journal of dental hygiene - american dental hygienists...

72 The Journal of Dental Hygiene Vol. 89 • No. 2 • April 2015

•Fibromyalgia Syndrome: Considerations for Dental Hygienists

•IndependentAnalysis:EfficacyofSealantsUsedinaPublicHealthProgram

•BarriersFacedbyExpandedPracticeDentalHygienistsinOregon

•ExploringPreadmissionCriteriaasPredictorsforDentalHygieneLicensureExaminationsPassRates

•AssessmentofPathologyInstructioninU.S.DentalHygieneEducationalPrograms

•TheRelationshipbetweenMethamphetamineUseandDentalCariesandMissingTeeth

•KnowledgeandBehaviorsRegardingEarlyChildhoodCariesAmongLow-IncomeWomeninFlorida:APilotStudy

Journalof

DentalHygiene

The AmericAn DenTAl hygienisTs’ AssociATion

April 2015 Volume 89 number 2

Vol. 89 • No. 2 • April 2015 The Journal of Dental Hygiene 73

Journal of Dental HygieneVOLUME89•NUMBER2•APRIL2015

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

Please visit http://www.adha.org/authoring-guidelines forsubmission guidelines.

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 EDITORJosh [email protected]

LAYOUT/DESIGNJosh Snyder

PRESIDENTKelliSwansonJaecks,MA,RDH

PRESIDENT–ELECTJillRethman,RDH,BA

VICE PRESIDENTBettyA.Kabel,RDH,BS

TREASURERLouannM.Goodnough,RDH,BS

IMMEDIATE PAST PRESIDENTDeniseBowers,RDH,MSEd

2014 – 2015 ADHA OFFICERS


InsideJournal of Dental Hygiene

Vol.89•No.2•April2015

Features

Editorial

Research

76 Fibromyalgia Syndrome: Considerations for Dental Hygienists AmberWalters,BSDH,MS;SusanL.Tolle,BSDH,MS;GayleM. McCombs,BSDH,MS

86 IndependentAnalysis:EfficacyofSealantsUsedinaPublic Health Program JodiL.Olmsted,RDH,PhD,FAADH;NancyRublee,RDH,CDHC;Laura Kleber,BS,CCRC;EmilyZurkawski,PTA

91 Barriers Faced by Expanded Practice Dental Hygienists in Oregon AmyE.Coplen,RDH,EPDH,MS;KathrynPBell,RDH,MS

101 Exploring Preadmission Criteria as Predictors for Dental Hygiene Licensure Examinations Pass Rates TammyR.Sanderson,RDH,MSDH;MarciaH.Lorentzen,RDH,MSEd, EdD

109 Assessment of Pathology Instruction in U.S. Dental Hygiene Educational Programs BarbaraB.Jacobs,RDH,MS;AnnA.Lazar,PhD;DorothyJ.Rowe, RDH,MS,PhD

119 The Relationship between Methamphetamine Use and Dental Caries and Missing Teeth E.MarciaBoyer,PhD;NancyThompson,PhD;TracyHill,RDH,BS,BA; M.BridgetZimmerman,PhD

132 Knowledge and Behaviors Regarding Early Childhood Caries Among Low-Income Women in Florida: A Pilot Study MaryamRahbari,BA,RDH,MPH;JaanaGold,DDS,PhD

75 Thank You for Your Support! RebeccaS.Wilder,RDH,BS,MS

Review of the Literature

Short Report


ThankYouforYourSupport!

EditorialRebeccaS.Wilder,RDH,BS,MS

The Journal of Dental Hygiene continues togrow and expand thanks to the many individu-alswhosubmittheirworktoourpublicationandthe numerous volunteers who provide their ex-pertisetoreviewthesesubmissions.Inaddition,wehavemanyindividualswhoarenotformallyonour Editorial Review Board who contribute theirtimewhenneeded.ThiseditorialisdevotedtoallofwhocontinuetosupporttheJournalofDentalHygiene.

Oureditorialreviewboardismadeupofagroupof ultimate professionals from dental hygiene,dentistry,nursing,basicscience,pathology,radi-ologyandphysicaltherapy.Asourprofessioncon-tinuestoexpandandcollaboratewithotherhealthcareprofessionals,havingawidevariationinex-pertisewillbeimportant.Thankyoutoallofthememberswhohave contributed their knowledgeandtimetoimprovingthewritingskillsofothersandenhancingthequalityofourpublication.

The past year has continued to see changes.Asyourecall, in2014we increased from4to6issues per year. In late 2014we transitioned toBenchPress, a web-based manuscript trackingandmanagementservicedevelopedbyHighWirePressforpublishersofscholarlycontent.Now,wecanprovideimprovedservicetoourmembers.Inaddition, our peer reviewers can provide timelyevaluationsofthemanuscriptswhichwillequateto quicker communication with authors.We ap-plaud the ADHA staff and ADHA Board for their supportofthissystem,toimprovetheservicetoour members.

I wish to gratefully acknowledge the supportandvaluablecontributionsoftheAmericanDen-tal Hygienists’ Association for their commitmentto the Journal ofDentalHygiene and for recog-nizing the value of scholarship to the growth ofthe profession. Specifically, I wish to thank ourJournal Staff Editor, Josh Snyder, for his atten-tiontodetail,professionalmanner,patiencewithauthors,reviewboardmembersandme!Also,aspecialthankyoutoAnnBattrell,ExecutiveDirec-toroftheADHA,forhersupportoftheCommuni-cationsDivisionsandherleadershipattheADHA.And,sincelastsummer,wehaveanewDirectorofCommunicationswhooverseesthedivisionthathousestheJournalofDentalHygiene.JohnIwan-skihasbeenvery supportiveof the Journalandhealsobringsmuchexpertise fromhispreviouspositionsatotherassociationswhopublishscien-tificpublications.

Finally, Iwould like toacknowledge thepass-ingofoneofourcherishededitorialreviewboardmembers,ProfessorMicheleDarby.Micheleservedas editor of the Journal of Dental Hygiene many yearsagoandshewasanactivereviewermostofhercareer.IwillpersonallymissMichele’senthu-siasmfornewresearchandscholarlyideas.

ThanksagainandIlookforwardtoworkingwitheachofyoutocontinuallyimproveourJournal!

Sincerely,

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

Guest Contributors - Editorial Review BoardRolandArnold,PhDKathrynBell,RDH,MS

ErikaBenavides,DDS,PhDSharonBrooks,DDS,MSKimonDivaris,DDS,PhDCarolynHuynh,DDS,MEd

SajithaKalathingal,BDS,MSAntonioMoretti,DDS,MSRicardoJ.Padilla,DDS

DavidPaquette,DMD,MPH,DMScBradPotter,DDS,MS

KarenRaposa,RDH,MBA


Fibromyalgiasyndrome(FMS)isaneurosensory disorder of unknownetiology characterized by chronicmusculoskeletal pain, fatigue, ten-derness and sleep disturbances.FMS can result in severe disabilityandlossoffunction, leadingtode-creasedqualityoflife.1 This disorder canaffectanyaspectofanindivid-ual’sbody,includingtheoralcavity,andadverseorofacialconditionsarecommon.Modificationsindentalhy-giene treatment are often needed to ensure patient comfort and op-timum treatment. In addition, oralcarepractitionersmayidentifyearlysymptomsofFMS,assistingthepa-tientinreceivingaproperdiagnosis.Appropriate dental hygiene manage-ment requires an understanding ofdisease characteristics and pathophysiology, oralhealthconsiderationsandtreatmentinterventions.

Epidemiology

FMS is the second most common diagnosismade by rheumatologists and is estimated to af-fect3to6%of thepopulationworldwide.2,3FMScan affect anyone regardless of age, gender orethnicity;however75to90%ofpeoplediagnosedarewomen.3Prevalenceoffibromyalgia ishigheratmiddleage(30to50years)orovertheageof50.4-13TheworldwideincidenceofFMSis6.88per1,000malesand11.28per1,000females.14 The incidencemay be increasing and is linked to in-creaseddiseaseawarenessamongphysicians.

Basic Characteristics

The 1990 American College of RheumatologyclassificationcriteriaforFMSincludedahistoryofchronic,diffusepainaffecting4quadrantsofthebody for at least 3 months and pain upon palpation in at least 11 out of 18 tender points.15In2010,the American College of Rheumatology revisedthiscriterion,eliminatingtheneedtoassessten-

Fibromyalgia Syndrome: Considerations for Dental HygienistsAmberWalters,BSDH,MS;SusanL.Tolle,BSDH,MS;GayleM.McCombs,BSDH,MS

AbstractPurpose:Fibromyalgiasyndrome(FMS)isaneurosensorydisor-dercharacterizedbywidespreadmusculoskeletalpain.Typicallypersistentfatigue,depression,limbstiffness,non-refreshingsleepandcognitivedeficienciesarealsoexperienced.Oralsymptomsandpainarecommon,requiringadaptationsinpatientmanage-mentstrategiesandtreatmentinterventions.Appropriatedentalhygienecareofpatientssufferingwiththisdisorderiscontingentuponanunderstandingofdiseaseepidemiology,pathophysiology,clinicalcharacteristics,oralsignsandsymptoms,aswellastreat-mentapproaches.WiththisinformationdentalhygienistswillbebetterpreparedtoprovideappropriateandeffectivetreatmenttopatientswithFMS.Keywords: fibromyalgia, oral hygiene, orofacial pain, specialneeds,medicallycomplexpatientsThisstudysupportstheNDHRApriorityarea,Clinical Dental Hy-giene Care: Assesstheuseofevidence-basedtreatmentrecom-mendationsindentalhygienepractice.

ReviewoftheLiterature

Introduction

derpoints.Instead,thecriteriarequiresadetailedinterviewtoevaluatetotalbodypainusingaWide-spreadPain Index,aswellasameasurementofsymptomseverity,knownastheSymptomSever-ityscale.16TobediagnosedwithFMSthecriteriafound in Figure 1 must be met.

ThemostpredominantsymptomofFMSischron-ic,widespreadmusculoskeletalpain,describedasbeing persistent, deep, aching and/or throbbing.Hyperalgesia(exaggeratedorprolongedresponseto stimuli), dysesthesia (unpleasant, abnormalsenseoftouch)andallodynia(perceptionofpaintoanon-painfulstimulus)arealsocommonfind-ings.17,18Somepeopleexperienceuniformpainalldaylong,whileothersreportpainthatisworseinthemorning,improvesduringthedayandworsensagain at night. Pain associatedwith FMS can beexacerbatedbyphysicaloremotionalstress,non-restorativesleep,strenuousactivityandchangesinweather.18,19

Fatigue, cognitive deficiency, tenderness uponmildpalpationandnon-restorativesleeparecom-monmanifestationsoftenaccompaniedbyawidearray of additional symptoms listed in Figure 2.20,21


Theonsetofsymptomscanappearsuddenly;how-ever,theyaregenerallyexperiencedgradually.20,22 Common psychiatric and medical comorbiditiesmayalsobepresent(Figure3).18,21

Diseases of fatigue andwidespread pain havesimilar signs and symptomsmaking the diagno-sisofFMSdifficult.Lymedisease,hypothyroidism,rheumatoidarthritis, systemic lupusandundiag-nosedcancerareoftenconfusedwithFMS(Figure4).18,22Becausetherearenoobjective laboratoryorradiographicteststodefinitivelydiagnoseFMS,patientsoftenreporta longdelaybetweenonsetof symptoms and a diagnosis.1

Sleepdisturbancesreportedincludenon-restor-ativesleep, insomniaandpoorqualityofsleep.23 Munguia-IzquierdoandLegaz-Arreserevealedtheprevalenceofpoorsleepqualitywas96%inpa-tientswithFMScomparedto46%forhealthysub-jects.24Qualityofsleepwasmuchlowerinpatientswith FMS compared to controls and poor sleepqualitywasstronglyassociatedwithpainandfa-tigue.24

FMScan result in severedisability and lossoffunction,making daily tasks, including oral self-care, difficult or unmanageable.1,19,25 ResearchbyBennettetal suggestspeoplewithFMShavedifficulty with routine activities such as walking2blocks(55%),climbingstairs(62%),shopping(66%),householdchores(68%)andcarrying10pounds(70%).19ThedebilitatingeffectsofFMScanalsobeseenintheworkplace.Decreasedabilitytofunctionleadstolossinproductivity,increasedworkabsenteeismandanoveralldecreasedqualityof life.26Infact,workingadultswithFMSmissanaverageofalmost17daysofworkannuallycom-paredto6daysforthosewithoutthesyndrome.27 Fatigue, inability to concentrate, decreased mo-tivation, and low self-efficacy may contribute topoorjobperformance.

Depression,anxiety,stressandimpairedcogni-tivefunctionarecommonpsychologicalfindingsinpatientswithFMS.Bennettelalfound38%ofFMSpatients reported anxiety and 40% reported de-pression.19Thesepsychologicaldisturbancesmaybe related to copingwith the debilitating effectsand chronic pain of FMS, rather than a primarysymptom.28 Cognitive deficiency in people withFMS issometimescalled“fibro fog”and includesshort-termmemoryloss,reducedmentalalertnessanddecreasedabilitytomultitask.18,21

Pathophysiology

FMSislinkedtoamultifactorialetiology.22 Sus-

Criteria:ApatientmeetsthediagnosticcriteriaforFMSifthese3conditionsaremet:• Widespreadpainindex≥7andsymptomseverityscalescore≥5orWidespreadPainIndex3to6andSymptomSeverityscalescore≥9

• Thepatienthasbeenexperiencingsymptomsatasimilarlevelfor3monthsorlonger

• Thepatientdoesnothaveanyotherconditionthatwouldexplainthepain

Scoring:WidespreadPainIndex:Countthenumberofregionsthepatientreportspainwithinthelastweek• Scorewillrange0to19.SymptomSeverityScaleScore*:Indicatehowsevereeach of these 3 symptoms (fatigue, waking unre-freshed,cognitivesymptoms)havebeenoverthepastweekusingthefollowingscale:• 0-Noproblem• 1-Slightormildproblems• 2-Moderate,oftenpresentand/oratamoderatelevel

• 3-Severe,continuous,life-disturbingproblemsConsideringcommonothersymptoms,notewhetherthe patient has:• 0-nosymptoms• 1-fewsymptoms• 2-amoderateamountofsymptoms• 3-manysymptoms

*TheSymptomSeverityscalescoreisthesumofthese-verityofthe3symptoms(fatigue,wakingunrefreshed,cognitivesymptoms)andtheextentoftheothersymp-tomsingeneral.Scorewillbebetween0and12.

Figure 1: 2010 Fibromyalgia Syndrome Di-agnosticCriteria16

Musclepain BlurredvisionIrritablebowelsyndrome Fever

Tiredness DiarrheaThinkingormemory

problems Tinnitus

Muscleweakness VomitingMigraines Seizures

Numbness or tingling Dry eyesStiffness Loss of appetite

Trouble sleeping RashDepression Sensitivitytolight

Nausea HearingdifficultiesFrequentorpainfulurination

Figure 2: Symptoms of Fibromyalgia Syn-drome16


pectedcausesofFMSincludeabnormalitiesinpainpathways, as well as genetic and environmentalfactors.21-23 Cerebrospinal fluid substance P is aneurotransmitterreleasedwhenaxonsarestimu-lated. Consistently elevated in people with FMS,this causes increased sensitivity and enhancedawarenessofpain.23,29SubstancePhelpsregulatethe responsiveness of N-methyl-D-aspartate re-ceptorstotheneurotransmitterglutamide,whichplaysarole incentralsensitizationandtemporalsummation.20,21 Concentration of substance P incerebrospinalfluidis2to3timeshigherinpeoplewith FMS compared to control subjects.23,29 Sub-stancePisinvolvedintransmissionofpaininfor-mationfromtheperipherytothecentralnervoussystem (CNS). Research suggests the combinedeffectoflowserotoninlevelsandhighsubstancePconcentration,contributetomorepainthaneitherabnormalityontheirown,andthisdualdysfunc-tionmayberesponsiblefortheonsetofFMS.21,30

TheCNS is thepredominant sourceof pain inFMS. CNS sensitization, increased excitability ofneuronsfoundinthespinalcord,makesneuronsmoresensitive to stimuli.Central sensitization ischaracterized by an exaggerated pain response,prolongeddurationofpain, increasedpain inten-sity andwiderpaindistribution.21 A related phe-nomenontosensitizationistemporalsummation,called “wind-up,”which occurswhen a stimuli isappliedrepeatedly.WitheachrepeatedstimulationthereisaprogressiveincreaseinpainleadingtoprolongedstimulationofCnervefibers.21Researchsuggests levels of temporal summation from re-petitivestimulationinpeoplewithFMSconsistent-lyexceedthoseofcontrolsubjectsoverarangeofstimulusfrequencies.31,32 These phenomenon most likelyresultinpeoplewithFMSexhibitingalowerthreshold of pain in response to stimuli.

Aneuroendocrinesystemdysfunctioninvolving

theabnormalfunctioningofthehypothalamicpi-tuitaryadrenalaxisislinkedtosleepdisturbancesinpatientswithFMS.21,22Inresponsetostress,thebody secretes cortisol, andduring chronic stressthe body continually increases secretion of thischemical. Inaneffort tocounteract theelevatedamountofcortisol,thenegativefeedbackloopisamplifiedwhicheventually leads toovercompen-sationandcortisoldeficiency.22Thiscortisoldefi-ciency ismost likely culpable in causing non-re-storativesleepforFMSpatients.22

Researchhasalsolinkedabnormallevelsoftheneurotransmitters serotonin, norepinephrine anddopaminewithFMS.2,20,22,23,30,33Lowserotoninlev-elsarethemostwidelyacknowledgedbiochemicalirregularity found in peoplewith FMSandareofparticularinterestduetotheiraffectondeltasleepand pain modulation.18,22,23,33-35 Serotonin and nor-epinephrine play a role in stopping pain response byhinderingpainpathways.WhenindividualswithFMS have decreased levels of these neurotrans-mitters their pain is prolonged.20,22 Dopamine plays acriticalroleinmodulatingpainperceptionintheCNSbyinhibitingpainpathwaysandinducingnat-uralanalgesiaduringacutestress.Duringchronicstress the body tries to restore homeostasis and dopamine eventually becomes decreased due toovercompensationofthenegativefeedbackloop,leadingtoahyperalgesicstate.

