatlyimpactingalldisciplinesoforalhealtheducation.23This,inturn,createsbothasetof implicationsandasenseofurgencyforrethinkingdentaleducation.

While it is generally agreed that instruction indentalhygieneprogramsmust incorporatecriticalthinkinganddecisionmakingskills,thereisanab-senceofresearchonthecognitivecomponentsofclinicaldecisionmaking,whichincludesconceptsofcritical thinking.7,8,10,24Asa result, it isdifficult tochartacourse forsuchchange indentalhygieneprogramswithoutexaminingthecurrentstatusoffacultyregardingtheirunderstandingandpracticeofteachingcriticalthinkingskillsintheirdiscipline.

Therefore,thegoalofthisresearchwastoexam-inedentalhygienefacultyperceptionsandthinkingsurroundingcriticalthinkingissueswithintheirac-creditedassociatedegreedentalhygieneprograms.Thefocuswasonfacultywhoteachorhavetaughtfirst and/or second year clinical theory courseswithintheirdentalhygieneprogram.Forthepur-posesofthisstudy,criticalthinkingisdefinedasanartofanalyzingandevaluatingthinkingbyself-dis-cipline,self-correctionandself-monitoringwithinaframeworktoimproveone’sthinking.25,26

TheworkofPaulandElderwaschosenasalensforthestudy.26-30Inalignmentwithothertheoristsandresearchers,13,14,18PaulandElderbelievethatwithinthecriticalthinkingprocessthereare3lev-elsof critical thinking, andmethodical practice isneededforapersontomovefromthelowestleveltothehighestlevel.Theseauthorshavealsoidenti-fiedeffectiveteachingactivitiesandpracticesthatoffer opportunities for deeper learning which arebasedupontheuseoftheircriticalthinkingmodel.Theirmodelhasbeenusedbyvarioushighereduca-tioninstitutionsandtheirideaspromotedthroughvarious faculty development centers, includingthosewithin thestatewhere this studywascon-ducted.31-33 In addition,Cosgrove et al developedan “international critical thinking basic conceptsand understanding test” which has been demon-stratedtohaveahighdegreeofconsequentialva-

lidity.34Theirwhitepapertitled“ConsequentialVa-lidity:UsingAssessmenttoDriveInstruction”goesinto furtherdetail supporting this critical thinkingskills test.35 It was therefore appropriate to usetheirworkforthestudyofdentalhygienefacultyinthisstate,whiletheworkofothercriticalthinkingexpertsmayserveasthelensforsimilarstudiesinotherstates.

Specifically,thisstudypursuedthefollowingre-searchquestions:

1. Howdodentalhygienefacultydefinethecon-ceptof“criticalthinking”(asviewedthroughthelensofPaulandElder’swork),andtheprocessofbecomingacriticalthinkerwithinthefieldofdental hygiene (includingwhenandhow theylearnedabouttheconceptofcriticalthinking)?

2. How do these faculty describe their personaland departmental rationale and decision re-gardingtheintegrationofcriticalthinkingskillsintotheircurriculum?

3. Howdotheydescribetheirstrategiesandpro-cessesforteachingcriticalthinkingskillsintheirdiscipline?

4. Whatchallengesdotheyexperienceastheyad-dressnewcurriculumstandardsforintegratingcriticalthinkingintheclassroomorclinic?

Methods and MaterialsA qualitative study approach is often used to

examinethesocialandculturalaspectsofapar-ticularprogram,groupororganization,and thuswasused inthisstudytoassesstheperceptionsofdentalhygienefacultyregardingvariouscriticalthinkingissues.36

The selection criteriawas all facultymemberswho have taught and/or teach first and secondyearclinicaltheorycourseswithineachofthe11accredited associate degree dental hygiene pro-gramsinoneMidwesternstate.Thetheorycoursesarethosethatfocusonclinicaltheoryasappliedto clinical procedures, andwere chosenbecausetheyfocusonhelpingstudentslearntothinkcriti-callyandwithsubstancewhentreatingapatient,includingassessment,diagnosis,planning,imple-mentationandevaluation.Thesecoursesalsocov-ersimilarcontentacrossthe11programsinthisstateaspartofpreparationfortheNorthEastRe-gionalBoardExam,theclinicalexamforthisstateandtheNationalBoardDentalHygieneExam.