Both genetic and environmental factors maybeinvolvedinthedevelopmentofFMS.Researchsuggests the high occurrence of FMS in familiesmaybe attributed to genetic factors.36-38Womenwhohavea relativewithFMSaremore likely tohavethesyndrome;however,itisunclearwhetherthisisduetogenetics,sharedenvironmentalfac-tors or both.39

Environmental triggers such as mechanical or

Anxiety Myofascialpainsyndrome

Chronicfatiguesyndrome Raynaud’sphenomenon

Depression Restlesslegsyndrome

Interstitialcystitis Sjögren’ssyndrome

IrritablebowelsyndromeTempormandibular

joint disorder(TMD)

Figure 3: Comorbidities of Fibromyalgia Syndrome18,21

Adrenaldysfunction MyofacialpainAnemia Psychiatricconditions

Bonemarrowdisease RheumatoidarthritisChronicfatiguesyndrome Sleep disordersHumanimmunodeficiency

virus(HIV)Systemicinflammationor

infection

Hypothyroidism Systemiclupuserythe-matosus

Lyme disease Viral hepatitis

Multiplesclerosis Vitaminand/ormineraldificency

Figure4:DifferentialDiagnosesforFibro-myalgia Syndrome18,22


physical trauma and psychosocial factors havebeencorrelatedwiththedevelopmentofFMS.33 A studybyBennettetalsuggestschronicstress isthemostperceivedtriggeringeventofFMSonset(41%) followed by emotional trauma (31.3%).19 Trauma and stress may alter the pain modulatory responseinthebrain,whichcouldcontributetotheenhanced pain perception. Acute illness, seriousinfection, physical injury, surgery, motor vehicleaccidentsandotherpainconditionsarealsocom-monly reported physical stressors.19,33 Psychoso-cialfactors,suchasacatastrophiceventorabuse(emotional, physical or sexual) have also beenassociatedwithonsetofsymptoms.19,33However,researchontherelationshipbetweenphysicalandemotional abuse and the diagnosis of FMS havebeeninconsistent.40,41Havilanetalrevealedacor-relation between both sexual assault/abuse andphysical assault/abuse and FMS diagnosis; how-ever, life-threatening trauma, emotional abuse/neglectandmajorlifestresswerenotfoundtobeassociatedwithFMSdiagnosis.42

Treatment

TreatmentofFMSfocusesonsymptommanage-mentand improvingqualityof life.Aholisticap-proachthatintegratesphysical,psychologicalandbehavioralfactorswiththeimplementationofphar-macological and non-pharmacological strategiesishelpful inmanagingFMS.1-3,18-21,33,35MedicationsapprovedbytheFoodandDrugAdministrationforthetreatmentofFMSincludepregabalin(Lyrica®;Pfizer,NewYork,NY),duloxetine(Cymbalta®;EliLilly and Company, Indianapolis, Ind.), andmil-nacipran(Savella®;ForestLaboratories,NewYork,NY).1,3,21Non–pharmacologicaltherapiesfortreat-mentofFMS includepatienteducation,exercise,and cognitive behavioral therapy. Additionally,acupuncture, hypnotherapy, balneotherapy (me-dicinalbaths),biofeedback,ultrasound,relaxationtherapyandtenderpointinjectionshavebeenre-portedastreatmentoptions;however,evidenceislackingtosupporttheeffectivenessofthesethera-pies.18,33

Oral Concerns

Most patients with FMS report symptoms offacial pain, including discomfort in the musclesof mastication, temporomandibular joint (TMJ),neck,earandjaw.43AstudybyAlonso-Blancoetal investigated thedifferences inprevalenceandlocalizationofreferredpainareasofactivetriggerpointsbetween20womenwithmyofacialtemporo-mandibularjointdysfunction(TMD)and20womenwithFMS.ResultsrevealedparticipantswithFMShadlargerreferredpainareasthanthosewithTMD

forthesternocleidomastoidandsuboccipitalmus-cles.44Leblebicietalsoughttodeterminethecor-relationbetweenFMS,TMDandmasticatorymyo-facialpain.Agroupof31peoplediagnosedwithFMSandagroupof21peoplediagnosedwithTMDcompletedaquestionnaireandunderwentaclini-cal examination,which includedbilateralmanualpalpation of themasticatorymuscles. The ques-tionnaireconsistedofquestionsaboutpriorheadand neck trauma, parafunctional habits, musclefatigue, crepitus of theTMJ, restrictedmandibu-larmovement,jawpainandpriorTMDtreatment.Results revealed 80% of patients with FMS hadmasticatorymyofacial pain and TMD.45 This data supportspreviousresearchthatindicatedthehighrate of involvement of the stomatognathic sys-tem in the course of FMS.46Myofacial pain in fi-bromyalgicpersonshasalsobeennotedinseveralotherstudies,rangingfrom40.9to85%.43,47,48 A studybyPimenteletalrevealedfacialmusclepainhasbeenreportedtobe31-timesmoreprevalentin people with FMS than thosewithout the syn-drome.43 Additionally, in a study conducted byFragaetal,masticatorymusclepainwasreportedby93.3%ofpeoplewithFMSinatleastonemas-ticatorymuscle.47AstudybyWolfeetalrevealedjawpainspecificallywasself-reportedby35.4%ofindividualswithFMS.49

ManypatientswithFMSalsoexperiencesymp-toms of TMD. A study by Pimentel et al investi-gated the prevalence of clinical features of TMDinpeoplewithFMS.FortywomenwithFMSwerecompared to 40 healthy controls using the Re-searchDiagnosticCriteriaforTemporomandibularDisorders (RDC/TMD). Results indicated 77.5%of the subjectswith FMSmet thediagnostic cri-teriaforRDC/TMDGroupI(muscle involvement)comparedto10%ofthecontrolgroup.43PreviousstudieshavealsoshownfibromyalgicpersonshaveahighprevalenceofsignsandsymptomsofTMD,rangingfrom67.6to93.4%.45-48,50-52Additionally,studiessuggestFMSmaybeapredisposingfactorfortheonsetofTMD,43,47,48,53,54especiallyconsider-ingtherearemoreindividualswithFMSwhohaveTMDthanpeoplewithTMDwhohaveFMS.45,46

RoutinetreatmentsofTMDmaynotbenefitpeo-plewithFMSbecausethecomorbidityofthese2conditionsmay result fromthealteration inpainperception. Failureof thedental hygienist to ac-knowledgetheunderlyingFMSdiagnosismayleadto lackofappropriatetreatment.Occlusalsplintsoften recommended for patients suffering fromTMD, have not been shown to be beneficial fortreatingmyofacialpaininpeoplewithwidespreadpain.55However,tactilestimulationintheformofmassagehashadapositiveeffectonclinicalsigns


andsubjectivesymptomsofTMD,aswellaswide-spreadpaininFMSpatientswhowereunaffectedbyroutineTMDtreatment.56

AdditionaloralmanifestationsprevalentinFMSpatientsincludelimitedmouthopening,painuponopeningandmasticatorypain.43,50MuscleandjointpainduringopeningandclosingisprevalentwithFMS.43 The prevalence of limitedmouth openinghas been reported to be 10 times higher in people withFMSthancontrolswiththeaveragemaximumvoluntarymouthopening for FMSpatients at 41mm,comparedto44mmin thecontrolgroup.43 Theexactcauseisunknown,butitislikelymusclepainduring jawmovements contributes to lowerrange of motion during mouth opening.

Xerostomiaisanothercommonoralmanifesta-tionassociatedwithFMS.Medicationssuchasan-tidepressants,hypnotics,muscle relaxants,anal-gesicsandanticonvulsantsusedtotreatFMSmaycontributetoxerostomia.17AstudybyRhodusetalinvestigatedtheprevalenceoforalsymptomsinpatientsdiagnosedwithFMS.Sixty-sevenwomenwithFMSandmatchedcontrolscompletedaques-tionnaireandunderwentanoralexamination.Thequestionnaire included questions about subjec-tivesymptomsofglossodynia(oralburning),xe-rostomia,dysphagia (difficultyswallowing), tasteabnormalitiesandTMD.Resultsrevealedapproxi-mately 70% of subjects with FMS experiencedxerostomia.51 Only 27.5% of FMS subjects whoexperienced xerostomia were taking xerogenicmedications, therefore research suggests a highprevalence of xerostomia in this patient popula-tionevenwhencontrollingforxerostomia-inducingmedications.51 FMS patients may experience in-creasedcariesrate,periodontaldisease,dyspha-gia,dysgeusia(distortionoftaste),mouthulcersandcandidiasisduetoxerostomia.17

Glossodynia is commonly accompanied by xe-rostomiaanddysgeusiaandisexperiencedbyap-proximately one-third of fibromyalgic persons.51 Glossodynia may represent hyperalgesia and al-lodynia resulting fromnervous system sensitiza-tion.51 The neurological mechanisms responsibleforglossodyniamayalsocontributetochronicpaininFMS.Treatmentofglossodyniacanbedifficultdueitsunknownetiology.Glossodyniaisasideef-fectofcertainmedications;however, itmayalsobecausedbynutritionaldeficiencies,hormonalim-balancesordepression.57TricyclicantidepressantsmaybenefitpeoplewithFMSandglossodyniabe-causetheycanbeusedtotreatdepression,whichmayplayaroleinthedevelopmentoforalburningandmanagechronicpain.2,17,33,57

DysgeusiaisalsoexperiencedbyFMSpatients.51 Itisunclearwhetherdysgeusiarepresentsatrueoral manifestation of FMS or is a side effect ofmedications.Xerostomiacaninducedysgeusiabe-causenormalsalivaryflowandconcentrationareessential for taste. If dysgeusia is drug-induced,patientscanconsulttheirphysicianaboutsubsti-tutinganothermedicationinplaceoftheonecaus-ingtastedisturbances.58

Patient Management

AdetailedhistoryofFMSshouldbedocument-edincludingdateofdiagnosis,courseofthesyn-dromeandallcurrentmedications.PatientsshouldbequestionedaboutorofacialpainandheadachesthatmaybeindicativeofTMD,aswellaspossibleoralmanifestations of FMS including xerostomia,glossodyniaanddysgeusia(Figure5).Whenper-forming an extraoral exam, the dental hygienistshouldbecognizantofpossiblepatientdiscomfortin the regionsof theTMJandmuscles ofmasti-cation. Additionally, if FMS is not diagnosed andsuspected, the dental hygienist should refer thepatientforfurthermedicalevaluation.17

Dental hygienists should consider adapta-tionsduringtheprocessofcaretoensurepatientcomfortandanefficaciousappointment.Patientsshouldbequeriedaboutwhattimeofdaytheyfeelbest and scheduled accordingly. Many FMS pa-tientsexperiencepainandstiffness that ismoresevere inthemorning;therefore,a latemorningor early afternoon appointment may work best.However, patients with FMS may cancel at thelast minute complaining of pain, fatigue or lackof restful sleep. Additionally, FMS patients maynot be able to tolerate long appointments due to jawtirednessandpain.Ifpossible,offertobreakup thepatient’s treatmentplan toaccommodateshorterappointments.Topromoteefficiencydur-ing the appointment, a dental hygiene assistantand4-handeddentistryisrecommended.Patientsshould alsobe asked to completemedical histo-ryformspriortoarrival.Toconserveenergyandhelppreventpostexertionalmalaisefollowingtheappointment,adisabledparkingspaceshouldbeavailableandFMSpatientsshouldbetreatedinanoperatoryclosetothereceptionarea.

Xerostomia DysgeusiaGlossodynia DysphagiaTemporomandibularjointdisorder(TMD)Painorfatigueintheorofacialregion

Figure5:OrofacialManifestationsofFibro-myalgia Syndrome17,50


A stress-free treatment environment is idealsincestresscanexacerbatethepainresponse inFMSpatients.18,19 Strategies to help manage stress duringtheappointmentincludedevelopingatrust-ingrelationshipbetweenthepatientandtheprac-titioner, effective pain management strategies,and, forsomepatients,nitrousoxide-oxygense-dation.Musclerelaxantsmayalsoassistpatientswithkeepingthemouthopenwiderandmorecom-fortablyforalongerperiodoftimealsoreducingstress.Moreover,FMSpatientsmayfindbreathingorrelaxationexerciseshelpfulpriortoandduringthedentalhygieneappointmenttoreducestress.

Preventingoral infection is important since in-fection increases stress on the body,which con-sequentlyexacerbatessymptomsofFMS.19,50 Fre-quentrecareappointmentsshouldbeencouragedtohelppreventoralinfectionandmonitororalself-care.Cautionshouldbeusedwhenprescribingan-tibiotics,as theymay increase therapeutic levelsofothermedicationsFMSpatientsmaybetakingsuchascitalopram(Celexa®;ForestLaboratories,NewYork,NY)andzopiclone(Imovane®;Sanofi-Aventis, Bridgewater, NJ).17 Some FMS patientsmaybenefitbytakinganti-anxietymedicationormusclerelaxantpriortotheirdentalhygieneap-pointmenttohelpreduceemotionalstressoranxi-ety.SinceFMSpatientsoftenexperienceheight-ened pain sensitivity and fatigue, modificationsmaybenecessarytoensurepatientcomfortandadequatepainmanagement.Bothtopicalandlocalanesthetic agents are recommended to managediscomfort during scaling and root debridement.Anestheticagentswithvasoconstrictorsshouldbeavoided forpatients takingamitriptyline (Elavil®,AstraZeneca,London,UK),venlafaxine(Effexor®,Wyeth Pharmaceuticals, Madison, NJ) or dulox-etine because they may create a hypertensivecrisis.17 Some patients may require intravenoussedationformoreextensivetreatment.Prolongedperiodsofjawopeningshouldbeavoidedandfre-quentbreaksmaybenecessaryforjawrest.Dur-ing dental hygiene care, practitioners will find amouthproporbiteblockmosteffectiveasthiscanprovideadditionalsupportforthosewhohavelim-ited mouth opening or fatigue easily.

Because jawpainmaypersistafter thedentalhygieneappointment,FMSpatientsshouldbeen-couragedtoeatasoftdiet,usewarmcompressesin the jaw region (unless heat exacerbates theirsymptoms)anduseanalgesics suchas tramadol(Ultram®; Janssen Pharmapeuticals, Titusville,NJ)ormuscle relaxants suchas cyclobenzaprine(Flexiril®;McNeilConsumerandSpecialtyPharma-ceuticals, Fort Washington, Penn) and tizanidine(Zanaflex®; Acorda Therapeutics, Ardsley, NY).17

NSAIDs (e.g., aspirin and ibuprofen) should notberecommendedforpatientstakingselectivese-rotoninreuptake inhibitorsbecausetheymay in-creasetheriskofprolongedbleeding.17

Patients with FMS are often hypersensitiveto stimuli such as noise, heat, cold, touch andlight.1,21,23Thesenormallynon-painfulstimulimayproducepainforpeoplewithFMS.Therefore,pa-tients should be consulted about the impact ofextraneous noise, such as background music,televisions andpowered scalers so these canbeeliminated or minimized if bothersome. A blan-ketorwarmneckrollshouldbereadilyavailableif the patient gets cold. A cervical pillow can beusedtosupporttheneckbetterthantheconven-tionaldental chairheadrestand reducepressureontenderpointslocatedonthebackoftheheadand neck. Additionally, since some FMS patientsexperiencehypersensitivitytolight,oralcarepro-fessionals shouldbe conscientiousofnot shiningthe dental light in the patient’s eyes and tintedeyewearshouldbeprovided.

Patient Education

In order to reduce stress and improve FMSsymptoms,oralcareprofessionalsshouldencour-agetheirpatientstoliveahealthylifestyle.Poornutritioncanincreasetheproductionandsecretionofstresshormonesanddecreasethesecretionofinsulin,whichcanleadtoaloweredresistancetoinfection such as periodontal disease.57 Dietary counselingcanbeutilizedwhenappropriatetopro-motehealthyeatinghabits.Datasuggeststobaccosmokingmayexacerbateclinical featuresofFMSpatients.59,60Aspartofencouragingahealthylife-style,tobaccocessationshouldberecommended.

Due to the debilitating effects of FMSand co-morbidities,patientsmayhavedifficultyperform-ing oral self-care. Extremities of FMS patientsoften feel swollen, with upper extremities moreimpacted than lower extremities; therefore, oralself-caremay be negatively affected.61 Addition-ally,FMSoftenco-occurs(upto25to65%)withother rheumatic conditions, and as a result ofthese conditions, some patientsmay experiencedexterity issues.62 FMS patients with impairedmanualdexteritymayfindpoweredtoothbrushes,flossingdevicesandinterdentalbrusheshelpful.62 However,thenoisefromapowereddevicemaybeaproblemforFMSpatientswithheightenedsen-sitivitytosound.AnotheroptionistheSurround® toothbrush,whichcanberecommendediffinancesornoisepreventthepurchaseoruseofpowereddevicesorthepatient fatigueseasily.63 For some patients, modifying the toothbrush by extend-


Conclusion

FMS is a common disorder that encompassessymptomsofchronic,widespreadmusculoskeletalpain, fatigue, cognitive deficiency and sleep dis-turbances. Oral manifestations of FMS are com-monandaffecttheoralandoverallhealthofthepatient.DentalhygienistsmustbeknowledgeableaboutoralsignsandsymptomsofFMSinordertoeducatetheirFMSpatientsonmanagementstrate-giesandoralself-caremodifications.Additionally,dentalhygienistsshouldbepreparedtomakeap-propriateadjustmentswhentreatingpatientswithFMStoensurehygienecareisrenderedinacom-fortableandeffectivemanner.

Amber Walters, BSDH, MS, is an adjunct assis-tant professor. Susan L. Tolle, BSDH, MS, is a uni-versity professor. Gayle M. McCombs, BSDH, MS, is a university professor and Graduate Program Di-rector, Director, Dental Hygiene Research Center. All are at Old Dominion University School of Dental Hygiene.

ing or enlarging the handle may also be helpful.63 Thesemodificationscanalsobeperformedonflosshandles and interdental brushes.

DepressionisanothercommonfindingwithFMSpatients thatmayhaveanegativeeffectonoralhealthdue to lackofself-care.Dentalhygienistsshouldbecompassionateandprovideencourage-menttoFMSpatientsrealizingself-caremaynotalwaysbeapriorityormaybedifficulttoaccom-plish.Cliniciansmustbecognizantofthepsycho-logicaltollFMStakesonmanyindividuals,aswellasitsoveralldebilitatingeffects.Duetothehighprevalence of cognitive issues resulting in de-creasedmentalalertnessandmemory(fibrofog),patients may benefit from written self-care in-structionsandeducationalmaterialstheycantakehometoreinforceimportantconcepts.

Patients should be educated on the differencebetween the chronic, widespread FMS pain andacutepain fromanoraldiseaseor infection.Pa-tients may attribute dental pain to symptoms of FMSandnotseekimmediatecare,resultinginmi-nordentaldiseaseescalatingtomajor.Therefore,frequent recare intervals are critical to ascertainoraldiseasestatusonaregularbasis.Additionally,withfrequentrecare,dentalneedsmaybeidenti-fiedearly,andbeprovidedbeforemoreextensivetreatment is required,whichmay be difficult forthepatienttowithstand.

Dental hygienists should encourage FMS pa-tients with xerostomia to take an active role inthemanagement of their symptoms tominimizeriskofadverseoraleffects.Strategiestohelpal-leviatexerostomiaincludeusingsalivasubstitutesand sialogogues, and avoiding alcohol and caf-feineconsumption.Salivasubstitutescanbeusedto replacemoisture and lubricate themouth forshorttermrelief.Sialogoguesareanyagent,over-

the-counterorprescription,thataidinmorelongtermreliefbystimulatingnewsaliva.Prescriptionsialogoguessuchaspilocarpine(Salagen®;Eisai,WoodcliffLake,NJ)andcevimeline(Evoxac®;Dai-ichiSankyo,Parsippany,NJ)canberecommendedforpatientswhodonothavemedication-inducedxerotstomia.Chewingsugarfreegumwithxylitolisalsotypicallyrecommendedforpatientswithxe-rostomiatostimulatesalivaryflow;however,manyFMS patients experience pain upon masticationandthereforethismanagementstrategywouldbecontraindicated.Xylitolmintsand lozenges couldbesuggestedastheyprovidebothcariesbenefitandimprovesalivaryflowwithoutstressingmasti-catorymuscles.


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Sealants are recognized as a pre-ventive tool for averting dental car-ies.1-3Multiple studies have validatedsealantefficacy,cost/benefitratiosandneedforpreventingthemostcommonchronic disease in children – dentalcaries.4-15Whensealantsareusedaspartofapublichealthprogram,theycanreducethenumberoflostschooldaysandcostofhealthcare,whileim-provingQualityofLife(QoL).9,11-22 This short report details part of the find-ingsofa larger,multiphasic researchstudy considering Quality of Care(QoC)andQoLforsocioeconomicandunderservedruralpopulationsaccess-ingdentalhealthcarethroughaPublicHealthDepartmentProgram.23

Cariescontinuetobethemostsig-nificant public dental health problemintheU.S.2,3,9,11-16,19-21,24-31Lackofac-cesstooralcareandbeingsocioeco-nomically disadvantaged plagues thepopulationdescribed in thisshort re-port.3,9,11-14,17 A childhood of dentalissues can lead to a lifetime of oralhealthproblems,ifearlyinterventionsare not implemented.1-21,24-31Relative-ly low cost easy solutions, includingsealantprograms,canresultinfewermissed school days, while reducingboth active disease and pain.3,9,13,21 Theburdenfromlong-termeffectsofdental disease on the entire health caresystemcanbereducedusingpreventivesealantprograms.1-4,7-15,18,22,25-31

IndependentAnalysis:EfficacyofSealantsUsedinaPublicHealthProgramJodiL.Olmsted,RDH,PhD,FAADH;NancyRublee,RDH,CDHC;LauraKleber,BS,CCRC;EmilyZurkawski,PTA

AbstractPurpose:Thisshortreportdetailspartofthefindingsofalarger,multiphasic researchstudyconsideringQualityofCare(QoC)andQualityofLife(QoL)forsocioeconomicandunderservedruralpopu-lationsaccessingdentalhealthcarethroughaPublicHealthDepart-ment.Improvingoralhealthforfamiliesthataresocioeconomicallydisadvantaged,withculturaldisparities,orlackingaccesstocarewasthegoalofthisproject.Thepurposeofthisprojectwasdocument-ingeffectivenessoforalhealthcarewhendentalhygienistswork-ingthroughlocalareahealthdepartments,asanalternativedeliverymodel,providequalityeducationalandpreventivecareservices.Clinical Outcomes: Over a 6 year period, 1,511 sealants wereplaced.Simpleclinicalpracticesusing4-handeddentistryandstrictisolation techniques led toachievinga95%orhigher cumulativesealantretentionrate.Dentalcarieswasavertedfor858individualsovera3yearperiod(2006to2009).Usingaconsultation-referralmodel,463individualsreceivedrestorativecare.Resultsfromthisshortreportdocumentclinicalcarepracticesforpopulationsinruralcommunitieswithlimitedaccesstocarewhileimprovingoralhealthoutcomes.Conclusion: Theclinicalfindings inthisshortreport illustratethesuccessesofanoralhealthcareprogramofferedbyadentalhy-gienistworkingcollaborativelythroughaCommunityPublicHealthDepartment.Sealantretention,averteddentalcariesandrestorativecareprovidedusingaconsultative-referralmodelallillustrateclini-calqualityofcareachievedwhenemployingalternativecaremodelsoutsidetherealmoftraditionalinofficeprocedures.Keywords:qualityoflife,qualityofcare,outcomes,healthdispari-ties,prevention,education,alliedhealth,dentalhygiene,dentalseal-antsThisstudysupportstheNDHRApriorityarea,Health Services Re-search: Investigatehowalternativemodelsofdentalhygienecaredeliverycanreducehealthcareinequities.

ShortReport

Introduction

Methods and MaterialsThePriceCountyPublicHealthDepartmentoffers

dentalhygieneservicestoclients.Servicesprovidedareeducational,preventiveand treatmentoriented.Populationsincludeun-servedandunderservedclientsinruralcommunitiesrangingfromprenataltogeriatric

careprogramming.Allprogramparticipantsandfami-liesareeducatedaboutnutrition,dentalcariespre-vention,brushing,flossingandfluorideuseaspartoftheseprograms.Oralscreeningsareconducted,fol-lowedbypreventivetreatmentusingacombinationoffluorideandsealantsbasedonneed.Thisshortreportfocusedonillustratingoutcomesassociatedwithseal-antuseaspartofapublichealthprogram.Thecon-sultative-referralmodel for clinical service and careisevidencebased,andprotocolsarestrictlyfollowed


byparticipatingclinicians.23,32StateserviceprotocolsweredevelopedbasedonCariesManagementbyRiskAssessment(CAMBRA)andtheAssociationofStateand Territorial Dental Directors (ASTDD).33-36 Whenrestorative care is required, a consultative-referralmodel is used.23,32 Sealant programs, and their re-sultantpreventiveoutcomes,arenotnew.Thisshortreportdocumentstheoutcomesofthesealantcom-ponentoftheoverallpreventivepublichealthprogramofferedinPriceCounty.

Four–Handed Dentistry/Isolation

Maintaining isolationduringanydentalprocedurecanbechallenging.Usingmobileequipment,lackofconsistentair/waterpressureduringconnections,lackoftrainedpersonnelprovidingassistanceduringpro-ceduresoruncooperativepatientscancauseretentionratestodecline.37Cliniciansinvolvedcollectivelyaver-agedover10yearsofexperienceplacingsealantsaspartofthisprogram.Four-handeddentalproceduresusingstrict isolation includingdentaldams,coupledwithstrictadherencetomanufacturer’srecommenda-tionsduringsealantplacementwereused,whichmayhavesignificantlyimpactedsealantretention.37 Dental hygienistsnewtoworkingfortheprogramcompletedtrainingandcalibrationpriortoactivelyparticipatinginprovidingclinicalcare.Trainingandcalibrationin-cludedassessment,useofscreeningtools,isolation,placement, retention checks and documentation asperserviceprotocols.23,32Strictisolation,trainingandusing4-handeddentistrytechniqueswerefactorsthatmayhavepositively influenced the reported clinicaloutcomesfoundinTableI.

Retention Rates

The successof sealant retentionwasdeterminedthroughanexaminationofpatientsatboth1and2year intervals post-placement. Researchers did nothaveaccessto2yearretentioncheckdata.Visualandtactileexaminationswereemployedusingmirrorsandexplorersfordeterminingifsealantmaterialswerere-tainedinocclusalgrooves.Thebasicscreeningsurvey

toolfromtheASTDDwasusedaspartofclinicalpro-tocolforsealantplacementandretention.32-36 This tool isalsousedforconsistentstatewidereportinginothercountieswithpublicdentalhealthprograms.Ifseal-antmaterialwaspresentingrooves,thesealantwasconsidered retained. Partial occlusal sealants wereconsideredretained,andrepairedifnecessary.Seal-antretentionratesexceeded95%foreachof5yearsreported(TableI).

Averted Dental Caries

AcomplexalgorithmdevelopedbyEpidemiologistsat theCenters forDiseaseControl (CDC)exists forassessingandcalculatingaverteddentalcarieswhendataisreportedforpublicdentalhealthprograms.38

Researchersat theCDCconsideran85%retentionrateastandardbenchmarkforQoCoutcomes.33 The findingsforthisprogramfarexceedtheestablishedbenchmark(TableI).TheCDCalgorithmrequires2yearsofdatabeforeaverteddentalcariescanbecal-culated,thus,nofindingswerereportedfor2004and2005. Sealant retention checks had not been con-ducted forcalculatingaverteddental caries rates in2009asdatahadnotyetbeencollectedforanalysis.Follow-updatafor2009weregatheredandincludedforthepurposeofcompletenessinthisshortreport.Dentalcarieswereavertedfor858childrenduringa3yearperiodfrom2006to2009asillustratedinTableI.

Referrals for Restorative Care

ThePriceCountyPublicHealthDepartment’sden-tal hygienist uses a consultative-referral model forpatients requiring restorative care.23,32 Referrals forrestorativecarearemadebythedentalhygienisttoFederallyQualifiedHealthClinics(FQHC)andCommu-nityHealthCenters(CHC)and/orprivatedentistsforrestorativedentalservicesandcasemanagement.23,32 FQHCs,CHCsandprivateofficesreportbacktothepublichealthdepartmentifindividualsareseenandtreated.Fourhundredandsixty-threereferralsweremade for restorativecare in theservicecommunityusingthismodelovera6yearperiod.Theneedforre-

Year ChildrenGivenSealantsinProgram

RetentionPercent1yearcheck AvertedDentalcaries RestorativeReferrals

Made2004 314 97.90% N/A 1532005 286 96.90% N/A 832006 259 95.00% 367 682007 216 97.00% 184 652008 236 96.00% 184 572009 200 98.3% 123 37Total 1511 96.85% 858 463

TableI:PreventiveOutcomes


ConclusionTheclinicalfindingsinthisshortreportillustratethe

successesofanoralhealthcareprogramofferedbyadentalhygienistworkingcollaboratively throughaCommunityPublicHealthDepartment.Sealantreten-tion,averteddentalcariesrates,andrestorativecareprovidedusingaconsultative-referralmodelallillus-trateeffectivenessofclinicalqualityofcarewhenem-ployingalternativecaremodelsandsystemsoutsidetherealmoftraditionalinofficeprocedures.

Jodi L. Olmsted, RDH, PhD, FAADH, is an Associ-ate Professor at the University of Wisconsin-Stevens Point in the College of Professional Studies, School of Health Care Professions - Health Sciences Program. Nancy Rublee, RDH, CDHC, is a committee member of the Wisconsin Oral Health Coalition and sits on the executive board of the Northern Area Health and Edu-cation Centers. Laura Kleber, BS, CCRC, is a Research Regulatory Specialist in the Clinical Trials Department for the Aurora Research Institute. Emily Zurkawski, PTA, is a Physical Therapy Assistant at the Veterans Home in King, Wisc.

DiscussionSome children are at risk for developing dental

caries. The findings illustrated in this short reportdocument some important but simple actions thatcanbeusedbydentalhygienistsworking inpublicand community health settings that may improveoralhealthcareoutcomes.Using4-handeddentistry,strictisolationtechniquesandparticipantcalibrationtraining while following evidence based protocolsmayhavesignificantlyimprovedretentionratesfordentalsealantsasillustratedinthispublichealthpro-gramIfcontaminationoccursduringprocedures,itisimportanttorecognize,re-isolateandretreatasur-facefor improvedretentionpermanufacturersandstandardclinicalpracticeguidelines.37 Findings from thisshortreportillustratefollowinghowsimpleclini-cal care practices discussed heremay significantlyimpact sealant retention and resultant oral healthcareoutcomes.

AccordingtotheSurgeonGeneral,diseaseburdencontinuesplaguingunderserved,minorityandsocio-economically disadvantaged populations.12,15 Wheredentalcariescanbeaverted in theory, it ishardertodosoinpractice.Familieswithchildrenthataresocioeconomicallydisadvantaged, orhavedifficultyaccessingcarebecausetheyaredemographicallyatadistancefromaproviderareatgreaterriskofde-velopingdentalcaries.2,3,9,11-14,17

Severalrecommendationsforongoingresearchre-latedtohowQoCimpactingQoLandmuchbroaderthantheinformationincludedinthisshortreportaremadehere.Furtherevaluationof impactsofeduca-tional and preventive treatment specifically for so-cioeconomicallydisadvantaged,racialandethnicmi-noritygroupsshouldbeconducted.9,13-15,28 Validating efficacyoftreatmentforchildrenofsocioeconomicallydisadvantaged, racial and ethnicminority groups isnecessary.Evaluatingriskassessmenttoolsandpre-ventive interventions is also required.17,24-26 Studies ofeffectivenessofprimarycareprovidersemployingformalriskassessmenttoolsforassessingdentalcar-ieswouldbebeneficial.2 Riskassessmenttoolsareavailable,buttheireffectivenesshasnotbeenmea-sured.2,17,24-26

Sealantsonlypreventdentalcariesinbuccalandlingualpitsandonocclusalsurfaces.OutcomesdataaboutaverteddentalcariesfromtheCDC38 does not includeinterproximallesionsthatdevelopifchildrenandfamilieshavepoororalhygiene,dietaryhabitsordevelopmentalstructuraltoothdefects.2,3,9,11-14,17

storativecaredeclinedovertime.Findingsarestatedin Table I.

Cariespreventionwhenusingfluoridevarnishap-plicationsinprimarycaresettingssuchasCommunityPublicHealthDepartmentsshouldalsobeanalyzed.Furtherclinicalscientificinvestigationregardingotherpotentialtreatmentsforpreventingdentalcaries,in-cludingxylitol, chlorhexidinevarnishesorpovidone-iodinesolutionsshouldbeinvestigated.46-48

Early childhood dental caries causes pain, im-pairedgrowth,missedschooldaysandnegativeef-fectsonQoL.2,3,9,11-14,17,44Inturn,theseimpactscanaffect self-esteem, appearance, speech and schoolperformance.3,13-15,17Over50millionschoolhoursarelostyearlybecauseofchildhooddental issues.9,13,21Individuals and families in underserved rural com-munities thataredemographically isolatedandso-cioeconomicallydisadvantagedoftenhavedifficultyaccessingcare.TheservicemodelemployedbythePriceCountyPublicHealthDepartmentprovidesedu-cational,preventiveandrestorativeclinicalcareser-vicesforpatientsandfamiliesthroughconsultation-referral,potentiallyimpactingtheirQoL.32

Community based outcomes for prevention andtreatment of dental caries including results fromsealantprogramsataepidemiologicpopulationlevelmustcontinue.2,38Wherethedatainthisshortreportnotes averted and declining rates of dental cariesovertime,findingsmayalsobeattributedtothesuc-cessofemployingaconsultative-referralmodelasabridgeforaccessingrestorativecareinrural,demo-graphicallyisolatedcommunities.32,39-48 Findings from all these investigations can supporthealthier com-munitiesandhealthiercitizensforthe21stcentury.


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2. ChouR,CantorA,ZakherB,MitchellJP,PappasM.Pre-ventingdentalcariesinchildren<5years:systematicreviewupdatingUSPSTFrecommendation.Pediatrics. 2013;132(2):332-50.

3. CaulfieldPW,GriffenAL.Dentalcaries:aninfectiousand transmissible disease. Pediatr Clin North Am. 2000;47(5):1001-1019.

4. GriffinSO,OongE,KohnW,etal.Theeffectivenessof sealants inmanagingcaries lesions. J Dent Res. 2008;87(2):169-174.

5. HiiriA,Ahovuo-SalorantaA,NordbladA,MäkeläM.Pitandfissuresealantsversusfluoridevarnishesforpreventingdentaldecayinchildrenandadolescents.Cochrane Database Syst Rev.2006;(4)CD003067.

6. BeauchampJ,CaufieldPW,CrallJJ,etal.Evidence-basedclinicalrecommendationsfortheuseofpit-and-fissuresealants:areportoftheAmericanDentalAs-sociationCouncilonScientificAffairs.Dent Clin North Am.2009;53(1):131-147.

7. ArmfieldJM,SpencerAJ.Communityeffectivenessoffissuresealantsandtheeffectoffluoridatedwatercon-sumption. Community Dent Health.2007;24(1):4-11.

8. NilchianF,RoddHD,RobinsonPG.Thesuccessoffis-suresealantsplacedbydentistsanddentalcarepro-fessionals. Community Dental Health.2011;28(1):99-103.

9. CasamassimoPS,ThikkurissyS,EdelsteinBL,Maiori-ni E. Beyond the dmft: the human and economiccost of early childhood caries. J Am Dent Assoc. 2009;140(6):650-657.

10. NainarSM,TinanoffN.EffectofMedicaidreimburse-ment ratesonaccess todental care.Pediatr Dent. 1997;19(5):315-316.

11. NationalCenterforHealthStatistics.HealthyPeople2010FinalReview.NationalCenterforHealthStatis-tics.2012.

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13. DyeBA,TanS,SmithV,etal.Trendsinoralhealthsta-tus:UnitedStates,1988–1994and1999–2004.Vital Health Stat 11.2007;(248):1-92.

14.KawashitaY,KitamuraM,SaitoT.Earlychildhoodcar-ies. Int J Dent.2011;2011:725320.

15. TinanoffN,ReisineS.Updateonearlychildhoodcar-iessincetheSurgeonGeneral’sreport.Acad Pediatr. 2009;9(6):396-403.

16.U.S.DepartmentofHealthandHumanServices.OralHealthinAmerica:AReportoftheSurgeonGeneral.U.S.DepartmentofHealthandHumanServices,Na-tional InstituteofDental andCraniofacialResearch,National Institutes of Health. 2000.

17. BaderJD,RozierRG,LohrKN,FramePS.Physicians’rolesinpreventingdentalcariesinpreschoolchildren:asummaryoftheevidencefortheU.S.PreventiveServicesTaskForce.Am J Prev Med.2004;26(4):315-325.

18. CentersforDiseaseControlandPrevention.Promot-ingoralhealth:interventionsforpreventingdentalcar-ies,oralandpharyngealcancers,andsports-relatedcraniofacialinjuries.AreportontherecommendationsoftheTaskForceonCommunityPreventiveServices.MMWR Recomm Rep.2001;50(RR-21):1-13.

19. SelwitzRH,IsmailAI,PittsNB.Dentalcaries.Lancet. 2007;369(9555):51-59.

20. Centers forDiseaseControl and Prevention.DentalCaries:Hygiene-RelatedDiseases.CentersforDiseaseControlandPrevention.2009.

21. JacksonSL,VannWFJr,KotchJB,PahelBT,LeeJY.Impact of poor oral health on children’s school at-tendance and performance. Am J Public Health. 2011;101(10):1900-1906.

22. VargasCM,CrallJJ,SchneiderDA.Sociodemograph-icdistributionofpediatricdentalcaries;NHANESIII,1988-1994. J Am Dent Assoc. 1998;129(9):1229-1238.

23. OlmstedJL,RubleeN,ZurkawskiE,KleberL.Publichealthdentalhygiene:anoptionforimprovedqualityofcareandqualityoflife.J Dent Hyg.2013;87(5):299-308

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40.NiedermanR,GouldE,SonciniJ,TavaresM,OsbornV,GoodsonJ.Amodelforextendingthereachofthetraditionaldentalpractices:theForsythKidsprogram.J Am Dent Assoc.2008;139(8):1040-1050.

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IthasbeenoveradecadesincetheU.S. Surgeon General issued a re-port stating that oral health is an es-sentialcomponentofoverallhealth.1 Yetgettingaccessforallpopulationstoqualitydentalcareisstillamajorconcern-reportsconsistentlydocu-ment a shortage of dentists in ru-ralandinnercitycommunities,andmarginalizedpopulationsthatdonotreceiveregulardentalcare,with45millionpeoplelivingintheseareas.2 Ithasbeenproposedthatexpandingthe role of dental hygienists is one way to increase access to care fortheunderserved.3,4

In order to expand opportunitiesfordentalhygienistsandimproveac-cesstocare,somestatesandcoun-tries utilize amid-level practitionerinthedentalfield.Examplesincludethe Dental Health Aide Therapist in NewZealand,theDentalHealthAideTherapist inAlaska,andtheDentalTherapist, aswell as theAdvancedDentalTherapist,inMinnesota.Mid-level providers can perform awiderange of clinical services such asbasic restorative procedures andextractions, in addition to the tra-ditional repertoire of dental hygiene services.5-7Whilemoststatesdonotutilizeamid-levelpractitioner,overthe past decademany states haveexpandedthelegalscopeofpracticeof dental hygienists.8 Currently, 35statesallowdentalhygieniststoini-tiatepatientcareinasettingoutsideof the private dental officewithoutthepresenceofadentistinwhattheAmericanDentalHygienists’Associ-ation(ADHA)definesasdirectaccessstates.9 The termdirectaccessmeansthatthedentalhygienistcaninitiatetreatmentbasedonhisorherassess-ment of patients’ needs without the specific au-

BarriersFacedbyExpandedPracticeDentalHygienistsinOregonAmyE.Coplen,RDH,EPDH,MS;KathrynPBell,RDH,MS

AbstractPurpose:Oregonallowsdentalhygieniststoprovideserviceswithoutthesupervisionofadentistiftheyholdanexpandedpracticepermit(EPP).Thisstudysurveyedpracticingandnon-practicingEPPholderswiththepurposeofassessingperceivedbarrierstopracticingindependentlyandbettereducatingstu-dentstobeginindependentpracticeupongraduation.Methods:Asurveywasdeveloped,approvedbytheinstitu-tional review board and pilot tested with current ExpandedPracticeDentalHygienists (EPDHs).A listofEPDHswasob-tainedfromtheOregonStateDentalBoard,and181surveysweremailedinNovember2011.Results: Theresponseratewas39%(n=71).DatafromthisstudyindicatealargenumberofnewEPPholders,with62%(n=41)holdingtheirpermitfor3yearsorless,butonly41%(n=29)ofrespondentsareactuallyprovidingcareinasettingrequiringanEPP.RespondingpracticingEPDHsreportedbarri-ersincluding:challengeswithinsurancereimbursement,lackofknowledge/acceptance,equipmentcost/maintenance,diffi-cultyobtainingacollaborativeagreement/cooperatingfacility,advertising and inability tomake a livingwage.Respondingnon-practicing EPDHs reported barriers including: currentlyworkinginanothersetting,lackofbusinessknowledge,time,start-upcost,inabilitytomakealivingwage,lackofopportu-nity,reimbursementdifficultiesandlackofexperience.Conclusion: Perceived barriers to practicing independentlydiffer between thosepracticingutilizing their EPP and thosenotpracticing.Waystoeliminatebarriers forbothpracticingand non-practicing EPDHs should be explored. There is po-tentialtoreducethebarrierstoindependentpracticethroughcurricularchanges,publichealthpartnershipsamongEPDHs,andnewhealthcaresystemsthatspecificallyaddressbarriersfound through this study.Keywords:dentalHygieneextendedpracticepermits,accesstooralhealthcare,directaccess,independentpractice,dentalhygiene,limitedaccess,expandedpracticeThisstudysupportstheNDHRApriorityarea,Health Services Research: Investigatehowalternativemodelsofdentalhy-gienecaredeliverycanreducehealthcareinequities.

Research

Introduction

thorizationofadentist,treatpatientswithoutthepresenceofadentistandcanmaintainaprovider-patient relationship.10


In thestateofOregonamid-levelpractitionerdoesnotexist,however,directaccessdoes.Legis-lationwaspassedin1997toallowdentalhygien-iststoattainalimitedaccesspermit.11 Legislation waslaterpassedin2012renamingthelimitedac-cesspermittotheexpandedpracticepermit(EPP).TheEPPenablesdentalhygieniststoprovideava-rietyofdentalhygieneservices,withoutthesuper-visionofadentist,for“limitedaccess”regionsorpopulations (Figure 1). Expanded practice dentalhygienists (EPDHs)are required to referpatientstoadentistatleastonceannuallyforexaminationandtreatmentofactivedentaldisease.EPDHsdonotneedacollaborativeagreementwithadentisttoinitiatedentalhygienecareforpatientpopula-tionsthatqualifyashavinglimitedaccesstocare.IfanEPDHwishestoperformadditionalservices,suchasprovidinglocalanesthesia,placingtempo-raryrestorations,andprescriptionofprophylacticantibiotics and non-steroidal anti-inflammatorydrugs (NSAIDs) (which are included in the law),theymusthaveacollaborativeagreementwithadentisttoprovidethoseadditionalservices.ManyEPDHsworkasemployees innon-dental settingslike nursing homes or schools. Other EPDHs be-come private business owners. One pathway toobtain an EPP is to have 2,500 hours of clinicaldentalhygienepracticeandcomplete40hoursofcontinuingeducationof the individual’s choosing.AnadditionalpathwaytoobtaininganEPPcreden-tial istocompleteacourseofstudyapprovedbytheOregonStateDentalBoardandhaveat least500hoursofdentalhygienepracticeonpatientsin“limitedaccess”settingswhileunderthedirectsu-pervisionofdentalordentalhygienefacultyofanaccreditedprogram(Figure2).UntilOctober2010,therewerenoboard-approvedcoursesofstudy.12 At that time, the Oregon Legislature passed abill allowingapplicants toapplyhoursspentdur-ingtraining(dentalhygieneschool)withpatientsinunderservedor limitedaccesssettingstotheir500-hour quota. Thus, under recently amendedlegislation,studentsarepotentiallyable toattainanEPPupongraduation.