Thispopulationoffacultywaspurposefullycho-sen,bothbecauseoftheirparticularknowledgeofthephenomenonbeingstudied,andbecausetheresearchershadaconnectionwiththisstate’sden-


talhygieneeducator’sassociation,makingitmorelikely that facultywould bewilling to participateinthisstudy.37Initially,26facultymemberswereidentifiedwhomettheselectioncriterion,andre-ceived an email invitation to participate. Threehadlefttheirinstitutionornolongertaughtthosecourses.Ofthe23remainingfacultymembersinthe targetpopulation,20 (87%),withat least1fromeachofthe11programsinthestate,offeredtheirassenttoparticipate(followingtheprotocolapproved by aHumanSubjects Institutional Re-viewBoard).

Tosupporttriangulationofthedata,3typesofdatawere collected for this study.38 First, open-endedquestionswerecreatedandpilotedtestedwith2dentalhygienecolleaguestoenhancefacevalidity.These2colleagueswereoutofstateandhave embraced the concepts of Paul and Elderthrough various faculty developmentworkshops.After appropriate revisions, the questions weresentbyemailtoparticipantstoelicittheirunder-standingofwhatcriticalthinkingis,andthestrat-egiesormethodsusedtoteachstudentstothinkcritically. The researchers choose this approachbecauseitallowedtimeforparticipantstoreflectupon the questions and craft their response byemail.

A second data set was obtained via follow-upphoneinterviews,withspecificinterviewquestionsdeveloped forparticipants toprobebeyond theirinitialemailresponses.Theseinterviewquestionswerealsopilottestedandrevisedpriortousage.Eachphoneinterviewwasapproximately20to40minutesinlength,andwasrecordedforlatertran-scription.

A third data set involved a review of artifactscollected from participants which demonstratedtheirintegrationofcriticalthinking,suchasclassactivities,syllabi,scoringrubricsandprogramwebpages.These itemswerereviewedtosee if theyprovided concrete evidence to back up (or not)whatparticipantshadindicatedtheyweredoinginrelationtothetopicofcriticalthinking.

The phone interview responses were tran-scribed,andtheprocessofinterpretativequalita-tiveanalysisbegan.Theresearchersfirstanalyzedtheverbatimtranscriptsandresponsestonarra-tivequestionnaires,identifyingthemesrelatedtounderstandingtheconceptofcriticalthinking.Aninitiallistofcommonalitieswascreated,andthenrefinedby sorting each commonality into similarcategories and subcategories. This was followedby the identification of common themesuntil anemergence of repeating premises or regularities

resulted.36-38Throughthisprocess,theresearcherswereabletoeliminateredundanciesandcreatealistof themesthatemergedfromanalysisof thedatarelatedtotheresearchquestions.

Theintegrityoftheresearchmethodswasen-hancedbyutilizingseveralapproachessuggestedbyCreswell.38Theemailquestions,aswellasthefollow-up interview questions, were piloted with2dentalhygienecolleaguesprior to theirusage,andrevisionsweremadetoenhancethefaceva-lidityofthesetools.37Member-checkingwasusedwhereby each participant was allowed to reviewthenarrativeconstructedfromtheirinterviewandofferedclarificationsasneeded.

Limitations

Itisimportanttonotethatthisresearchstudyhad a specific targeted population and thereforecannotbegeneralizedtopopulationsbeyondthefacultywithinthese11accreditedassociatedegreedentalhygieneprogramsinoneMidweststate.36-38 However,whilethefindingscannotbegeneralized,theymaybeofinformationalinteresttootherden-talhygieneprogramsthatareworkingtoincludecriticalthinkingskillswithintheirprograms.

Inaddition,theprimaryresearcherchosetousetheworkofPaulandElderasaframeworkforthisstudy,whiletheworkofothercriticalthinkingex-pertsmayserveasthelensforsimilarstudiesinotherstates.26-30

ResultsParticipants included 19 females and 1 male,

ranging inage from30 to60yearsold.Yearsofteachingexperiencerangedfromoneto25years.Two participants held doctoral degrees, 12 heldmastersand6hadbaccalaureatedegrees.Itshouldbenoted thatparticipantdemographicswerecol-lectedasameanstodescribethepopulationinthestudy,nottolookfordifferenceswithinthisqualita-tivestudy.

Analysis of data revealed themes which weresubsequently grouped under the core researchquestionareas.