Thegoalof recent legislativechanges is to fa-cilitateasignificantimprovementintheaccesstocarecrisisinOregon.Todate,however,limitedin-formationexistsregardingtheimpactofexpandedpractice dental hygienists aswell as the barriersfaced in pursuing expanded practice. The onlystudytodateofOregonEPDHswasconductedin2005 by Battrell et al.13Thisqualitativestudy in-cluded7OregonEPDHsaswellas2dentists.Par-ticipantsperceivedaneedforexpansionofscopeof education to prepare for independent practiceandcalledforadditionalcurricularexperiencestoinclude coursework on organizational structure,

ExpandedPracticeSettings:Anexpandedpracticedentalhygienistmayrenderallserviceswithinthescopeofpracticeofdentalhygienewithoutthesupervisionofadentisttopatientsofthefollowingfacilitiesorprogramswho,duetoage,infir-mityordisability,areunabletoreceiveregulardentalhygiene treatment:• Nursing homes• Adult foster homes• Residentialcarefacilities• Adultcongregatelivingfacilities• Mentalhealthresidentialprograms• Facilitiesformentallyillpersons• Facilitiesforpersonswithdevelopmentaldisabili-

ties• Localcorrectionalfacilitiesandjuveniledetentionfacilities

• Publicandnonprofitcommunityhealthclinics• Adultswhoarehomebound• Studentsorenrolleesofnurseryschoolsanddaycareprogramsandtheirsiblingsunder18yearsof age

• Primaryandsecondaryschools,includingprivateschoolsandpubliccharterschools

• PersonsentitledtobenefitsundertheWomen,In-fantsandChildrenProgram

• Patients inhospitals,medicalclinics,medicalof-fices or offices operated by nurse practitioners,physicianassistantsormidwives.

• Patientswhoseincomeislessthanthefederalpov-ertylevel

• OtherpopulationsthattheOregonBoardofDen-tistrydeterminesareunderservedorlackaccesstodentalhygieneservices

Figure1:PracticeSettingsinWhichEPDHsAreAllowedtoWork

ExpandedPracticePermitCriteria:To receive an expandedpractice permit, dental hy-gienists must:Pathway1• Holdavalid,unrestrictedOregondentalhygienelicense

• Presentproofofcurrentprofessionalliabilityinsur-ance

• Completed2,500hoursofsuperviseddentalhy-gienepractice

• Completed40hoursofcourses,chosenbyappli-cantin:1. Clinicaldentalhygiene2. Publichealth

Pathway2• Completeacourseofstudyapprovedbytheboardthatincludes500hoursofdentalhygienepractice,completedbeforeoraftergraduationfromadentalhygieneprogramonlimitedaccesspatientswhileunderthesupervisionofamemberofthefacultyofadentalprogramordentalhygieneprogramac-creditedbytheCommissiononDentalAccredita-tionoftheAmericanDentalAssociation.

Figure 2: CriteriaWhich Must be Met toObtainanExpandedPracticePermit


ResultsTheresponserateforthesurveyofEPDHswas

39% (n=71). Approximately 41% (n=29) of therespondentswerecurrentlyusingtheirEPPandanadditional21%(n=15)wereplanningtostarttheirownindependentpractice.TheaverageageoftheEPDHwas49,witharangeofreportedagesfrom25to71yearsofage.Sixty-twopercentofthesamplehasheldtheirEPPfor3yearsor less(n=41).OfthecurrentpracticingEPDHs,theaverageweekly

Methods and MaterialsIn the fall of 2011, a list of all current EPDHs

wasobtainedfromtheOregonBoardofDentistry(n=186).Aconveniencesampleof2%wasselect-ed to pilot test the survey.Subsequent revisionsweremade according to feedback from the pilottesters. Following approval of the Pacific Univer-sityInstitutionalReviewBoardwithexemptstatus,thesurveywasmailedtoallEPDHsinthestateofOregon inNovember2011,with theexceptionofthoseincludedinthepilottest.Datawerecollect-ed using a self-administered survey. A follow-upmailingwassentinDecember2011toallnon-re-spondents.Tomaintainconfidentiality,thesurveyswerenumericallycoded.Thelinkagefilewasmain-tained solely to facilitate the second mailing (a

billing,coding,prescriptionwritingandthepublichealthdeliverysystem.OnedentalhygieneschoolinOregon,PacificUniversity,hasimplementedcur-ricular changes aimed at decreasing the barrierstoenteringindependentpractice,buttheinfluencethesecourseshaveonthelikelihoodofgraduatespursuingindependentpracticehasnotbeenmea-sured.Theperceivedbarrierstodatehavealsonotbeen formally measured.

ThisstudysurveyedcurrentEPDHs,bothprac-ticingandnon-practicing,withthepurposeofas-sessing perceived barriers to practicing unsuper-visedandbettereducatingstudentstobeginEPPpracticeupongraduation.Specificresearchques-tionsincluded:

• If participants are currently practicing as anEPDH,whatspecificbarriersdotheyfacethatmakeitchallengingtopracticeinthisrole?

• If participants are not currently practicing asanEPDH,whatspecificbarriershavekeptthemfrompracticinginthatrole?

• Dospecific characteristics like levelofeduca-tion,yearssincegraduation,oryearsholdinganEPP increase the likelihood of utilizing theexpandedpracticepermit?

• Howwelldoesaspecificinstitutionwhichgrantsat least 500 hours of practice on patients in“limited access” settings prepare students tobegin independent practice upon graduationbasedonreportedbarriers?

Theresultsofthisstudywillbeusedtoadvisestu-dents,furtherdevelopthedentalhygienecurricu-lumattheauthors’ institutioninsupportofinde-pendentpracticeandtosuggestfuturedirectionsfor eliminating barriers to independent practiceinOregonasawholetoaddresstheneedforim-provedaccesstocare.

secondsurveywasonlysenttonon-respondents).Once data collection was completed, the linkagefilewasdestroyed.Themailingincludedaconsentdocumentexplainingthepurposeofthestudyandthat itwas confidential. In addition to a copy ofthesurveyandtheconsentdocument,abusinessreplyenvelopewas included(signedconsentwasnot requested; consentwas implied by return ofthequestionnaire).

The16-itemquestionnairecontainedbothclosedandopen-endedquestions thatassessed the fol-lowing areas: demographics, income from EPDHpractice, amount of services provided, details ofEPDHpracticeandperceivedbarrierstopracticingasanEPDH.Thisarticlefocusesonthedemograph-icsandperceivedbarrierssections.TheamountofservicesprovidedanddetailsofEPDHpracticehasbeen addressed in a separate report.14

Whenanalyzingopen-endedqualitativedatare-latedtobarriers,2 investigatorsdeterminedpre-liminary categories to be able to do quantitativeanalysisofthedata.Eachinvestigatorcategorizedthe answers individually and the answers werethencompared.Additionalcategorieswereaddedifatleast3individualsansweredsimilarly.Ifare-sponse had less than 3 respondents reporting simi-larlytheresponsewasplacedinthe“other”cate-gory.Anywhereconsensuscouldnotbereachedonaparticularansweritwasalsoplacedinthe“other”category.Ultimately, open-ended responseswerecategorizednumericallyforthepurposeofstatisti-calanalysis.

ThedatawereanalyzedusingSPSS(version20,IBM).Frequencydistributionsareprovidedtode-scribethefindings,andChi-squaretestsusingtheFreeman-HaltonextensionoftheFisherexacttestwereusedtoinvestigatewhetherpossiblefactorssuchaslengthoftimeholdingEPP,levelofeduca-tionandyearssincegraduationinfluencedthelike-lihoodofEPDHstobepracticinginasettingwhichrequiresanEPP.Forlevelofeducation,thesamplecontained2certificateholders; therefore,Certifi-cate/Associatesdegreeswerecombined.


Category n Percent

Age by Category (n=70)

20 to 3031to4041to50

>50

6101539

9%14%21%56%

YearsheldEPP(n=66)

0 to 34to67 to 9≥10

419511

62%14%8%17%

PracticingusingEPP(n=71) 41% – –

MeanHoursPerWeekusingEPP(n=25)

9.3(Std.Dev.12.47) – –

IncomefromEPP(n=27)

≤10,00010,001to20,00020,001to30,00030,001to40,00040,001to50,000

>50,000

1843101

67%15%11%4%0%4%

LevelofEduca-tion(n=67)

CertificateAs-sociateBachelors

Masters

222394

3%33%58%6%

*Not every respondent answered every question. Thenumberofrespondentswhoansweredeachisindicatedintheleftcolumn.Percentagesmaynottotal100%dueto rounding.

TableI:DescriptiveStatisticsofRespond-ingEPDHs

hoursworkingunsupervised is9.3hours(n=25).Onaverage,unsupervisedpracticecomprises22%of their totalannual income(n=27).Thehighestlevelofeducationheldbythesamplewasabach-elor’sdegree(58%,n=39).AlldemographicdataissummarizedinTableI.

BarriersfacedbyEPDHswereexaminedforbothpracticingandnon-practicingEPDHs.Thenumberofresponsesislargerthanthesamplesizeforeachgroupbecauseparticipantswereallowedtoreportmultiple barriers. For non-practicing EPDHs themostfrequentlyperceivedbarrierswere:current-lyworking in another setting (21%, n=14), lackofbusinessknowledge(15%,n=10),time(10%,n=7),inabilitytomakeasalary/livingwage(10%,n=7)andstart-upcosts(10%,n=7)(Figure3).

For practicing EPDHs, themost frequently cit-ed barriers were: challenges with insurance re-imbursement (39%, n=13), lack of knowledge/acceptance (21%,n=8), equipment cost/mainte-nance(11%,n=4),andlackofcollaborativeagree-ment/cooperatingfacility(11%,n=4)(Figure4).

Chi-squaretestsusingtheFreeman-Haltonex-tensionoftheFisherexacttestwereusedtoex-plorepossiblerelationshipscontributingtothelike-lihood of EPDHs to be practicing currently.Whilenostatisticallysignificantresultswerefound,therewere several trends identified in the sample ofpracticingEPDHs.Thehighestpercentageofprac-ticingEPDHshaveheldtheirEPPfor3yearsorlessat21%(n=14)(TableII).ThehighestpercentageofpracticingEPDHsheldaBachelorsdegreeoranAssociates/Certificate at 19% (n=13) and 18%(n=12), respectively (Table III). The largestper-centofpracticingEPDHshadgreaterthan20yearssincegraduation,20%(n=14)(TableIV).

DiscussionAlthoughsomeformoftheEPPhasexistedin

Oregonsince1997,thelargestpercentageoftheexistingEPDHshaveonlyhadtheirpermitfor3yearsorless,whichindicatesanincreasingsup-portofOregondentalhygienistsforunsupervisedpractice.AccordingtotheOregondentalboard,the number of EPDHs in Oregon has increasedfrom186to356sincethissurveywascompleted.Thisisaneardoubleincreaseinthepast2years.This increase is likelydue to theabilility toob-tainanEPPthroughthenewpathway(pathway2).Whilethemajorityhaveheldtheirpermitfor3yearsorless,nearlyhalfthesampleofEPDHsareover50yearsoldandhavebeenoutofdentalhygieneschoolforlongerthan20years.Thissug-geststhatdentalhygienistswhohavebeenprac-

ticingtraditionallyshowstrong interest inmov-ing toward alternative settings to provide care.Authorsattemptedtoevaluatewhetherconcretedemographiccharacterisiticslikelevelofeduca-tion,numberofyearsholdinganEPPandyearssincegraduation influnced the likelihoodof EPPholderstobepracticing.Unfortunately,asignifi-cantindicatorofwhetherparticipantsweremorelikelytobeutilizingtheirEPPtoprovidecarewasnotfoundinthisstudy.Characteristicsthatinflu-encethelikelihoodofEPPholderstobepractic-ingaremuchmoredifficulttomeasure,althoughone previous study found that a motivation toattainindependentdecisionmakingandastrongdedication to providing services to underservedpopulationsinfluencethelikelihoodofindividualstopracticeusingtheirEPP.13

Thedatademonstratethatbothpracticingandnon-practicingEPDHsperceivesimilarbarrierstoprovidingcaretounderservedpopulations.Bothgroupscitedinsurancereimbursementasachal-lenge, but amuch higher percentage (61%) ofpracticing EPDHs reported reimbursment as an


CurrentlyWorkinginaDifferentSetting

LackofBusinessKnowledge

Time

Salary/LivingWage

Start-UpCost

LackofOpportunity

Reimbursement

LackofExperience

Other

0 2 4 6 8 10 12 14 16

Number ofRespondents

*Totalbarriersexceedsnumberofparticipantsbecausemanyparticipantsreportedmorethanonebarrier.

Figure3:PerceivedBarriersofNon-PracticingEPDHs(n=46)

issue and nearly half stated they have neverreceived insurance reimbursement. This is con-trarytowhatwasreportedintheDentalHygieneProfessional Practice Index,which gaveOregonarankofexcellent intheareaofreimbursmentcomparedtootherstateswithindependentprac-ticelegislation.15Non-practicingEPDHsreportedreimbursment as a concern but much less sothanpracticingwithonly4individualscitingitasabarrier.Thisismostlikelypercievedaslessofachallengeduetolackofexperienceinprovidingcareinalimitedaccesssetting.

It has been suggested that expanding thepractice of dental hygienists could be a poten-tiallysignificantincomesource.16Yetbothgroupssawtheinabilitytomakeadecentsalaryorlivingwageasabarrier.Thisstudy’sfindingssuggestthemajorityofpracticingEPDHsmakelessthan$10,000ayearusingtheirEPP.Alargerpercentofnon-practicingEPDHs,15%comparedto10%of practicing EPDHs, saw this as a barrier. Thismay indicate thatmotivation for those utilizingtheirEPPisnotdirecltylinkedtotheincomethatit provides. Other motivating factors cited byBattrelletal includedthedesiretoobtaininde-pendentdecisionmakingandastrongdesiretoserve underserved populations.13 These factorsmayoutweightheneedforindependentpracticetosupplyasignificantportionofincometothoseutilizingit.

Finally,bothgroupscitedlackofknowledgeasabarrier.Non-practicingEPDHsreportedlackof

knowledge regardinghow to begin an indepen-dent practice, business knowledge and knowl-edgeofthelaws.Participantsofthe2005quali-tativestudyofOregonEPDHsidentifiedasenseofentrepreneurshipandmarketingskillsaskeystosuccess.13Inaddition,Astroth,etalreportthatthemajority of independently practicing dentalhygienists in Colorado had additional educationin business management.17 For non-practicingEPDHsthere isanapparentnecessityofeduca-tionassociatedwithstartingabusinessaswellasacallforunderstandingthemostcurrentlegisla-tiveadvancesinindependentpracticefordentalhygienistsinOregon.PracticingEPDHsreportedadifferent typeof lackof knowledgewhich re-latestoacceptanceandeducationonthepartofdentistsandthecommunity.ThisincludedlackofknowledgeforcaregiversregardingtheservicesprovidedbyEPDHs,aswellaslackofknowledgeinthecommunityastowhatEPDHscando.Re-movingthisbarrierwouldrequireadditionaledu-cationforthecommunitiesinwhichEPDHsserve.

Manybarrierscitedwereuniquetoeitherprac-ticing or non-practicing EPDHs. A barrier facedby practicing EPDHs was equipment cost andmaintenance.Inaddition,establishingapatientbase and advertising services were also citedas barriers.Whenminimal salary andability toget reimbursed for services is low, unexpectedcostsofequipmentanduncertaintyofavailablepatients to treat threatenEPDHsability tocon-tinueprovidingcaretounderservedpopulations.Asindependentpracticebecomesmorecommon,


InsuranceReimbursement

LackofKnowledge/Acceptance

EquipmentCost/Mainanence

CollaborativeAgreement/CooperatingFacility

Advertising/EstablishingPatientBase

Salary/LivingWage

Other

0 2 4 6 8 10 12 14

Number ofRespondents

*Totalbarriersexceedsnumberofparticipantsbecausemanyparticipantsreportedmorethanonebarrier.

Figure4:PerceivedBarriersofPracticingEPDHs(n=21)

options to reduce barriers for EPDHs alreadypracticingbecomeextremelyimportant.

AnotherbarrierfacedonlybypracticingEPDHsissecuringacollaborativeagreementwithaden-tist.AcollaborativeagreementallowsanEPDHtoadminister local anesthetic and gives the EPDHadditional prescriptive power. Lack of dentists’support for hygienists practicing independentlyhas also been reported in other studies.16,18Onereason dentists may not support independent-ly practicing dental hygienists is the perceivedthreat they may pose to patients seeking carefrom a dentist. However, having care providedby an independently practicing dental hygienistmay not necessarily deter patients from seek-ingroutinedentalcare.Thisitemwasspecificallymeasuredinasurveyofpatientstreatedby in-dependentlypracticingdentalhygienistsinCali-fornia.Inthatstudy,atthe24monthfollow-upalmost 90% of the patients had been seen bya dentistwithin 12months of being treatedbyan independentlypracticinghygienist.19,20 It ap-pearsthat,inCalifornia,patientswhoaretreatedbyindependentlypracticingdentalhygienistsarenot less likely toseekroutinecare fromaden-tistasaresult.Inaddition,EPDHsinOregonarerequired by law to refer patients at least onceper year to a dentist who is available to treatthem.IfpatientstreatedinOregonaresimilartothosetreatedinCalifornia,triagecarewithrefer-ralprovidedbythedentalhygienistmayincreasetherateatwhichthispopulationseekscarewitha dentist. Further research is necessary to testthis hypothesis.

Thelargestbarrierseenbynon-practicingEP-DHs is that theyare currentlypracticing some-whereelse. These settings ranged fromprivate

practice to public health and education. Whileworking in another settingmight be viewed asmoreofapersonalchoiceratherthanabarrier,participantsstateditwasabarrier.Anotherbar-rierreportedwasalackofopportunitywhichmaymoreaccuratelyrepresntwhyworkinginanothersetting was cited. While holding an EPP showsstrongsupportfordentalhygienistspracticinginunsupervised settings, additional barriers suchasstartupcosts,toofewinternshipsettingsandmentors, and lack of experience are prevent-ingEPPholdersfromenteringintounsupervisedpractice.WhenEPDHsspendthemajorityoftheirtimepracticing elsewhere there is little time topursuetheeliminationofotherbarriers.WithagrowingnumberofEPDHsinthestateofOregon,there is a responsibility to give individuals thetoolsnecessarytobeginpracticingindependentlyso that this practicemodel does in fact reducetheaccesstocareissue.

Non-practicingEPDHshadavarietyofbarriersthatkeepthemfromutilizingtheirEPP.Reasonsvariedwidelywhichiswhythe“other”categoryreceivedthesecondmostresponses.Since3ormore respondents who cited a particular bar-rierwere required tobecomeacategory,manyresponseswere placed in the “other” category.Someexamplesincluded:“I’mholdinganEPPinsupport for advancement of the profession buthave no personal interest in using it,” “I justhaven’t branchedout yet, although I live in anunderservedarea,”“I’mlateinmycareer”and“Iamnotcurrentlypracticing.”

Implications for Education

Theadditionofpathway2tothePracticeActhasmade iteasier fornewgraduates toobtain


anEPP. Targeting thepopulation of newdental hygiene gradu-ates who have notalready obtained em-ployment could po-tentially increase thenumber of hygienists practicing indepen-dently since alreadyworking in anothersettingwasthegreat-est barrier for non-practicing EPDHs.Many of the docu-mented barriers found through this study for both practicing andnon-practicing EP-DHscouldbereducedthrough additional curriculumfocusedonpracticing indepen-dently.With35statesallowing direct ac-cess, the question ofeducating new dentalhygienists to pursue thiscareerpathmustbe addressed. Argu-ment could be madethat educators havethe responsibility to prepare students for the additional pro-fessional aspects ofdirect access in thestatesthatallowit.

Currently,theCom-missiononDentalAc-creditation (CODA) standards do not explicitlyrequiredentalhygieneprogramstoeducatestu-dents on aspects relating to independent prac-tice.However, CODAdoes require graduates tobecompetentinassessing,planning,implement-ingandevaluatingcommunitybasedoralhealthprogramsincludinghealthpromotionanddiseasepreventionactivities,andthecurriculummustin-cludecontentincommunitydental/oralhealth.21 CODAconceptsthatrelatetoindependentprac-ticearetheabilitytocompetentlyplanand im-plementcommunitybasedoralhealthprogramswith the intention that studentswill be able toapplycommunitydentalhealthprinciplestopre-ventdiseaseandpromotehealth.Withdentalhy-gienecurriculumsalreadybeingtightlyconstruct-ed, it isdifficult toentertain the ideaofadding

additionalmaterial.Authorsbelievethatcoursesbeing taught to fulfill theseCODArequirementscould slowly begin to incorporate independentpracticeasatopic.Thisisagoodstartingpointandmayalreadyexistinmanyschools,butdoesnotaddressallofthebarriersperceivedtoenter-ingindependentpractice.

At one educational institution in Oregon, Pa-cific University, curricular changes have beenimplementedtoreducethebarriersforstudentsgraduating with the intention of practicing ind-pendentlywith limitedaccesspopulations.Spe-cific curricular changes address the barriers oflackofexperience,businessknowledge,andre-imbursement.These includeanexpandedprac-tice rotation, implemented in 2011,where stu-

LengthofTimeHoldingEPDH PracticingEPDH Non-PracticingEPDH0 to 3 years 21%(n=14) 41%(n=27)4to6years 8%(n=5) 6%(n=4)7 to 9 years 3%(n=2) 5%(n=3)10 years or longer 11%(n=7) 6%(n=4)

Freeman-Haltonexten-sionoftheFisherexact

p=0.29

*Percentagesmaynottotal100%duetorounding.

Table II: Percent of Practicing EPDHs Based on Length of TimeHoldingEPP(n=66)

Degree Type PracticingEPDH Non-PracticingEPDHCertificate/Associates 18%(n=12) 18%(n=12)Bachelors 19%(n=13) 39%(n=26)Masters 3%(n=2) 3%(n=2)

Freeman-HaltonextensionoftheFisherexactp=0.46

TableIII:PercentofPracticingEPDHsBasedonDegreeType(n=67)

YearsSinceGraduation PracticingEPDH Non-PracticingEPDHLess than 5 years 1%(n=1) 16%(n=11)6to10years 7%(n=5) 4%(n=3)11 to 20 years 13%(n=9) 14%(n=10)Greaterthan20years 20%(n=14) 24%(n=17)

Freeman-Haltonexten-sionoftheFisherexact

p=0.053

TableIV:PercentofPracticingEPDHsBasedonYearsSinceGradu-ation(n=70)

*Percentagesmaynottotal100%duetorounding.


dentsprovidedentalhygieneservices in limitedaccesssettingstogainexperiencewiththispa-tientpopulation.Forthisrotation,studentsworkalongside an EPDH to see firsthand what goesinto practicing indpendently. In addition, stu-dentstakeanindpendentpracticecourseinthesummeroftheirsenioryear,alsoimplimentedin2011.Thiscoursegivesanoverviewofindepen-dentpracticefordentalhygienistsincludingstateregulation, employment opportunities, businessmodels,marketing,reimbursementandcommu-nity relations.

Businessknowledgeisalsoakeypiecetohav-ingasuccessfulindependentpracticeandlackofbusinessknowledgewasreportedasabarrierbynon-practicing EPDHs. Since 2007, students atPacificUniversityhavetakenabusinessmanage-mentcoursewheretheylearnbasicprinciplesofbusiness with emphasis on application of busi-ness management skills in dental health caresettings.

Cultural competence has also been reportedasanimportantskillforexpandedpracticeden-talhygienists inOregondue toa largenumberofHispanic populations being seenbyEPDHs.13 Whilethiswasnotanaspectdirectlymeasuredinthisstudy,itisanadditionalwayPacificUniversi-typreparesstudentstoworkwithlimitedaccesspatients.Sincetheprogram’sinception,studentshavebeenrequiredtotake2semestersofSpan-ish for dental professionals and treat primarily Spanishspeakingpatientsintheschool’sclinicaswellasmanyoftheiroffcampusrotations.

AlthoughPacificgraduatescomprisedonly9%of theEPDHs inthecurrentsurvey,at thetimePacifichadonlygraduated4cohortsofstudents.According to the Oregon dental board, sincethis studywas completed thepercentof PacificUniversity graduates holding an EPP has grownfrom 9 to 27% of the total EPP holders in Or-egon.While thepercentageofEPPholderswhograduated from Pacific has grown significantlysincemanycurricularchangeswere implement-ed,whetherthesechangeshaveinfluencedtheirlikelihoodtopracticeinasettingwhichrequiresanEPPisyettobemeasured.Itisapparent,atleastatoneschoolinOregon,thattheadditionofpathway2hasbeenasuccessfulwaytoincreasethenumberofEPP-holdersinthestate.

Unfortunately, not all the barriers discoveredthroughthisstudycanbeaddressedineducation.Therearestillmanypracticingandnon-practic-ingEPDHswhohave completed their educationandneedsupporttoenter independentpractice

inOregon.Thecurrentsample isalsoprimarilyolder andmore experienced. Potential avenuesto addressing these barriers are: business fo-cusedcontinuingeducationcoursesforindividu-alsholdinganEPPandmentorshipprogramswithcurrentlypracticingEPDHs.Otheravenuescouldincludeenlistingthehelpofcommunityleaders,communityclinics,HeadStartprogramsandlongterm care facilities. The solution will no doubtneedtobeamulti-facetedendeavor.

Study Limitations

There were several limitations to this study,withoneofthemostsignificantbeingthesamplesize.BecausethissurveywasalsoanoutcomesassessmentaskingEPDHstoreporttheamountof services provided and details of EPDH prac-tice,EPPholderswhoarenotcurrentlypracticingmaynothavethoughtthesurveywasapplicableto them. The questions about perceived barri-erswere at the end of the survey. This limita-tionhadanimpactontheabilitytoconductsta-tisticalanalysisbecause therewerenotenoughpracticing and non-practicing EPDHs in each ofthe categories to be able to find any statisticalsignificance.Anadditional limitationwasantici-patinghowmodestasalaryEPDHsreceivedwith$10,000or less being theonly possible option,whichmany EPDHs reportedmakingmuch lessthan$10,000annually.Ifthishadbeenanopen-endedquestion,itwouldhavebetterallowedforreporting smaller income ranges. When askedabout reimbursement, a large number of prac-ticingEPDHsreportedneverreceivinganyreim-bursementbut several individualswrote in thatthey had never tried. This would have been avaluableoptionthatwasnotincluded.Finally,theauthorswerenotabletoestablishsurveyperfor-mancereliability.Thesurveyhasbeenadminis-teredonly1time,sotest-retestreliabilitycouldnotbedetermined.Inordertokeepthesurveyto a minimal length, no redundant questionswere included toevaluate internal reliability.Tofacilitatedataentryandconsistencyofinforma-tion, every survey mailed was identical, so noalternate-formreliabilitywasestablished.

Recommendations for future research includeexploringhowcurricularchangeshaveinfluencedPacific University graduates’ likelihood to enterinto independentpracticesettings.WhereasthebusinessmanagementandSpanishcoursehaveexisted since the beginning of the program in2006, theexpandedpractice rotationand inde-pendent practice course have only been taughtsincethefallof2011whenthissurveywascon-ducted.Inaddition,investigatinghowdentalhy-


ConclusionDatafromthisstudyindicatethattherearean

increasingnumberofnewEPPholdersinOregon,but less than half are actually providing care asanEPDHtounderservedpopulations.Lackofbusi-nessknowledge,lackofexperience,insurancere-imbursement, start-up costs and the inability tomakealivingwagearebarriersnon-practicingEP-

giene programs in other stateswith some typeofindependentpracticepreparetheirstudentstopursue this avenue of providing care is impor-tant.Opinionsastowhetherdentalhygienepro-gramsshouldhavethetaskofpreparingdentalhygieniststopracticeunsupervisedindirectac-cessstatesorifitshouldbedonethroughotherpathwaysshouldalsobeexamined.

DHsfacewhendecidingwhetherornot toutilizetheirEPP.Ifthesebarrierscanbeaddressedduringdentalhygieneeducation,thepotentialexiststoin-creasethenumberandimpactofEPDHsinOregon.Fordentalhygienistswhohavealreadycompletedtheireducationwithoutthebenefitofnewcurricu-lum, addressing independent practice, continuingeducationcoursesinbusinessmanagementandin-dependentpracticestrategies,andpaidinternshipswithexperiencedexpandedpracticedentalhygien-istsmayalsobehelpfulinfacilitatingthetransitiontoindependentpracticeandtofacilitateincreasedaccesstocare.

Amy E. Coplen, RDH, EPDH, MS, is an Assistant Professor, School of Dental Health Science, Pacific University. Kathryn P Bell, RDH, MS, is an Assistant Professor, School of Dental Health Science, Pacific University.


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References


Dental hygiene programs use a varietyofadmissionscriteriaintheiradmissionsselectionprocesses.Pro-gramadmissionsreviewcommitteesidentifystudentscapableofsuccess-fully completing thedentalhygieneprogram and passing licensure ex-aminations.Admissionscommitteesare often tasked with determiningwhich variables are most likely toimpactstudentsuccessinacademicprograms.Researchspecifictoden-tal hygiene admissions is inconsis-tent and the validity of the criteriaused for admissions has not been established.

Grade Point Average (GPA)

Previousacademicachievementisa factorused inmanyalliedhealthprograms for admissions. A number of accredited dental hygiene pro-grams consider high school gradesin the admissions process. Twen-ty percent use high school scienceGPA,9%usenon-scienceGPA,9%use overall high school GPA and12%reported“other” forassessinghigh school grades. College gradesare also considered in dental hy-giene admissions.1Seventypercentof accredited programs use collegescienceGPA,45%usenon-scienceGPA,70%useoverallcollegeGPAand26%reported“other”forassessing college grades.1 DeAngelis noted posi-tiveassociationsbetweenenteringGPAandscoresfortheNationalBoardDentalHygieneExamination(NBDHE).2Bauchmoyeretalvalidatedthesefind-ings.3AustinfoundcollegeGPAwasweaklycorre-latedtoNBDHEscores.4AlzahranietalfoundGPAwasnotastatisticallysignificantvariablewhenas-sociatedwithsuccessfuloutcomesontheNBDHE.5 Dental hygiene studies relate conflicting findingsas towhether or not GPA is a positive predictor

ExploringPreadmissionCriteriaasPredictorsforDentalHygieneLicensureExaminationsPassRatesTammyR.Sanderson,RDH,MSDH;MarciaH.Lorentzen,RDH,MSEd,EdD

AbstractPurpose:Researchspecific todentalhygienecanprovidepro-gramsguidancetoimplementthebestadmissionspractices.Thisstudy sought to first identify all admissions variables currentlybeingutilizedbydentalhygieneprograms.Secondly, thisstudylookedforassociationsbetweenthesevariablesandprogrampassratesonnationalandregionalclinicalboardexaminations.Methods:Anonlinesurveywassentbyemailto309dentalhy-gienechairs/programdirectors.Thesurveywascomprisedof18questionstocollectprogramdemographic information,programadmissionsrequirements,andprogrampassratesonboththeNa-tionalBoardDentalHygieneExamination(NBDHE)andregionalclinicalboardexaminations.Results: Onehundredand thirty-nine respondentsparticipatedinthesurveyforaresponserateof45%.Twenty-nineadmissionsvariableswerefoundandcorrelatedtoprogramclinicpassrates(n=131)andprogramNBDHEpassrates(n=133).The2admis-sionsvariablesmostoftenusedbydentalhygieneprogramsareoverallcollegegradepointaverage(GPA)at67.6%andcollegescienceGPAat61.2%.Multipleregressionanalysisdetectednostatisticallysignificantvariablesaspositiveindicatorsforlicensureexaminationpassrates.Conclusion:Currentlytherearenodefinedvariablesassociatedwithclinicalandnationallicensurepassrates.Furtherresearchisneededtoidentifyvariablesthatareassociatedwithclinicalandnationallicensurepassrates.Keywords:admissionscriteria,dentalhygiene,programadmis-sions,performanceindicatorsThisstudysupportstheNDHRApriorityarea,Professional Edu-cation and Development: Identifythefactorsthataffectrecruit-mentandretentionoffaculty.

Research

Introduction

ofNBDHEsuccess.Furthermore,thereiscurrentlyno dental hygiene research to validateGPA as apredictorof successon clinic licensureboardex-aminations.

Standardized Testing

AlongwithGPA,standardizedtestingisusedindental hygiene admissions. Thirty-one percent ofaccrediteddentalhygieneprogramsusetheAmer-ican College Test (ACT), 18% use the ScholasticAchievementTest(SAT)and46%reported“other”


fortestscoreassessment.6EdenfieldandHansennotedlinkagesbetweenACTandSATwithsuccesson the NBDHE.6Thereadingcomprehensioncom-ponentoftheACThasshownpotentialinpredict-ingNBDHEscores.4SeveralnursingstudiesfoundtheSATandACTtopredictlicensureexaminationscoresfornursingstudents.7,8Thepredictiveabilityfoundinthesestudiescouldtranslatetodentalhy-gienecliniclicensureexaminationsuccessbuthasyet to be determined.

A standardized test formally used for admis-sions to dental hygiene programswas called theDental Hygiene Aptitude Test (DHAT). The DHAToriginatedin1956andwasusedasapre-admis-sionexaminationfordentalhygiene.9 The intent of this examwas tomeasure numerical ability, sci-enceknowledge,verbalknowledge,andcapabilityof readingandcomprehendingscientific informa-tion.10TheDHATwasshowntobeapositivepre-dictorfortheNBDHEaccordingtoastudydonebyLongenbeckerandWood.11Inaddition,thisstudycompared predictive capability of both the DHATandtheACTindicatingtheDHATasthe“mostvalidsinglepredictorofNBDHEscores.”11Totheauthors’knowledge,therehavebeennostudiesrelatedtothe DHAT in more than 25 years and none that validatethistestasapredictorforclinicallicensureexaminationsuccess.

ThepurposeoftheDHATissimilartowhatdentalschoolsuseforadmissions.TheDentalAdmissionTest (DAT) provides an assessment of academicaptitude and understanding of scientific knowl-edge. In addition, it provides an assessment ofperceptualability.12InastudyconductedbyParketal,clinicalperformanceonoperativeprocedureswasassociatedwiththebiologycomponentoftheDATforstudentsattheHarvardSchoolofDentalMedicine.13 Bergman et al reported that the read-ingcomprehensioncomponentoftheDATwassta-tisticallysignificantwhenassociatedto theNBDEpart I.14DeBalletalfoundsimilarassociationsbe-tweentheDATreadingcomprehensioncomponentandNBDEanatomicsciencescores.15Forcompre-hensive examinations, the quantitative reasoningandtotalscienceportionsoftheDATwerepositivepredictorsofperformance.16 These studies suggest thattheDATisassociatedwithperformanceontheNBDEpossiblydemonstratingthepredictivevalid-ity of the use of standardized testing to foreseecandidates’ability topass licensureexaminationsduringpre-admissionselection.

OtherstandardizedtestssuchastheAlliedHealthProfessionsAdmissionTest(AHPAT)showanabilitytopredictalliedhealthin-courseGPAaswellasna-tionalcertificationexams.7,17,18TheHealthScience

Reasoning Test (HSRT) is used to assess criticalthinking skills aspartof theadmissionsprocess.ScoresontheHSRTcorrelatewithbothcandidaterankandscoresonthePharmacyCollegeAdmis-sionTest(PCAT).19,20Anotherpre-admissiontesttoassesscriticalthinkingskillsistheCaliforniaCriti-calThinkingSkillsTest(CCTST).Thistesthasbeenpositively linked toalliedhealthprogramsuccessaswellasclinicaljudgment.21 Initial dental hygiene clinicalperformancehasbeenpositively linkedtotheCCTST.Additionally,theCCTSTisapredictorofNBDHEscores.22,23StudieshaveidentifiedtheTestof Essential Academic Skills (TEAS) as a predic-tivetool fornursingprogramsuccess.24,25SchultzetalfoundtheHealthOccupationsBasicEntranceTest(HOBET)abetterpredictorofacademicstu-dent success inalliedhealthprogramscomparedto the ACT.26TheTEASandHOBETshowpredictiveabilityforseveralalliedhealthprograms,yetonlytheACT,SAT,DHATandCCTSThavebeenlinkedtodentalhygieneacademicsuccess.TheACT,AHPAT,CCTST, DHAT, HOBET, HSRT, PCAT, SAT and theTEAShavenotbeenvalidatedaspredictorsofclin-ical licensure examination success. Furthermore,theAHPAT,HSRT, TEAS andHOBET assessmentshaveyettobevalidatedfortheirabilitytopredictscoresontheNBDHE.

Non-cognitive Variables

Dental hygiene programs also use non-cogni-tive variables for admissions requirements suchasmanualdexterityorpsychomotorskillstesting.Three percent of accredited dental hygiene pro-gramsutilizemanualdexteritytests.1ResearchershaveexploredthePerceptualAbilitiesTest(PAT)orPartIIoftheDATforusefulnessinmeasuringmo-torskills.27InastudybyHolmesetal,studentswhopassedtheclinicalboardexaminationdemonstrat-edhigherPATscoresthanthestudentswhofailedtheclinicalboardexamination.28PsychomotortestspredictdentalstudentcoursegradesforOralAnat-omyandOperativeDentistry.29Tweezersdexterityaptitudehasbeenstudiedasapredictorofdentalstudent success. In a study by Lundergan et al,theuseoftweezersdexterityteststoaugmentthepredictivecapabilityofthePATisuncertain.30 The Purdue Pegboard Test is used to evaluatemotordexterityamongmedicalstudents.Studentspur-suingasurgicalfielddidnothavegreaterdexterityscores than thestudentspursuinganon-surgicalfield.31Theresearchisunclearastotheusefulnessofassessingmotorskillasapredictorforacadem-icandclinicalperformance.Thesedexterity testsalongwiththeCrawfordSmallPartsDexterityTest,California Performance Test and Perception andControlTesthaveyettobecorrelatedwithdentalhygienelicensureexaminations.


Letters of recommendation are used by 26%of accredited dental hygiene programs.1 There is currently no dental hygiene literature availableto validate the use of letters of recommendationinadmissions.Pre-admission interviewsareusedby 35% of accredited dental hygiene programs.1 EvansandDirksdeterminedthatinterviewscoreswere significantly related to laboratory grades.32 InterviewscoreshavestillnotbeencorrelatedtoNBDHEandclinicallicensureexamscores.

Previous dental office experience is requiredaspartof thedentalhygieneadmissionsprocessby 46% of accredited dental hygiene programs.1 Previousdentalexperience,specificallydentalas-sisting,waspositivelycorrelatedtodentalhygieneclinicperformanceandclinicGPAinastudydonebyDeAngelisandGoral.33Parketalreportedthatdentalstudentswithpriorassistingexperiencearemore apt to obtain higher scores in pre-clinicalcourses.34Therequirementofdentalofficeexperi-enceforadmissionshasnotbeenconfirmedasapredictor forNBDHEor regional clinical licensureexaminationsuccess.

Althoughmanualdexterityexams,lettersofrec-ommendationandinterviewsarevariablesusedbydentalhygieneprogramsforadmissionsdecisions,there is no dental hygiene literature available torelate these variables toNBDHE and clinic licen-sureexamscores.Thisstudysoughttoidentifyallvariables that are currently used by U.S. dentalhygieneprogramsandtoexplorepossibleassocia-tions between these variables and program passrates on national and regional clinical licensureboardexaminations.

Methods and Materials

Results

This quantitative study is both exploratory anddescriptive indesign.Thisstudywasapprovedbythe University of Bridgeport Institutional ReviewBoard.Theinstrumentusedfordatagatheringwasasurveydevelopedbytheresearchersandadmin-isteredviaemail.Thesurveywascomprisedof18questionstocollectprogramdemographicinforma-tion, program admissions requirements, and pro-gram pass rates on both the NBDHE and regional clinicalboardexaminations.Readabilityandvalidityweredeterminedthroughapilotsurveyreviewedby5dentalhygienefacultyatvariousacademicinstitu-tions.Thefacultyreportedanyproblemsandques-tionsneedingclarificationtotheresearchers.

Email addresses for dental hygiene program di-rectors were obtained from the American DentalHygienists’Associationwebsiteand309directors/chairsfromtheU.S.wereinvitedtoparticipate.The

emailinvitationprovideddirectorswithacoverlet-ter and a link to the electronic survey hosted bySurveyMonkey. A second request for participationwasemailedtoprogramdirectors11dayslaterandthesurveywasclosed4daysafterthesecondre-quest.Programdirectoremailaddresseswerenotlinkedtosurveyresponses.Surveyresponseswerereviewedforcompleteness.

DatawasenteredintoSASversion9.2(SASIn-stitute Inc.).Descriptivestatisticsusingmeasuresofcentraltendencywereusedaswellasinferentialstatisticsusingmultipleregressionanalysis.Anal-pha level of 0.05was used for statistical testing.Multiple regression analysis was used to look forrelationships between the independent variables(dental hygiene admissions criteria) and the de-pendentvariables(NBDHEpass rates/clinicalpassrates).Forthepurposesofthisstudy,NBDHEpassratesaredefinedas thepercentageofcandidatesperprogramthatpasstheNBDHEonthefirstat-tempt.Likewise,clinicalpass ratesaredefinedasthepercentageofcandidatesperprogramthatpasstheclinicallicensureboardexaminationonthefirstattempt.

Of the 309 programs invited to participate, 139programschosetoparticipateforaresponserateof45%.Becausesomeoftherespondentsdidnotan-swereachquestion,thesamplesizewhenexploringclinic pass rateswas n=131 and for national passrateswasn=133.

Admissions Variables Currently Utilized

There are many different combinations of GPAvariables used for dental hygiene program admis-sions.Additionally,severaltypesofstandardizedtestassessments were reported as well as numerousnon-cognitivevariables.Thepercentagesofpartici-patingprogramsthatutilizeeachofthevariablescanbereviewedinTableI.ThetypeofmanualdexteritytestutilizedbythedentalhygieneprogramsincludetheCaliforniaPerformanceTest,CrawfordSmallPartsDexterity Test, JohnsonO’Connor Tweezer Dexter-ityTest,PerceptionandControlTest,PurdueManualDexterity,andapegboardandsymboldigittest.TheCCTSTwasreportedby1participant.Thisvariablewas a linear combination of other variables in themodelsoisnotshowninthedataset.Additionally,the Wonderlic assessment was reported, however,clinicalandnationalpassratedatawasnotprovided.