ResearchQuestion1:KnowledgeoftheConceptofCriticalThinking

Research question 1 examined how dental hy-giene facultydefine theconceptof “critical think-ing”(basedupontheframeworkoftheconceptsofcritical thinking fromPaul andElder’swork), andtheprocessofsomeonebecomingacriticalthinker


withinthefieldofdentalhygiene(includingwhenandhowtheylearnedabouttheconceptofcriticalthinking).

Threethemesemergedtoaddressthisresearch.First,most facultymembers offer at best only apartialdefinitionoftheconceptofcriticalthinking(theme 1.1). Only 5 of the 20 participants wereable to give a complete and specific definition ofcriticalthinkingasdefinedbyPaulandElder.26Suchresponses includedallessentialelementssuchasclearly formulating vital questions and problems,assessing relevant information, determining well-reasonedconclusionsandsolutions,thinkingopen-mindedlywithalternativesystemsofthought,andeffectivelycommunicatingwithothers.Forexam-ple,participant#8(viatheopen-endedquestion-naire) provided this completedefinition of criticalthinking, “Students critically thinkwhen they canassess information, define the problem, draw aconclusion,devisepossiblesolutions,comeupwitha plan of action, and can evaluatewhether theirideaorplanworked.”Theother15participantsof-feredonlysegmentedcriticalthinkingconcepts.

The second theme which addressed this re-searchquestionswasthatmostparticipantsinitial-lylearnedabouttheconceptofcriticalthinkinginaformalmanner(theme1.2).Eighteenofthe20participantsindicatedtheylearnedaboutthecon-ceptofcriticalthinkingthroughdifferentformsofeducationalopportunities,with12ofthese18firstlearningabouttheconceptofcriticalthinkingskillsthroughsomesortof facultydevelopmentoppor-tunity.Severalnotedthattheyhadinitiallylearnedabouttheconceptaspartoftheirownformaltrain-ingasastudentdentalhygienistordentalstudentintheclassroom.

Thethirdthemeforthisresearchquestionswasthatallparticipantsindicatedtheylearnedhowtoteachcriticalthinkingskillsthroughvariousfacultydevelopmentopportunities(theme1.3).All20par-ticipants learned how to teachwhat they believetobecriticalthinkingskillsduringfacultydevelop-mentworkshopsand seminars. Thirteen reportedsuchworkshopswereofferedbytheirowneduca-tionalinstitutions,whiletheother7attendedtrain-ingatotherinstitutions.

Research Question 2: Decisions toTeachCriticalThinkingSkills

Research question 2 examined how dental hy-giene faculty describe their personal and depart-mentalrationale,andtheirdecisionsregardingtheintegrationofcritical thinkingskills intotheircur-riculum.Twothemesemergedtoaddressthisques-

tion.Thefirstthemewasthatthemajorityagreedasafacultygrouptoincludetheteachingofcriticalthinkingskillsintotheirprograms(theme2.1).Thir-teenofthe20participantsindicatedtheyagreedasafacultygrouptoimplementtheteachingofcriticalthinking skills into their curriculum. For example,participant#3(viatheopen-endedquestionnaire)sharedthisresponse,“programfaculty(full time)decided togetherhow to implementcritical think-ingskillsintothecurriculum.Thisissomethingthathasevolvedovertimeforus.”Theother7partici-pantsindicatedtheydecidedontheirowntoteachcriticalthinkingskillsinthecurriculum.

Thesecond theme for researchquestion2wasthatamajorityof facultyexpressed limitedresis-tance to changing their curriculum to include theteaching of critical thinking skills (theme 2.2).Fourteenofthe20participantsexpressednoma-jorresistancetothechangesneededastheyincor-poratedtheteachingofcritical thinkingskills intotheir coursework.Mostparticipantsembraced theteaching of critical thinking skills, indicating thatteachingcriticalthinkingskillsisamustforhealthcareproviders.Forexample,participant#2(viathefollow-upphoneinterview)sharedthisstatement,“Iloveteachingthisway.Itallowsandencouragesstudentstosharetheirpersonalexperiences,whathasworkedandwhathasnot.Itincorporatesalloftheir personal experiences to be applied and uti-lizedashealthcareproviders.”