Clinical Pass Rates

Participatingprogramsprovidedthepercentageof


Variable MeanOverallCollegeGPA 67.6%CollegeScienceGPA 61.2%AmericanCollegeTest 30.2%Pe-AdmissionInterview 29.5%PreviousDentalExperience 28.1%Essay 23.7%ScholasticAptitudeTest 20.9%LettersofRecommendation 18.7%HighSchoolScienceGPA 16.5%PrerequisiteGPA 15.1%OverallHighSchoolGPA 14.4%CommunityService 13.7%HealthOccupationsBasicEntranceTest 11.5%PersonalStatement 11.5%HealthOccupationsAptitudeExam/Psycho-logicalServicesBureau 7.9%

Compass 6.5%TestofEssentialAcademicSkills 6.5%Accuplacer 5.8%Spatial Ability 4.3%GeneralEducationRequirements 3.6%ManualDexterityTests 3.6%PersonalityAssessment 3.6%AlliedHealthProfessionsAdmissionsTest 2.2%National League for Nursing PreadmissionExamination 2.2%

Asset 1.4%HealthScienceReasoningTest 1.4%TexasAssessment 1.4%Wonderlic 1.4%CaliforniaCriticalThinkingSkillsTest 0.7%

TableI:VariableUsedbyDentalHygieneProgramsforAdmissionsDecisions

Admissions Variable Estimate tValue Pr>ltlIntercept 89.5% 24.76 <0.0001Essay -6.8% -1.81 0.074HealthOccupationsAptitudeExam(PsychologicalServicesBureau)

-10.6% -1.75 0.084

PreadmissionInterview 6.0% 1.68 0.096ManualDexterityTests -15.2% -1.34 0.183PreviousDentalOfficeExperience -3.8% -1.19 0.236

National League for Nurs-ingPreadmissionExami-nation

9.1% 1.16 0.249

PrerequisiteGPA -3.8% -1.01 0.314AlliedHealthProfessionsAdmission Test 8.5% 1.01 0.316

TestofEssentialAcadem-icSkills 4.6% 0.94 0.35

CollegeScienceGPA 2.4% 0.89 0.376Spatial Ability 12.4% 0.86 0.389PersonalStatement 4.2% 0.86 0.392HighSchoolScienceGPA 3.1% 0.79 0.429AmericanCollegeTest 2.3% 0.68 0.495HealthScienceReasoningTest 5.3% 0.55 0.581

Asset -5.4% -0.5 0.615Compass 2.5% 0.47 0.643ScholasticAptitudeTest 1.4% 0.38 0.701Accuplacer -1.9% -0.36 0.717PersonalityAssessment 3.5% 0.19 0.852GeneralEducationRe-quirements 1.3% 0.17 0.868

CommunityService 0.8% 0.16 0.875TexasAssessment -1.0% -0.1 0.919LettersofRecommenda-tion 0.4% 0.09 0.931

OverallCollegeGPA -0.3% -0.08 0.933HealthOccupationsBasicEntranceTest -0.3% -0.07 0.944

OverallHighSchoolSci-enceGPA 0.0% 0 0.997

Table II:MultipleRegressionAnalysis forClinicalPassRates

their eligible candidates that passed the clinical li-censureexaminationonthefirstattempt.Themeanforprogramclinicalpassrateswas91.8%.Multipleregressionanalysis foundnostatisticallysignificantindependentvariables(p<0.05).TableIIshowstheresultsofmultipleregressionanalysisforclinicalpassratesforeachoftheadmissionscriteriaprovidedbydental hygiene programs.

NBDHE Pass Rates

ParticipatingprogramsprovidedthepercentageoftheireligiblecandidatesthatpassedtheNBDHEonthefirstattempt.Themeanfornationalboardpass

rateswas 96.8%. The independent variableswerecorrelated toNBDHE pass rates usingmultiple re-gressionanalysis.Ofthesevariablesanalyzed,noneemergedasstatisticallysignificantcriteria.TableIIIshowstheresultsofmultipleregressionanalysisforNBDHEpassratesforeachoftheadmissionscriteriaprovidedbydentalhygieneprograms.


Discussion

Thefirstobjectiveofthisstudywastoidentifyallvariables currentlyutilizedbydentalhygienepro-grams. The admissions variables identified in thisstudyandthecorrespondingmeanforthesefactorsisdisplayedinTableI.Someofthesevariablescol-lectedarenotmadeavailableasaresponsechoiceintheyearlyAmericanDentalAssociation’sSurveyof Dental Hygiene Education Programs. This factmay account for selection of “other’ categories inthesurvey.1

Thesecondobjectiveofthisstudywastoexplorepossibleassociationsbetweentheidentifiedadmis-sionsvariablesandpassratesonlicensureexami-nations.The3categoriesofindependentvariablesthatwereexploredinthisstudyareGPA,standard-izedtestingandnon-cognitivevariablesusedinpro-gramadmissions.Pre-requisiteGPAwasreportedby15.1%ofparticipatingprogramsandgeneraledu-cationrequirementswerereportedby3.6%.TheseGPAadmissionfactors,inadditiontooverallcollege,collegescience,overallhighschoolandhighschoolscienceaverages,werenotidentifiedinthisstudyasstatisticallysignificantvariables.Thisdatasup-ports the study done byAlzahrani et al reportingthatthereisnostatisticallysignificantrelationshipbetweenincomingGPAandNBDHEsuccess.5

Standardized tests were explored as potentialpreadmission predictors for licensure examinationsuccess.Thesample sizeused foranalysisof theACT(30.2%)forthisstudywascomparabletothepercentages reported in theSurveyofDentalHy-gieneEducationPrograms(31%).1 The ACT did not emerge as a statistically significant variable. Thisdata fails to corroboratefindingsofEdenfieldandHansen,whichnotedlinkagesbetweentheACTandthe NBDHE.6

As for non-cognitive variables, less than2%ofparticipatingprogramsreportedusingmanualdex-terity tests foradmissions.Thissmallsamplesizeis consistent with the Survey of Dental HygieneEducationProgramswhere3%ofaccreditedden-talhygieneprogramsreportedusingthiscriterion.1 Theanalysisofthisvariableshowednorelationshiptopass rates.Theuseof lettersof recommenda-tion was not statistically significant as related tolicensureexaminationpass rates.As therearenootherdentalhygienestudiestovalidatethesefind-ings,additionalresearchinthisareamustbecon-sidered.AlthoughEvansandDirksfoundapositiverelationship between laboratory grades and inter-viewscores,thosefindingsdidnottranslatetothisnational study.32Whileinterviewswerenotfoundtobestatisticallysignificantinthisstudy,theuseofa

Admissions Variable Estimate tValue Pr>|t|Intercept 96.30% 56.39 <.001Accuplacer -4.73% -1.88 0.063National League forNursingPreadmissionExamination

-4.65% -1.25 0.214

PrerequisiteGPA 2.01% 1.15 0.255Compass 2.70% 1.05 0.296Essay 1.71% 0.96 0.337CollegeScienceGPA 1.19% 0.96 0.341HealthOccupationsAptitudeExam(PsychologicalServicesBureau)

-2.61% -0.91 0.366

PreadmissionInterview 1.41% 0.84 0.402Letters ofRecommendation -1.53% -0.69 0.493

AmericanCollegeTest -0.96% -0.61 0.541OverallCollegeGPA -0.90% -0.60 0.548PersonalStatement 1.31% 0.56 0.577OverallHighSchoolScienceGPA 0.85% 0.44 0.663

HealthScienceReasoningTest 1.89% 0.42 0.677

Spatial Ability 2.57% 0.38 0.705CommunityService -0.86% -0.37 0.715ScholasticAptitudeTest 0.55% 0.31 0.759Asset -1.23% -0.24 0.808TexasAssessment 1.13% 0.24 0.814PersonalityAssessment -1.71% -0.19 0.848HighSchoolScienceGPA -0.33% -0.18 0.856ManualDexterityTest 0.89% 0.17 0.868AlliedHealthProfessionsAdmission Test -0.49% -0.12 0.902

GeneralEducationRequirements -0.38% -0.10 0.918

HealthOccupationsBasicEntranceTest -0.20% -0.10 0.921

PreviousDentalExperience -0.08% -0.05 0.960

Test of EssentialAcademicSkills 0.00% 0.00 0.999

TableIII:MultipleRegressionAnalysisforNBDHEPassRates

standardizedinterviewforadmissionsneedstobeinvestigated.Researchsupportstheuseofastan-dardizedorstructuredinterviewformedicaladmis-sionselectioncriteria.35,36

Anothernon-cognitivevariableistheuseofprevi-


Acknowledgments

ousdentalexperience.DeAngelisandGoralshowedapositivecorrelationbetweenpreviousdentalas-sistingexperienceanddentalhygieneclinicperfor-mance,aswellasclinicGPA.33 This study did not validatethosefindingspossiblyduetothelowre-sponse rate of this category by participating pro-grams. The Survey of Dental Hygiene EducationProgramsestablishedthat46%ofaccrediteddentalhygieneprogramsusepreviousdentalexperienceasanadmissionscriterion.1Inthisstudy,only28.1%of participating programs reported using previousdentalofficeexperience.Itispossiblethatmanyofthe non-participating programs utilize this admis-sionsfactortherebyaffectingtheresponserateforthisparticularvariable.

The data collected from the survey revealed amultifaceted approach to requirements for dentalhygiene program admissions. Programs reportedusingavarietyofcombinationsofGPAaswellasnumerous standardized test assessments and anumber of non-cognitive variables. The currentstudyfoundnoneofthesevariablestobepositivelycorrelated to program pass rates on the NBDHE.Additionally, none of the admissions criteria werestatisticallysignificantforpredictingprogrampassratesonclinicallicensureboardexams.

Thedentalhygieneprofessionrequiresthesamemotor skills needed in dentistry. The professioncouldcontemplateusinganadmissionsexamsimi-lar to the DAT. Historically, there existed a DHATavailable for dental hygiene admissions. Dentalhygiene studies have inferred that the DHAT hasgreaterpredictivepowerovertheACTandSATtodetermineNBDHEsuccessaswellasdentalhygieneclinicalanddidacticgrades.9-11 The authors suggest considerationofthedevelopmentofanadmissionstestspecifictodentalhygiene.

Datacollectedfromthisnationaldentalhygienesurveyshowedalackofstandardizationforadmis-sionscriteriarequiredbydentalhygieneprograms.The question to be raised is do themulti-dimen-sional,varyingcriteriabeingutilizedfordentalhy-giene program admissions lend itself to the inability toestablishvalidpredictorsofdentalhygienesuc-cess?Additional researchcorrelatingcombinationsofthesevariablescouldleadtofindinganevidence-basedstrategyfortheadmissionsselectionprocess.Furtherresearchtoconfirmabasicdentalhygieneadmissionsplatformisstillwarranted.

Moreover,theauthorsproposethatthetheoreti-cal implicationsofthisstudy includeconsiderationtoadifferentviewonadmissionsprocedures.Theliterature review shows conflicting results onbestadmissions practices. This study failed to identify

anystatisticallysignificantpreadmissionpredictorsfor success on dental hygiene licensure examina-tions. Theoretically, candidates with certain attri-butes along with expert faculty instruction couldyield successful outcomes. Considerationmust begiventothepossibilitythatastudent’sbasicapti-tudeforlearningclinicalskillsmaynotbeaneces-saryfactorduringtheadmissionsselectionprocess.However,furtherinvestigationtodiscovermeasuresthat canassess clinical abilityprior toadmittancemaybewarranted.

While admissions and demographic data werecollectedinthisstudy,futurestudiesshouldnarrowthe investigation to specific categories of admis-sionsvariables.Alimitationofthisstudyisthatself-reporteddatahasthepotentialtobeskewedandbi-asedbyparticipants.Anotherlimitationofthisstudyisthatitisuncertainastowhattypesofvariablesthenon-participatingdentalhygieneprogramsarecurrentlyusing.Itisconceivablethatanundiscov-eredadmissionsfactorexiststhatcanbepositivelylinkedtoprogramlicensureexaminationpassrates.Furtherresearchtoinvestigatethemultiplecombi-nationsofGPA,standardizedtestassessmentsandnon-cognitivevariablesforadmissionsissuggested.Asthisstudyinvestigatedprogrampassrates,itisalso recommended that researchbe initiated thatexplorestherelationshipofthesevariablestoindi-vidualscores.

ConclusionThisstudyexploredfactorsusedindentalhygiene

admissionsthatcanbefurtherinvestigatedtode-terminetheirvalidityandreliability.Inaddition,thisstudydemonstratestheneedforthedevelopmentofnewdentalhygieneprogramadmissionsstandards.Thisstudysuggeststhata foundationforreliable,valid andevidence-baseddental hygieneprogramadmissionsstandardsstillneedstobedeveloped.

Tammy R. Sanderson, RDH, MSDH, is an assis-tant professor of dental hygiene at The Ohio State University. Marcia H. Lorentzen, RDH, MSEd, EdD, is Dean of the Fones School of Dental Hygiene at the University of Bridgeport.

The authorswould like to thankDr.WilliamM.Johnston for his guidance, mentorship, and sta-tistical expertise inassistingwith this study. Theauthorswouldalso like to thankRachelK.Henry,RDH,MS,AssistantProfessorandMicheleP.Carr,AssociateProfessorandChairfromTheOhioStateUniversityfortheirsuggestions,patience,andguid-ancethroughoutthisproject.


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Medically compromised patientsare individuals disabled from sys-temic diseases or conditions aris-ing fromaging, obesity, new infec-tions and use and abuse of drugs.1 These pathologic conditions can beassociated with oral health prob-lems. The needs of these individu-alsfororalhealthcarearenotbeingmet due to their limited access tooral health care professionals. TheSurgeon General’s Report, NationalOralHealthCall toAction,reportedthedisparitiesinthenation’shealthdelivery system, stating that itwilltake all health care professionalsworking together to promote oralhealth of our nation.2 Dental hy-gienistsarelicensedpreventiveoralhealth professionals who have thepotential to meet the needs of this medically compromised population.However, it is not known whetherornottheyareadequatelypreparedfor this role.

According to the National DentalHygiene Research Agenda, studiesare needed to evaluate the extentto which current entry-level den-talhygienecurriculapreparedentalhygienists tomeet the increasinglycomplex oral health care needs ofthepublic.3,4Instructioninpathologycontentareashelppreparestudentsfor this role. It has been stated that theknowledgegained frompathol-ogy instructionenables students tounderstandandparticipatecompre-hensively in the delivery of healthcare.5

TheCommissiononDentalAccreditation(CODA)Standards forDentalHygieneEducationspecifiesthat pathology clock hours (i.e., classroom time)beclassifiedintermsofgeneralpathologyandoral

AssessmentofPathologyInstructioninU.S.DentalHygieneEducationalProgramsBarbaraB.Jacobs,RDH,MS;AnnA.Lazar,PhD;DorothyJ.Rowe,RDH,MS,PhD

AbstractPurpose:Toassesstheinstructionofpathologycontentinen-try-levelandadvancedpractitionerdentalhygieneeducationalprogramsandtheprogramdirectors’perceptionswhethertheirgraduates are adequately prepared to meet the increasinglycomplexmedicalandoralhealthneedsofthepublic.Methods: A 28-question survey of instructional content andperceptions was developed and distributed using Qualtrics® softwaretothe340directorsofentry-levelandadvancedprac-titionerdentalhygieneprogramsintheUS.Respondentsratedtheir level of agreement to a series of statements regardingtheirperceptionsofgraduates’preparationtoperformparticulardentalhygieneservicesassociatedwithpathology.Descriptivestatisticsforall28categoricalsurveyquestionswerecalculatedandpresentedasthefrequency(percentage).Results: Ofthe340directorssurveyed,130(38%)responded.Mostentry-levelrespondents(53%)agreedorstronglyagreed(29%)thattheirgraduateswereadequatelypreparedtomeetthecomplexmedicalandoralhealthneedsofthepublic,whileall respondents of advanced practitioner programs stronglyagreed.Morerespondentsstronglyagreedtostatementsrelat-edtoclinicalinstructionthantodidacticcourses.While64%ofrespondentsagreedthattheirgraduateswerepreparedtoprac-ticeunsupervised,ifitwerelegallyallowed,21%wereambiva-lent.Theextentofpathologyinstructioninentry-levelprogramsvaried,butmostused traditional formatsof instruction,edu-cational resourcesandassessmentsofeducationaloutcomes.Advanced practitioner programs emphasized histological andclinicalexaminationoforallesionsandpatientcasestudies.Conclusion:Strengtheningpathologyinstructionwouldensurethatfuturegenerationsofdentalhygienistswouldbeadequate-lypreparedtotreatmedicallycompromisedpatients.Keywords: dental hygiene students, dental hygiene curricu-lum,dentalhygieneprograms,oralpathology,oralcancer,med-icallycompromisedpatientsThisstudysupportstheNDHRApriorityarea,Professional Ed-ucation and Development: Evaluatetheextenttowhichcur-rentdentalhygienecurriculapreparedentalhygieniststomeettheincreasinglycomplexoralhealthneedsofthepublic.

Research

Introduction

pathology.6 By definition, general pathology con-tent area focuses on “the nature of diseases, itscauses,itsprocesses,anditseffects,togetherwithassociated alterations of structure and function,”


whilecontentinoralpathologyisdevotedto“theetiology,pathogenesis,identification,andmanage-mentofdiseases,whichaffecttheoralandmaxil-lofacial regions.”5Systemicpathology, thebranchof pathology that is concerned with the “etiolo-gies,pathogenesis,andthehostresponsespecificto a particular organ system,”7 is not specificallylisted as a content area in theCODAdocumentsandisoftencoveredingeneralpathologycourses.Clinicalcoursesreinforcetheseconceptsandapplythemtoclinicalsituations.

Assessmentofgeneralandoralpathologyinstruc-tionintheentry-leveldentalhygieneprogramshasnotbeenreportedintermsofinstructionalcontent.Itisnotknownwhethertheinstructioninsystemicandoraldiseasesandtheirtreatmenthasevolvedtotheextentthatstudentsarepreparedtotreatthemedicallycompromisedpopulation.Itisknownthat one study of dental hygienists’ knowledge,opinionsandpractices,relatedtooralandpharyn-geal cancer risk assessment, demonstrated that74% of those surveyed believed that they wereadequately trained toprovideoral cancerexami-nations, yet only16%correctly identified11outof the14risk factors fororalcancer.8 That study indicatedthatcurrentinstructioninoralpathologymay not be adequately preparing the dental hy-gienisttoconductoralcancerriskassessments.

Entry-level programs may benefit from study-ing the curricula of advanced practitioner den-tal hygiene programs: the California RegisteredDental Hygienist in Alternative Practice (RDHAP)program9,10 and the Minnesota Advanced DentalTherapist(MSADT)program.11,12 Both types of ad-vanced practitioner programs require completionof an entry-level dental hygiene program and abaccalaureatedegreeoritsequivalenceforadmit-tance.Theseprogramsemphasizeeducatingden-talhygieniststoeffectivelyandsafelyprovidecaretopopulationsdisenfranchisedbythecurrentsys-temofdentalcaredelivery,whilepracticingunsu-pervised.9,11-14Theseunderservedpopulationsarelikelytohavecomplexhealthhistoriesandsufferchronicmedical anddental conditions; therefore,extensive preparation in pathology to recognizerisk factors for systemicdiseasesandoralmani-festationsofsystemicdiseaseisrequired.

Thepurposeofthisstudywastoassessthein-struction of pathology content in entry-level andadvanced practitioner dental hygiene educationalprogramsandtheperceptionsofprogramdirectorswhether theirgraduatesareadequatelypreparedtomeettheincreasinglycomplexmedicalandoralhealthneedsofthepublic.


Thiscross-sectionalstudywasapprovedbytheUniversityofCalifornia,SanFrancisco(UCSF)In-stitutionalReviewBoard.Alldirectorsof theU.S.dentalhygieneprogramswereselected(337CO-DA-approvedentry-levelprogramsintheU.S.,theMetropolitanStateUniversityMSADTProgramand2CaliforniaRDHAPPrograms).Programdirectorswereselectedbecausetheauthorsexpectedthattheywouldhavea comprehensiveunderstandingofboththedidacticandclinicalaspectsofthecur-riculum. The program directors’ email addresseswereobtainedfromtheAmericanDentalHygien-ists’Association(ADHA)ortheprogram’swebsite.

Thesurveyquestionnaireconsistedof28close-endedquestionsinthefollowingdomains:curricu-lum includingclockandcredithours,educationalformat, educational resources, and assessmentsofeducationaloutcomes,andinstructorqualifica-tions (12multiple-choice questions); perceptionsofgeneralandoralpathologyinstructionpreparingstudentsforparticulardentalhygieneservices(11Likert-likestatements);anddemographicinforma-tion about the program (5multiple-choice ques-tions).

The questionnaire items were pre-tested by 3experienceddentalhygieneeducators:1whowasteaching in a community college program and 2whowere teaching or had taught in a universitydental school/baccalaureateprogramanda com-munity college/associate degree program. Theyansweredeachsurveyitemandprovidedfeedbackontheclarityofthequestionsandtheamountoftime spent to complete the questionnaire. Revi-sionsbasedupontheeducators’inputwereincor-poratedintothefinalsurveyquestionnaire.