The other 6 participants expressed frustrationandorfeltresistancefromtheirstudentstoengageinclassroomteachingstrategiesthat includedus-ingcriticalthinkingskills.Forexample,participant#18(viatheopen-endedquestionnaire)sharedherfrustration: “With increasingdemandson instruc-tors forqualityassurance,thenecessarystepstoprovideaqualityaccreditedprogram,thereseemstobelessandlesstimetoperfectthepedagogicalskillsinvolvedinthegoalofactuallyteachingcriti-calthinkingskills!”

Research Question 3: Teaching StrategiesUsingCriticalThinkingSkills

Thethirdresearchquestionexaminedhowfac-ulty described their strategies and processes forteaching critical thinking skills in their discipline.Threethemesemerged.Thefirst themewasthatmany faculty described using research-basedteachingapproachestohelpstudentslearncriticalthinkingskills(theme3.1).Fifteenofthe20par-ticipants indicated they are using several specificstrategiestoteachcriticalthinkingskills,including:self-assessment, concept mapping, case studies,Socraticquestioningandsubstantivewriting.Some


participantsindicatedthatcasestudieswereusedmostoften.

The other 5 participants provided responses ofotherteachingstrategiesnotidentifiedbyPaulandElderasthemosteffectivewaystoteachstudentscritical thinking skills (e.g., lecture, group work;question and answer).26 For example, participant#8(viatheopen-endedquestionnaire)sharesthiscontent, “Inmy Theory course, I lecture to stu-dents,andaskthemtheiropinionsorideas,ratherthanjustaskingfor“therightanswer.”

The second theme which addressed researchquestion3wasthatallparticipantsexpressedtheyfeltresponsibletoteachcriticalthinkingskillsinor-dertopreparestudentsfortheworkworld(theme3.2).All20participantsbelievedtheyhaveadutytoteachstudentscriticalthinkingskills,helpingthemtoengageinrealworldexperiences.Forexample,participant#20(viathefollow-upphoneinterview)noted,“Theprimaryresponsibilitylieswiththein-dividualinstructorstointegratecriticalthinkingintothevariouscoursesthattheyteach.Asafacultywearealwaysworkingonwaystobringcriticalthink-ingskillsintotheclinicalenvironmentmodelingthereal work world.” In congruence, participant #9(viatheopen-endedquestionnaire)noted:“Criticalthinkingispurposefullyinstalledwithincoursesbyindividualfaculty.Criticalthinkingskillsaresome-thingthatmustbeimplementedwithinourcurricu-lumasoftenasispossible.”

Thethird themefor this researchquestionwasthatthemajorityofparticipantsreportedthatsec-ondyearstudentsaregivenmoreautonomy,andasaresultteachingstrategiesusedtoteachcriticalthinkingskillsbecomemorecomplex(theme3.3).Twelve of the 20 participants identified studentshavingmore autonomyas theyprogress throughthe lastsemesterofthecurriculum,andteachingstrategiesusedtoteachcriticalthinkingskillsbe-comemorecomplex.Forexample,participant#6(viatheopen-endedquestionnaire)noted:“Meth-ods taught to first year students are self-correc-tive,andself-disciplined.Methodstaughttosecondyeararehowto increaseknowledge,skillassess-ment,andevaluatecontinuingcaretopatientcasetypes.” The other 8 participantswere not consis-tentwith their responseswhen questioned aboutthe complexity of teaching strategies as studentsprogressedthroughthecurriculum.

ResearchQuestion4:ChallengeswithToday’sStudentsTeachingCriticalThinkingSkills

The fourth research question focused on thechallenges faculty experiencedas theyaddressed

new curriculum standards for integrating criticalthinking in the classroom or clinic. Two themesappeared: the first theme is thatmany reportedtheirstudentssimplyhavea“tellmewhatIneedto know” approach rather than a desire to learnhow to learn to thinkcritically (theme4.1).Thir-teenof the20participantsbelievemoststudentswanttobetaughtwhattheyneedtoknowtopasstheboardsandnothowtolearntothinkcritically.Forexample,participant#10(viatheopen-endedquestionnaire) wrote: “The challenge is that stu-dentswantfacultytospoon-feedthemeverythingandtellthemtheanswersbecausethatmayhavebeenhowtheylearnedandweretaughtinthepre-dentalhygienecourses.”

Thesecondthemewhichaddressesthisresearchquestionisthatmanyparticipants’indicatedthereshould be more calibration of instruction whenteachingcriticalthinkingskillsindidacticandclini-calsettings(theme4.2).Asonemajorchallenge,11 of the 20 participants agreed thatmoreworkis needed to truly integrate critical thinking skillsbothintheclassroomandtheclinic.Asthepartici-pantsresponded,itwasalmostasifthiswasaself-realizationastowhatstepstheparticipantand/ortheprogramwastakinginregardstothecohesiveteachingofcriticalthinkingskills.

Other participants shared broad categories ofchallengestheyfacewhenteachingcriticalthinkingskillswithindentalhygieneprograms.Somesharedthefactthattime,reductionofcredithoursperpro-gram,andawarenessofstudents’differentstylesoflearningcreatestheneedforcongruencyamongfacultyteachingintheprogram.

Overall,onvaryinglevels,allparticipantsmen-tionedthedifficultyofpreparingstudentstocriti-callythinkasrequiredforsuchademandinghealthcareprofession.Asnotedearlier,participantsvoicedtheneedformoretimetoteachtherequiredden-talhygienecoursecontentutilizingteachingstrate-gies incorporating critical thinking skill, especiallyastheystrivetoensurethatstudentsactuallylearnthecontentbycriticallythinking.

DiscussionThe overall goalwas to understand dental hy-

giene faculty perceptions and understanding ofcriticalthinkingissues.Afterreviewingthethemesfoundinthisstudy,8majorfindingswereidentified.Thesefindingsareonlyapplicabletothepopulationinvolvedinthisstudyandwhiletheframeworkforthis researchwas based upon a single theory, itshould be noted that there aremore theoreticalmodelsresearcherscouldexplore.


First,thedentalhygienefacultyinourstudygen-erallyunderstood theconceptofcritical thinking,butinterpretationsvaried,andnotallcouldofferacompletedefinition.Thisfindingissimilartoworkbywhofoundmostgeneraleducationfacultybe-lievetheyknewwhatcriticalthinkingis,butcouldnotgiveaconcreteunderstandingoftheconcept.25 Indeed, over 75% of the faculty were unable toadequatelydefinetheconstructsunderlyingcriticalthinking.

Second, dissimilar to aspects of previous re-search by Paul and Elder,26Williams et al,39 Gid-densandGloeckner,40andHessheimeretal41whichrevealsmultipleresearched-basedteachingstrate-giestopromotecriticalthinkingskills,mostofourparticipants primarily focused on one particularteachingstrategythroughoutthecurriculum-thatofcasestudies.Facultydidnotetheimportanceofotherresearch-basedteachingstrategies,butcitedcase studiesas themost important. This revealsaseriousdisconnectbetweenthetheoriesofhowcritical thinking should be taught (i.e.,with casestudies being just one of many strategies), andwhatwasactuallyhappeninginthefieldwiththefacultyinthisstudy(andperhapswhatishappen-ingelsewhereaswell).

Third, adding to theprevious researchofAsa-doorianetal,5Hessheimeretal,41andKassebaumetal,42whichfoundthatfacultydevelopmentop-portunitiesontheinstructionofcriticalthinkingareessential, our participants identified theneed forspecificalliedhealth-focusedfacultydevelopmentopportunities.Theshifttoteachingcriticalthinkingskills requires a commitment from organizationsto help faculty understand what critical thinkingis,andidentifywhateducationalstrategiescanbeusedtoeffectivelyteachcriticalthinkingandassesschangesinstudents’criticalthinkingskills.Organi-zationsmustoffercontinuousalliedhealth-focusedfacultydevelopmentopportunities,andvenuestodiscuss,implementandexaminethescholarshipofteaching.

Fourth, while participants believed all facultywereteachingtheconceptofcriticalthinking,theyexpressed concerns of not knowing specificallywhatothersweredoing,orhowwell thingswereworking.Theneedforfacultytime,tosharetheirexperiences and assesswhatmethods are reallyhelpingthestudentstolearncriticalthinkingskills,was very apparent. Participant recommendationswerethatcalibrationofinstructionwasneededsothatallfacultycanmakethenecessarychangesinaneffectiveway,andallowthemtofocusoneffec-tiveteachingstrategies.Nosimilarfindingcouldbefoundinpreviousresearch.