ThestudywasimplementedusingtheUCSFon-linesurveysoftwareprogram,Qualtrics®.Acoverletterwassenttothedentalhygieneprogramdi-rectors’ email addresses, stating the purpose ofthestudy.The“UCSFConsenttobeinResearch”formwasalsosentfortheparticipantstokeepfortheir records. Informedconsentwas impliedwiththecompletedreturnofthesurvey.Identificationnumberswereusedtoensuresubjectconfidential-ity,whilepermittingfollow-upofnon-respondents.Two follow-up letterswere sent viaQualtrics® to participantswho did not respond to the first re-quest.

Respondentsrefertoprogramdirectorsorrep-resentatives who completed the survey. Respon-dentsratedtheirlevelofagreementtoaseriesofstatementsregardingtheirperceptionsofwhether


currentinstructioningeneraland/ororalpathologyhasadequatelypreparedtheirstudentsforparticu-lar dental hygiene services. Descriptive statisticsforall28categoricalsurveyquestionswerecalcu-lated,usingSASversion9.3(SASInstitute,Cary,NC)andarepresentedasthefrequency(percent-age).

ResultsOfthe340surveyquestionnairessenttodental

hygieneprogramdirectors,130(38%)werecom-pleted.All3directorsoftheadvancedpractitionerprograms(2RDHAPand1MSADT)responded.

Demographic Characteristics of Institutions

The institutional settings of the respondents in the entry-level dental hygiene programs repre-sented 4 different types of institutions known tosponsor dental hygiene programs,with themostcommontype(57%)beinginapublicorcommuni-tycollege(TableI).Most(76%)oftheinstitutionsawardedanassociatedegree(TableII).

Curriculum of Entry-level DentalHygiene Programs

Generalandoralpathologycontentispresentedinentry-levelprogramsineither1course,includingbothgeneralandoralpathology,orin2separatecourses.Mostof theentry-levelprograms(83%)combinethecontentintoone3-credithourcourse.Inthemajorityofprograms(75%)inwhichthereare2separatecourses,generalpathologywasal-lotted1to2credithours,andoralpathologyal-lotted2credithours.Whilethemajorityofentry-levelprograms(68%)dedicated15to29hourstogeneral pathology, the dedicated clock hours fororalpathologyhadabroaderdistribution,withthehighestpercentage(40%)ofprogramsinthe30to44clockhourrange(TableIII).

Classsessionsintheentry-levelprogramscon-sistedoflectures(100%ofrespondents),andmostprograms(80%)includedclassdiscussionsofcasestudies.Manyother typesofeducational formatswereutilized:studentpresentations(47%),smallgroup discussions (36%), video and DVD media(29%), and clinical demonstrations (21%). Theeducationalresourcesusedintheeducationalpro-cess forpathologycontent reliedmostlyon text-books,especiallythosewrittenfordentalhygienestudents(TableIV).Manyprogramssupplementedinstructionwithclinical imagesof lesions,patientcase studies and histological/microscopic imagesof lesions. In most programs, educational out-comeswereassessedbywrittenexams(78%)and

Institutional Setting NumberofRespondents(Percent)n=126

Vocationalortechnical 20(16%)Publicorcommunity

college 72(57%)

University,notassociatedwithadentalschool 20(16%)

University,associatedwithadentalschool 14(11%)

Table I: Distribution of Institutional Set-tings of the Entry-Level Dental HygienePrograms

Type of Degrees NumberofRespondents(Percent)n=123

AssociateDegree 96(76%)Bachelor’sDegree 22(17%)CertificateinDentalHygiene 5(4%)

TableII:DistributionofTypesofDegrees/CertificatesGrantedByInstitutionsSpon-soringtheEntry-LevelPrograms

writtenexamsincludingidentificationofpathologi-calimages(78%),andevaluationofcasestudies(58%).

Adentalhygienistwithtraininginpathologywasthemostfrequentqualification(27%)oftheedu-catorwhoprovidedthemajorityofthepathologyinstructionintheentry-levelprograms.Otherfre-quentlycitedproviders includeddentalhygienists(20%),generaldentists (19%)anddentistswithtraining in pathology (20%). Themost prevalentsettingforinstructioninconductingoralcancerriskassessments intheentry-levelprogramswastheclinical courses (83%). Preparation for oral can-cerriskassessmentwasalso included intheoralpathologycourse,accordingtoahighpercentage(72%)ofrespondents.

Perceptions of Entry-level DentalHygiene Program Directors

Respondentsratedtheirlevelofagreementtoaseriesofstatementsregardingtheirperceptionsofwhethercurrentinstructioningeneraland/ororalpathologyadequatelyprepared their students forparticular dental hygiene services (Table V). Thestatements related to students’ preparation frominstruction in general pathology (i.e. recognizingrisk factors for systemicdiseasesandoralmani-festationsof systemicdiseases)elicitedagreeas


DidacticClockHours(h)n(Percent)

15 to 29 h 30to44h 45to59h 60to74h >75 hGeneralPathologyn=125 85(68%) 20(16%) 15(12%) 4(3%) 1(1%)

OralPathologyn=125 45(36%) 50(40%) 25(20%) 3(2%) 2(2%)

Table III: Distribution of Didactic Clock Hours (i.e. ClassroomTime)IntheEntry-LevelProgramsoftheRespondentsofGeneralPathologyandOralPathologyContentArea(n=125)

EducationalResource NumberofRespondents(Percent)n=126

Audio-visualmaterials 71(56%)Textbook 120(95%)Websites 43(34%)Evidence-basedresearcharticles 68(54%)

Histologicalimagesoflesions 79(63%)

Clinicalimagesoflesions 111(88%)Patientcasestudies 100(79%)

Table IV: Educational Resources Used IntheEducationalProcessbytheEntry-LevelPrograms

the most frequent re-sponse, while mostrespondents selectedstrongly agree to the statement of students’being adequately pre-pared to identify riskfactors for oral cancer.The majority of respon-dents selected com-parable percentagesof agree and strongly agree to statements probing risk factors when conducting health his-tory, counseling patients on reducing exposuretooralcancerriskfactorsand identifyingoral le-sions.Stronglyagreewastheoverwhelmingchoicefor2questionsrelatedtoclinicalinstruction(i.e.,performing a comprehensive intraoral and extra-oralexamination,includingthepalpationoflymphnodes, and feeling comfortable with performingtheexam).Thegreatestpercentageofambivalentresponses(21%,neitheragreenordisagree)wasrelatedtothestatementwhethergraduateswerepreparedtopracticeunsupervised,ifitwerelegallyallowed.Throughoutthesurveytherewasasmallpercentage of respondents (5%) who selectedstronglydisagreetoeachstatement.

Themostcriticalstatementassessedinthisstudywaswhethergraduatesareadequatelypreparedtomeet thecomplexmedicalandoralhealthneedsofthepublic.Twenty-ninepercentoftherespon-dentsstronglyagreedand53%agreed,foratotalof 82%. The corollary statement of respondents’feeling confident about the students’ preparationelicited responses of agreed (27%) and stronglyagreed(58%)foratotalof85%.

Advanced Practitioner Programs inDental Hygiene

All3advancedpractitionerprogramsoffergen-eral and oral pathology content in their curricu-lum.The2RDHAPprogramsuseanonlineformat,supplemented by limited classroom instructionand weekend seminars,9,10 whereas the MSADTprogramisafull-timegraduateprogramthatuti-lizesclassroom-based,web-enhanced,andclinicallearningenvironments.11Whiletheprogramsdifferinformat,allusedthesameeducationalresourc-es: audio-visualmaterials, histological images oflesions,clinicalimagesoflesionsandpatientcasestudies. Accordingly, identification of pathologicalimagesandevaluationofcasestudieswereusedtoassesseducationaloutcomes.OneprogramalsousedtheObjectiveStructuredClinicalExamination(OSCE),whichusesavarietyofwrittenandcom-

puter based techniques.15 The pathology instruc-torsinadvancedpractitionerprogramshadallbeeneducatedatthedoctoratelevel:ageneraldentist,adentistwithtraininginpathologyandascientistwith background in pathology. Students receivedinstruction in conducting oral cancer risk assess-mentsinclinicalandoralpathologycourses.Oneprogramincludedoralcancerriskassessmentsina course, titled “HealthAssessment andOralDi-agnosis Reasoning.” All advanced practitioner re-spondentsselectedstronglyagreetowhethertheirgraduatesareadequatelypreparedtomeetthein-creasinglycomplexmedicalandoralhealthneedsofthepublic.Oftherestofthestatementsregard-ing perceptions that current instruction preparesgraduates for particular dental hygiene services,all but one of the respondents selected stronglyagree. The exception was that one respondentsimply agreed to the statement regarding the stu-dents’preparationtopracticeunsupervised.

DiscussionThis study assessed pathology instruction in

dentalhygieneprogramsfrom2differentperspec-tives:examiningtheinstructionofpathologycon-


Statement(n=numberofrespondents) Strongly Agree Agree

Neither Agree or Disagree

Disagree Strongly Disagree

Thecurrentinstructioningeneralpathologyadequatelypreparesourgraduatestorecognizeriskfactorsforsystemicdiseases(n=126)

32% 48% 12% 3% 5%

Thecurrentinstructioningeneralandoralpathologyadequatelypreparesourgraduatestorecognizeoralmanifestationsofsystemicdisease(n=125)

39% 52% 3% 1% 5%

Thecurrentinstructioninoralpathologyadequatelypreparesourgraduatestoidentifyriskfactorsfororalcancer(n=126)

60% 33% 2% 0% 5%

Thecurrentinstructioninoralpathologyadequatelypreparesourgraduatestoprobetheseriskfactorswhenconductingahealthhistory(n=125)

42% 46% 8% 0% 4%

Thecurrentinstructioninoralpathologyadequatelypreparesourgraduatestocounselpatientsonreducingexposuretooralcancerriskfactors(n=124)

45% 41% 8% 2% 4%

Thecurrentclinicalinstructionadequatelypreparesourgraduatestoperformacomprehensiveintraoralandextraoralexamination,includingthepalpationoflymphnodes(n=124)

65% 27% 3% 0% 5%

Thecurrentclinicalexperiencesadequatelyprepareourgraduatestofeelcomfortableperformingacomprehen-siveintraoralandextraoralexamination(n=125)

70% 24% 2% 0% 5%

Thecurrentdidacticandclinicalinstructioninoralpathologyadequatelypreparesourgraduatestoidentifyorallesions(n=126)

44% 48% 3% 2% 4%

Thecurrentinstructioningeneralandoralpathologyadequatelypreparesourgraduatestomeetthecomplexmedicalandoralneedofthepublic(n=126)

29% 53% 10% 5% 4%

Thecurrentinstructioningeneralandoralpathologyadequatelypreparesourgraduatestopracticeindependently,iflegallyallowed(n=126)

22% 42% 21% 10% 5%

TableV:PerceptionsoftheRespondentsFromEntry-LevelDentalHygienePrograms

tentandsurveyingdirectorsofbothentry-levelandadvancedpractitionerprogramsastotheirpercep-tions of their graduates’ preparation to performparticulardentalhygieneservices.Resultsindicat-edthat29%ofrespondentsfromentry-levelpro-gramsstronglyagreedand53%agreedthattheirgraduateswereadequatelyprepared tomeet thecomplexmedicalandoralhealthneedsofthepub-lic. All respondents of advanced practitioner pro-grams strongly agreed that their graduateswereadequatelypreparedforthatrole.

Thecurriculaofentry-levelprogramsvariedastotheextentofgeneralandoralpathologyinstruc-tion.ThisisnotsurprisingasCODAdoesnotdic-tatespecificcredithours,clockhoursorformatofinstruction tomeetaccreditationstandards.Their

requirementsaregeneralandcurrentlyallowcon-siderableflexibilityandlatitudeinstructuringandimplementingeducational curriculaandassessingoutcomes of the educational process. While thisphilosophy has stimulated curricular innovation,with excellent academic results, some programsmayhavebenefittedfrommorestringentrequire-mentsfromCODA.

Combining general and oral pathology into 1 course, often also covering systemic pathologycontent, seems popular. The general pathologycontent includesbasicpathologicprocesses,suchas inflammation, infectionand immunity,andtheapplication of these processes to specific organsystems. These applications are often consideredtobesystemicpathology.Astrongbackgroundin


generalandsystemicpathologyisessentialtobeadequately prepared to recognize risk factors forsystemicdiseasesandoralmanifestationsofsys-temicdiseases.Multiplestudieshaveshownthelinkbetweenperiodontitisandsystemicdiseases,suchasdiabetesandcardiovasculardisease.However,this relationshipbetweenperiodontaldiseaseandsystemic disease is complex and requires a fun-damentalknowledgeofpathologicalmechanisms.16

Theemphasisofprogramsonoralpathologicalconditionsisevidentinthenumberofclockhoursoforalpathologycontent.Accordingly,morerespon-dentsagreedthattheirstudentswereadequatelypreparedinthedentalhygieneservices,whicharebasedonoralpathologycontent.Thiscontentmaybemoredirectlyrelatedtoclinicaldentalhygiene,such as identifying oral lesions. Oral cancer, itscommonoralsitesandrisk factors, isasubstan-tialpartoforalpathology.Theseconceptsarealsotaughtintheinitialdentalhygieneclinicalcourse,wherestudentslearnhowtoconductcomprehen-siveextraoralandintraoralexaminations.

Instructioninconductingoralcancerriskassess-mentsoccurredinboththeoralpathologycourseand in the lectureandclinicalcomponentsof theclinicalcourses.Mostrespondentsagreedthattheirstudents areadequatelyprepared to identify riskfactorsfororalcancer.Adequatepreparationinthisservicemaybeoverlyoptimistic, considering theresultsofonestudyofgraduatedentalhygienists,whichdemonstratedthatonly16%correctlyiden-tified11outof14riskfactors.8Generally,respon-dentsagreedmorepositivelyaboutthepreparationoftheirgraduatesinclinicalexperiencesthanindi-dacticmaterial.Becauseinthisstudythemajorityofpathologyinstructorsweredentalhygienistswithtraininginpathology,perhapsthereisgreaterem-phasisonclinicalaspectsofpathologyinstruction.Clinical procedures, such as intraoral and extra-oralexaminationandmedicalhistory,arerepeatedwitheachclinicpatient,sothehighpercentageofadequatepreparation for theseprocedures isnotsurprising.Ontheotherhand,only74%ofgradu-atedentalhygienists inthepreviouslymentionedstudyrespondedthattheywereadequatelytrainedto provide oral cancer examinations.8 That study differedfromthecurrentstudy,inthatitsurveyeddentalhygienistsastotheirpreparation,whilethecurrentstudyquestionedprogramdirectorsas totheirperceptionsofthepreparationoftheirgradu-ates.

Graduatingdentalstudentshavebeensurveyedastotheirperceptionsoftheiroralcancereduca-tion. In one study the students perceived a lackofrequisiteknowledgeandskills,whichwouldbe

necessarytoincorporateoralcancerdetectionpro-ceduresintotheiroralhealthcaredelivery.17 In a similar studydental studentsperceived that theywerenotadequatelytrainedtoperformbiopsiesorto interpret pathology reports, although they feltcomfortableperforming theoral cancer examina-tion.18 Dental students, aswell as dentists, havebeenassessedas to their knowledgeof commonsitesfororalcancer.Asexamples,only55%ofstu-dentsatonedentalschoolknewthemostcommonsitesfororalcancer,19andonlyapproximatelyhalfthe dentists in a nation-wide survey knew the 2mostcommonintraoralsitesofcancer.20 This leads onetospeculateastowhatfactorsareimportantinimprovingcomprehensionandretentionofpathol-ogyinstruction.

In thecurrentstudy, the formatofdidactic in-struction in the pathology courses included thetraditionalmodes of lectures, but with a greateremphasisonnewtechnology.Lecturewasthemostcommonly utilized instructional format in the re-spondingdentalhygieneprogramswithavarietyofotherusefuladjuncteducational tools incorporat-ed into thecurriculum(e.g.YouTube,student-leddiscussions and onlineweekly activities.) Severalresearchstudieshaveprobedtheeffectivenessofvarious educational models. Digital teaching ele-mentswerereportedtoenhancestudentlearningusingpen-technology,YouTube,andvirtualconfer-encinginorganicandbiochemistrycourses,aswellas using virtualmicroscopy to study pathologicalimages.21,22Medicalstudents’retentionratesofin-structionalmaterialimprovedwiththeuseofinter-activesoftwareandmultimediatutorials,ascom-paredtolectureformat.23,24Multimediainstructionin health professions education is equal ormoreeffectivethantraditionalinstructionforattainmentofknowledge,skillandperformance,asevidencedbyaliteraturereview.25

Thecurriculaofall3advancedpractitionerpro-gramsuseaudio-visualmaterials andhistologicaland clinical images of lesions, emphasizing theimportanceofbeingabletorecognize,aswellasunderstand,theunderlyingmechanismsofpatho-logical lesions. Patient case studieswereanotherpopulareducationalresource.Studyingthesecasestudies provides excellent opportunities for thestudentstoapplytheirknowledgeofgeneral,sys-temicandoralpathologytohypotheticalpatients,aswellastopracticemakingdecisionsashowbesttotreattheirfuturepatients,whomayhavecom-plexmedicalanddentalneeds.Utilizedmorefully,theseeducationalresourceswouldstrengthenthepathologyinstructionintheentry-levelprograms.

Students fromsomeentry-levelprogramsmay


not be prepared, as evidenced by 5%of the re-spondentsthatstronglydisagreedwitheachoftheperceptionstatements.Onecanonlyspeculateastothereasonscreatingthesenegativeevaluationsof the pathology instruction at the respondents’institutions. There could be budgetary problemsordifficultyinrecruitingaqualified,conscientiouspathologyinstructor.Perhapsthestudentsareen-teringtheprogramwithoutanadequatescientificbackground tobeable to comprehendpathologicconcepts. Programs in educational settings thatlimit their lengthare said to struggle to incorpo-ratenewcontentand technology into their over-crowded curriculum.26 Examining the curricula ofthe advanced practitioner programsmay provideexamplestooffer ideasforstrengtheningthepa-thologycurriculumattheseinstitutions.

Theadvancedpractitionerprogramsweredevel-opedtohelpservetheunderservedpopulationandimprove access to care. Furthermore, Mertz andcolleagues confirmed that RDHAP practices weresuccessfully“improvingaccesstocare,particularlyforminority,medicallycompromisedanddisabledpopulations.”27Bothtypesofadvancedpractitionerhavebeenabletomeettheneedsofthispopula-tionbecausetheyarelegallyabletopracticeunsu-pervisedinresidentialcarefacilities,publichealthclinics andwithhomeboundpatients. In the cur-rent study, the statementwhethergraduates arepreparedtopracticeunsupervised,ifitwerelegallyallowed,elicitedmanyundecided responses.Thismayindicatethatthedirectorsofentry-levelpro-gramshavenot formulated theiropinionson thiscontroversialissue.Perhapstheyarenotawareofwhatunsupervisedpracticeentails,so theycouldnotevaluatethestudents’preparationforit.Unsu-pervisedcanhavemultiplemeanings,oftenbaseduponthescopeofpracticeofindividualstates.Di-rectaccessmaybeabetterterm,asdefinedinarecentdocument:dentalhygienistsbeing“allowedto initiate treatment, based on their assessmentof a patient’s needswithout the specific authori-zationofdentists,totreatthepatientwithoutthepresenceofadentist,andtomaintainaprovider-patientrelationship.”28In2001,ADHAdevelopedapolicywhichstatedthat“dentalhygienistswhoaregraduates of accredited dental hygiene programsarecompetenttoprovideserviceswithoutsupervi-sion.”29Thissituationwouldincreasetheopportuni-tiestocarefortheunderservedpopulation.

Themajor limitations of this study involve thelackof definitionor clarificationof termsused inthequestionnaire. Inthequestionnairenodefini-tions of pathology were provided, and all state-ments related topathology instructionwerewrit-ten specific to either general pathology or oral

pathology,withnomentionofsystemicpathology.Directorswhoarefamiliarwiththeterm,systemicpathology,mayhavebeenconfusedastohowtoaddress the statements related to student prepara-tionbasedonthestudents’ instruction ingeneralpathology,becausestudentsmayhavebeenpre-pared for the task, not basedongeneral pathol-ogy content, but on systemic pathology content.Another undefined term was “adequate prepara-tion.”Respondentsmayhave interpreted thisex-pression with variousmeanings of student profi-ciency. The intent was the extent of preparationforstudentstobedeemedcompetent,definedbyCODAas“thelevelofknowledge,skills,andvaluestobeginthepracticeofdentalhygiene.”6However,itisnotclearwhetherrespondentsinterpretedthisin the samemanner. “Training in pathology”wasanotherambiguousexpression,notdefinedinthequestionnaire.Theauthorsintendedthat itwouldbe interpreted as advanced education; even so,advancededucation couldhaveabroad rangeofeducational possibilities, from completion of onecontinuing education course to being board cer-tified inoral pathology.Theauthorsneglected toformulateaquestionaddressingtheseoptions,sotheinterpretationoftherespondentsisnotknown.Consequently,nodatawerecollectedtobasearec-ommendationofthemostappropriatequalificationofaneducatorwhowouldprovidethemajorityofpathologyinstruction.