Fifth,addingtothepreviousworkofDoyle,Taggand Weimer, who identified a paradigm shift inteaching, the participants in this study identifiedchallengeswith teaching today’s students.14,19,21,43Faculty found resistance from students who didnotwant toengage in the teaching strategies topromotecritical thinking,andsomestudentsjustwanted“tobespoonfedinordertoknowwhatwasgoingtobeontheboards.”

Sixth, supporting thepreviousfindingsofBar-lett,Ellerman,andPaulandElder,whichrevealedthatintellectualtraitsmustbetaughtinhealthcur-riculamovingfromthenovicetotheexpertthinker,the participants agreed that coursework intensi-fiesthroughout thecurriculumandsoshouldthestudents’ ability to think critically.25-29,44,45 Faculty identifythatfirstyearstudentsarelearninglargeamountsoffoundationalcontent,andthatstudentsbecomemoreautonomousastheymovethroughthesecondyearofthecurriculum.

Seventh,participants in this study felt respon-sibleforteachingcriticalthinkingskillstostudentsas part ofworkforce preparation.Many acknowl-edge that a health professionalmust be able tothink critically during patient clinical treatment.Clinical dental hygiene practice demands criticalthinkingandassuchfacultyareattemptingtoin-cludecriticalthinkingactivitiesdailyintheirteach-ingpractices. Inaddition, faculty recognized thatcritical thinking skills had been taught to themduringtheirownexperiencesasstudentsindentalhygieneschool,andfeltresponsibletonowteachcriticalthinkingskillstoothers.Facultyreminiscedthattheyrememberedhearingandlearningaboutcriticalthinkingwhilebeingastudentintheirun-dergraduate dental hygiene program, and havebeen fortunate to receive institutional support tonowlearnhowtoteachcriticalthinkingskillsthem-selves.Boudetal46andMezirow47wouldhaveindi-catedthatthesefacultyareengaginginthereflec-tive process from their own student experiencesintheclinicalsetting,connectingittopriortheo-reticalknowledgeinordertoimprovefutureclinicalpractice,andultimately, learning fromone’sownexperience.

Lastly, participants identified a lack of time toadequatelyteachcriticalthinkingskillsinthecur-riculum.Researchindicatesittakestimetodevel-opincreasedlevelsofcriticalthinkingandstudentsmust progress through the various levels.25 PaulandElderalso indicate facultymustbewilling tomovestudentsthroughthevariouslevelsofthink-ing utilizing research-based teaching strategiesemployingcriticalthinkingskills.26-30Whileourpar-ticipantsexpressedwillingnesstoengage insuch


ConclusionThefindingsofthisstudyserveasoneresponse

to the American Dental Education AssociationCommissiononChangeandInnovation’schallengefor dental hygiene educators to expand their re-search-basedpedagogicalapproachestoteachingandlearningwithaparticularemphasisonthecon-ceptofcriticalthinking.11ThisresearchprovidesaninterpretationofhowdentalhygienefacultyinoneMidweststatedefineandunderstandtheconceptofcriticalthinkingwithintheirdentalhygienepro-gram.

While a qualitative study focusing on theden-talhygieneprogramswithinasinglestatecannotbe generalized to all dental hygiene programs,

activities,andhadanunderstandingofhowsuchskillsbecomemorecomplexovertime,theyidenti-fiedtimeasaconstraintwhentryingtoincorporatecriticalthinkingskillsintotheircoursework.

this study revealed a very strong desire amongthese faculty to incorporate critical thinking intotheirwork.Theywanttodowhattheybelieve istherightthing,buttheiractualknowledgeofthedefinitionalandapplication theoriesabout criticalthinkingisstillintheearlystagesofdevelopment.It is important for the profession to ascertain ifotherfacultyacrossthecountryarealsoinasimi-larposition,andifso,energyshouldbeexpendedviatargetedfacultydevelopmenttohelpmovetheprofessiontowardtheirultimategoal–havingwelltrainedhealthprofessionalsusingcriticalthinkingskillsintheirdailypractices.

Kimberly S. Beistle, PhD, RDH, CDA, is Program Coordinator of Dental Hygiene and associate pro-fessor in the College of Health Professions at Ferris State University. Louann Bierlein Palmer, EdD, is Professor and the Educational Leadership PhD Pro-gram Coordinator in the Department of Education-al Leadership, Research and Technology, Western Michigan University.

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