Clock hoursmay have been a weak choice toassesstheamountofpathologyinstructioninthecurriculum. Reporting clock hours may have re-quired respondents to do the calculations, whichcould contribute to either an over or under esti-mateofclassroomtime.Theauthorsassumedthatprogram directorswould have been familiar withreportingclockhours,as completionof thebian-nualsurveyofdidacticclockhoursrequireslistingoftheclockhours,whichprovideinstructionintherequired content areas, suchas general andoralpathology.30Thewidevariationinclockhoursmayhavebeenduetothelackofclearpathologytermsinthesurvey,causingthedirectorstointerpretthequestionsdifferently.

Another limitation of this study is the low re-sponse rate (38%). Although the quick responsetime and ease of electronic surveysmakes elec-tronicsurveysdesirabletouse,theytendtohavelowerresponseratesthanmailedsurveys.31,32Inter-netsurveysalsohaveahigherproportionofincom-pletequestionnaires.33Whileinthecurrentstudy,174(52%)questionnaireswerestarted,only130(38%)were completed. A few program directorsrequested to forward the research questionnairetothepathologyinstructor,sothesesurveysmay


ConclusionThe majority of program directors, who re-

sponded to thissurvey,agreed that theircurrententry-levelcurriculadopreparegraduatestodeliv-ereffectivedentalhygienecaretothemedi¬callycompromised population. However, some studyrespondents strongly disagreed. These programs may benefit from a standardized curriculum,as well as evaluating the pathology learning ex-periences of their students and addressing theweaknesses. Applying the pathology curriculumguidelines, employing educators with advancededucationinpathology,andintroducingmoreanddiversemultimedia resources into the curriculum

havebeenstartedbytheprogramdirector,butnotfinishedbythepathologyinstructor.Asthepopu-lationofelectronicmailuser increases,electronicsurveysmaybecomemorepopular and theusermorelikelytorespond.34

may strengthen these programs. As the popula-tionagesand thenumbersofmedically compro-mised patients increase, entry-level curriculawillneed to evolve to serve this patient population.Strengthening and standardizing pathology in-structionamongprogramswillensurethatfuturegenerationsofdentalhygienistswillbeadequatelypreparedtomeettheincreasinglycomplexmedicalandoralhealthneedsofthepublic.

Barbara B. Jacobs, RDH, MS, is a registered dental hygienist at the California Department of Corrections and Rehabilitation, Sacramento, Calif. Ann A. Lazar, PhD, is an assistant professor in the Department of Preventive and Restorative Dental Sciences and the Department of Epidemiology and Biostatistics at the University of California, San Francisco. Dorothy J. Rowe, RDH, MS, PhD, is an associate professor emeritus in the Department of Preventive and Restorative Dental Sciences at the University of California, San Francisco.


1. LittleJW,FalaceDA,MillerCS,RhodusNL.In:Dentalmanagement of themedically compro-misedpatient.7thed.St.Louis:Mosby/ElsevierPublishing;2008.p.7.

2. U.S.DepartmentofHealthandHumanServices.Nationalcalltoactiontopromoteoralhealth:areportoftheSurgeonGeneral.U.S.DepartmentofHealthandHumanServices.2000.

3. American Dental Hygienists’ Association. Na-tionalDentalHygieneResearchAgenda:revisedMarch2007.AmericanDentalHygienists’Asso-ciation. [Internet]. 2007 [cited 2012Sep15].Available from: http://www.adha.org/resourc-es-docs/7834_NDHRA_Statements.pdf

4. ForrestJL,SpolarichAE.ADelphistudytoup-date the AmericanDental Hygienists’ Associa-tionNationalDentalHygieneResearchAgenda.J Dent Hyg.2009;83(1):1-20.

5. ADEAcompendiumofcurriculumguidelines(re-visededition).Allieddentaleducationprograms:pathologyfordentalhygieneeducation.Ameri-can Dental Education Association [Internet].2005 Feb [cited 2013Nov 6]. Available from:http://www.adea.org/sitecollectiondocuments/compendiumofcurriculumguidelinesforalliedden-taleducationprograms.pdf

6. American Dental Association Commission onDentalAccreditation.Newandrevisedaccredi-tation standards. [Internet]. 2011 [cited 2012Sep20].Availablefrom:http://www.ada.org/~/media/CODA/Files/2016_dh.ashx

7. SystemicPathologyDefinition.[Internet].2014[cited2014Jan10].Availablefrom:http://www.cram.com/search?query=systemic+pathology+lecture+1&image_filter=all&period=any&sm=1

8. ForrestJ,HorowitzA,ShmuleyY.Dentalhygien-ists’knowledge,opinionsandpracticesrelatedtooralandpharyngealcancerriskassessment.J Dent Hyg.2001;75(4):271-281

9. Community involvement: special care resourc-es. University of the Pacific,Dugoni School ofDentistry[Internet].2012[cited2012Sep8].Available from: http://dental.pacific.edu/Com-munity_Involvement/Pacific_Center_for_Spe-cial_Care_(PCSC)/Special_Care_Resources.html

10. RDHAP program spring 2014.West Los Ange-les College [Internet]. 2012 [cited 2012 Sep8].Availablefrom:http://www.wlac.edu/allied-health/RDHAP%20Program%202014%20-%20Flyer.pdf

11. Wherelifeandlearningmeet.MetropolitanStateUniversity[Internet].2012[cited2012Sep20].Available from: http://www.metrostate.edu/msweb/explore/gradstudies/masters/msadt/

12. GlasrudP,EmberstonC,DayT,DiericksRW.Min-nesotaDentalAssociation:AhistoryofMinne-sota’sdentaltherapistlegislation:or…whattheheckhappenedupthere?AAPD[Internet].2009[cited 2012 Sep 20]. Available from: http://www.aapd.org/assets/news/upload/2010/4131.pdf

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Boththeillicitproductionandtheuseofmethamphetamine,apower-fulstimulantthataffectsthecentralnervoussystem,haveatremendousimpactonpeople’slivesandonna-tionalandstateresources.1Between1996 and 2012, the percentage ofadults admitted to treatment facili-tiesformethamphetamineincreasedfrom2.6to8.5%forthenationandfrom9.7to21.9%forIowa.2 In ad-dition toburdening thehealth caresystem,methamphetamineproduc-tion and use have negatively im-pacted the criminal justice system.In 2012, 50.9% of people impris-oned on drug charges in Iowa hadcommitted a crime related to thedrug methamphetamine.3

Methamphetamine use has beenpurportedtocausedestructiveden-talcaries.Someauthorshavesug-gestedthat itmaybethechemicalor physical qualities of metham-phetamineor its components, suchas their acidity or toxicity, directlyattacking tooth structure.4,5 Otherstudies suggest that methamphet-amine causes drymouthwhich re-ducesprotectiveaspectsofsaliva.6-8 Othersdonot attribute it tometh-amphetaminebuttousers’poororalhygiene, high consumption of re-finedcarbohydratesandlackofrou-tinedentalcare.4,8,9 The relationship betweenmethamphetamineuseandpoor oral health was first suggest-ed forprescriptionuseofmetham-phetamineandthenillicituse.10,11 The relationship with illicit usehasbeen reported inanumberofarticles,4,5,8,9,11-25andhasbeen investigated in re-searchstudieswhichmeasuredoralhealthbyself-report26-29andbyclinicalexaminationsorscreen-

TheRelationshipbetweenMethamphetamineUseandDentalCariesandMissingTeethE.MarciaBoyer,PhD;NancyThompson,PhD;TracyHill,RDH,BS,BA;M.BridgetZimmerman,PhD

AbstractPurpose:Thisstudyexaminedtherelationshipbetweenmeth-amphetamine use and oral health status.Methods:Usingacross-sectionaldesign,datawerecollectedin1998from174newlyadmittedprisonersinIowa.Oralex-aminationsidentifieddentalcariesandmissingteeth,andper-sonalinterviewsidentifiedmethamphetamineuseandcovari-ates.Descriptivestatisticswereusedtosummarizethedata,andbivariateandmultivariatelinearregressionanalyses,in-cludingtestingfor interactioneffects,wereusedtoexaminetheeffectsofmethamphetamineuseonoralhealthstatus.Results: Multivariate regression analyses for cariousteeth and surfaces showed significant interaction effects:methamphetamine*race/ethnicity (carious teeth: p=0.039;surfaces: p=0.023) and methamphetamine*tooth brushingwhenondrugs(cariousteeth:p=0.044;surfaces:p=0.035).Methamphetamineusehadasignificanteffectondentalcar-ies amongNon-Whites and among thosewho brushed theirteethlessthanonceadaywhenondrugs.Sodaconsumption(cariousteeth:p=0.026;surfaces:p=0.030)andreasonforlastdentalvisit(cariousteeth:p=0.025;surfaces:p=0.011)were also associated with caries. For missing teeth therewas a significant methamphetamine*race/ethnicity interac-tion (p=0.028) amongWhites who usedmethamphetaminecomparedtoWhiteswhodidnotusemethamphetamine.Age(p=0.0001)andreasonforlastdentalvisit(p=0.0001)werealsoassociatedwithmissingteeth.Conclusion: The effect of methamphetamine use onmiss-ing teeth wasmoderated by race/ethnicity,; while its effectondental carieswasmoderatedby race/ethnicity and toothbrushingwhenondrugs.Keywords: methamphetamine use, polydrug use, caries,missingteeth,oralepidemiologyThisstudysupportstheNDHRApriorityarea,Health Promo-tion/Disease Prevention: Investigate how environmentalfactors (culture, socioeconomic status-SES,education) influ-enceoralhealthbehaviors.

Research

Introduction

ings.7,30-33Ofthestudiesusingclinicaldata,mixedresults were found from bivariate analyses. Twostudiesconcludedthatmethamphetamineusehadanegativeimpactonoralhealth,7,32 and 2 studies reported that therewas no impact.30,31Multivari-


ateanalysisalsoresultedinmixedresults.Control-ling fordemographicvariables,professionalcare,oralhygiene,sugarconsumptionandtobaccouse,Cretzmeyer et al found that oral health (numberof teeth present and total filled and carious sur-faces)wasnot statisticallydifferent formetham-phetamine abusers and those who abused otherdrugs.31 Conversely, Shetty et al, controlling fordemographic and professional care variables,found that methamphetamine abusers had more missingteethandpoorerself-reportedoralhealththanadultNHANESIIIrespondents;however,theydidnotfindadifferencefordentalcaries.33 Based onasystematicreviewofmethamphetamineuseandhealthforadolescents,MarshallandWerbcon-cluded that there isa researchgap in that thereis insufficientevidenceofanassociationbetweenmethamphetamineuse anddental outcomes andthatfutureresearchshouldassesspotentialcovari-atesandadjustforthemusingstratifiedormulti-variateanalyses.34

This study examined the relationship betweenmethamphetamine use and oral health using data collectedin1998fromapopulationofrecentlyad-mittedprisoners.Thisstudyisimportantbecausepreviousresearchhasnotresolvedthisquestion.Studiesusingclinicalmeasuresoforalhealthsta-tusarefewinnumberandnoneofthesestudiesadequately controlled for covariates.Additionally,thefindingsfromthesestudieshavebeeninconsis-tent. A better understanding of the relationship of methamphetamine use on oral health status should assistdentalprofessionsinprovidingtreatmenttomethamphetamine users, especially preventiveservices like thoseprovidedbydentalhygienists,andcouldhaveimplicationsforpolicydecisionsre-latedtodentalcareformethamphetamineusersinprisons,drugtreatmentcentersanddentalhealthclinics.

Methods and MaterialsThiscross-sectionalstudywasconductedwithin

the confines of the staff dental hygienists’workday. Oral health evaluations and personal inter-views were used to collect data from a sampleof inmates newly admitted to the Iowa MedicalClassification Center (IMCC) between June andDecember1998.

All inmatesentering Iowa’sprison systemareevaluated at the IMCC for mental and physicalhealth conditions. Oral health evaluations areconducted on the day after admission and newinmatesareexaminedbythestaffdentistorden-talhygienist.Mouthmirrors,explorersandpano-graphicradiographsarestandardequipmentused

at the IMCC to evaluate each tooth surface foreach inmate and the oral health information isrecorded on the IMCC anatomical odontogram,achartdepictingthecrownandrootforeachofthe 32 teeth possibly present in an adult mouth. Becausetheevaluationsareconductedtodeter-mine treatment needs, adequate fillings are notdifferentiatedfromsoundsurfaces.Whenthedatawerecollected,thedentalhygienisthad16yearsofclinicalexperience,3yearsatIMCC,7yearsatamaximumsecurityprisonand6yearsinprivatepractice.Thepurposeofthestudywasdiscussedwiththedentalandmedicaldirectorsandwardenduringtheplanningphaseandadesignwhichre-stricted data collection to the dental hygienist’spatientswasaccepted.Themedicaldirectorandwardenapprovedthestudyprotocolandconsentform.TheUniversityof Iowa institutional reviewboard(IRB)determinedthat,becausethisstudywas limited to analysis of de-identified data, itdidnotmeettheregulatorydefinitionofresearchinvolvinghumansubjectsand thereforewasnotsubjecttofurtherIRBreview.

Asstatedabove,studyparticipantsweredrawnfrom the inmates evaluated by the staff dentalhygienist.Ondayswhenthereweretoomanyin-matesforthedentalhygienisttobothprovideanoral health evaluation and collect study data, aset format of offering study participation to ev-erysecond,thirdorfourthinmate,dependingonthenumberofinmatestobeexamined,wasused.Withinthistimeconstraint,inmateswereinvitedtobeapartofthestudyandtherewerenoexclu-sionsbasedongender,race,ageoranyotherco-variate.Inmateswhoelectedtoparticipatewerereadtheconsentform,whichtheysignedpriortotheoralhealthevaluation.

Photocopiesoftheodontogramsweremadeandidentifyinginformationwasremoved.Eachphoto-copyandcorrespondingquestionnairewasgivenauniqueidentifier.Oralhealthwasmeasuredby3 variables: total numberof carious teeth, totalnumberof carious surfacesand total numberofmissing teeth. For the study, incipient lesions,thosenot into thedentin,wereexcluded,whichisconsistentwithoralhealthepidemiologicalandsurveyresearch.

Data regarding demographic, oral hygiene,professionaldentalcare,sugarconsumptionanddrugusewereobtainedfrompersonalinterviewsadministered by the dental hygienist after the oral evaluation. Demographic variables included sex,age,race/ethnicity,education,maritalstatusandemployment.Oralhygienewasmeasuredbyusu-altoothbrushingfrequency,usinga6-pointscale


Results

from 3 or more times/day to less than weekly,andtoothbrushingfrequencywhenondrugs.Thelatterwasobtainedwiththeopen-endedquestion“Whenyouwereusingdrugs,howfrequentlydidyoubrushyourteeth?”Of92subjects’responses(measured on the 6-point scale previously de-scribed),32statedtheybrushedthesameasusu-al,23statedtheyneverbrushedwhenondrugsandwerecodedat the lowest frequency,4stat-ed theybrushedmorewhenondrugsandwereraised1usualfrequencylevel,20statedtheydidnotusedrugsoronlycigarettesandwerecodedattheirusualfrequency,and3subjects’answerscouldnotbecoded.For regressionanalysis, the3wereincludedusingtheirrespectiveusualfre-quencies. Professional dental care included thenumberofyearssincethelastdentalvisitandthereasonforthelastdentalvisit.Consumptionof8typesofsweetenedbeverageandfoodwasmea-suredwiththesame6-pointscaleastoothbrush-ing. Sugar consumption was analyzed using 2variables:soda(thefrequencyofsodaconsump-tion)andnon-sodasugars(asummedvariableoftheother7sugaritems).Formultivariateanaly-sis,bothsugarvariableswererenderedclosertoscalebyconvertingthemtothecommondenomi-natoroftimesperweek.Participantswereaskediftheyhadeverusedtobacco,alcohol,marijuana,methamphetamine,otherstimulants,cocaineandheroinandweregiventheoptiontonameupto2additionaldrugs.Respondentsweredividedintousersandnon-usersforeachofthedrugsfordataanalysis.

Datawereenteredinthecomputerbystudentresearch assistants and one of the authors. Alldatawereverifiedand thenanalyzedusing IBMSPSSStatistics19andSAS.

Distributionsanddescriptivestatisticswerecal-culated.Bivariateanalysiswasconductedtotestfor differences between users and non-users ofmethamphetamine.Continuous,normally-distrib-utedvariableswerecomparedusingtwo-samplettests,whileMann-WhitneyUTestswereusedfornon-normally distributed and ordinal variables.Pearson’s chi-square or the Fisher’s Exact Testwasusedforcomparingcategoricalvariables.Bi-variate analysis was also conducted to examinetheassociationofcovariateswiththe3dependentvariablesusingSpearman’sRho,Mann-WhitneyUTestsandKruskal-WallisTests.

Sincetheprimaryobjectivewastodescribetheeffect of methamphetamine use on oral healthcontrolling for the influenceofcovariates,multi-variatelinearregressionanalysiswasused.Sepa-rateregressionmodelswereanalyzedforeachof

the3oralhealthdependentvariables.Asnoneoftheoralhealthvariableswasnormallydistributed,they were transformed for regression analysis:caries with the square root transformation andmissing teeth with the natural log transforma-tion.35,36

Thecovariatesincludedintheregressionmod-elswere demographics (sex, age, race/ethnicityandmaritalstatus),sugarconsumption(sodaandnon-soda sugars), personal oral hygiene (toothbrushing frequencywhenon drugs), profession-aldentalcare(numberofyearssincelastdentalvisitandreasonforlastdentalvisit)anddruguse(tobacco, alcohol,methamphetamine,marijuanaandcocaine).Heroinusewasnotincludedduetothesmallnumberofheroinusers(n=6).Noneofthe sample used other stimulants.

Inadditiontofittingamain-effects-only-regres-sionmodel,interactioneffectsinvolvingmetham-phetamineandothercovariateswerealsoexam-ined.Thiswasdonebyfittingseparateregressionmodelswith a single interaction effect added tothemain effectsmodel. Interaction effects withap-value≤0.10wereconsideredforpossiblein-clusioninthefinalmodel.Thepresenceofasig-nificantinteractioneffectofanyofthesevariableswithmethamphetamine indicates that the effectofmethamphetamineoncariesormissingteethismoderatedbythisvariable.Amongtheinteractioneffects thatwere tested, therewere 3 variablesthatmettheinclusioncriteria:race/ethnicity,ageandfrequencyoftoothbrushingwhenondrugs.Regressionmodelswerethenfittedthatincludedvarious combinations of these interaction vari-ables.Theextent towhicheachmodelprovidedthebestfitwasassessedbytheAkaikeInforma-tion Criterion.37

Fromthefinalmodelthatincludedinteractioneffects,theeffectofmethamphetaminewasthenexaminedusingthetestofmeancontrasttotestfor differences in dental caries ormissing teethbetweenmethamphetamineusersandnon-usersat each level of the moderating variable. Sincemultipletestswereperformedtotestfortheef-fect of methamphetamine (i.e. 2 tests by race/ethnicity), thep-values for these testsweread-justedusingBonferroni’smethod.38

There were 174 individuals in the study,withonlyone individualdeclining toparticipate(99.4%).Theaverageagewas30years(SD=8.3,


Variable Total(n=174)n(percent)

MethUser(n=95)n(percent)

MethNon-user(n=79)n(percent) p–value

Age(inyears) 0.596t

17 to 2021 to 3031to4041to55

25(14.4%)75(43.1%)55(31.6%)19(10.9%)

9(9.5%)43(45.3%)40(42.1%)3(3.2%)

16(20.2%)32(40.5%)15(19.0%)16(20.2%)

Sex 0.006P

MaleFemale

149(85.6%)25(14.4%)

75(78.9%)20(21.1%)

74(93.7%)5(6.3%)

Race/Ethnicity <0.001P

WhiteNon-White

142(81.6%)32(18.4%)

89(93.7%)6(6.3%)

53(67.1%)26(32.9%)

Maritalstatus 0.060P

NevermarriedMarriedDivorced/separatedWidowed

88(50.6%)39(22.4%)46(26.4%)1(0.6%)

42(44.2%)23(24.2%)29(30.5%)1(1.0%)

46(58.2%)16(20.3%)17(21.5%)0(0.0%)

Education(highestgradecompleted) 0.244M

5 to 1112GEDSomecollege

70(40.2%)41(23.6%)45(25.9%)18(10.3%)

41(43.2%)21(22.1%)28(29.5%)5(5.3%)

29(36.7%)20(25.3%)17(21.5%)13(16.5%)

Employment 0.355P

Full timeParttimeUnemployed/laidoffOndisabilityHomemaker

136(78.2%)11(6.3%)21(12.1%)4(2.3%)2(1.1%)

72(75.8%)6(6.3%)15(15.8%)1(1.0%)1(1.0%)

64(81.0%)5(6.3%)6(7.6%)3(3.8%)1(1.3%)

Usualtoothbrushingfrequency 0.739M*

3 or more per day2xperday1xperday3to6xperweek1to2xperweek<weekly

23(13.2%)62(35.6%)69(39.7%)11(6.3%)5(2.9%)4(2.3%)

13(13.7%)32(33.7%)43(45.3%)4(4.2%)2(2.1%)1(1.1%)

10(12.7%)30(38.0%)26(32.9%)7(8.9%)3(3.8%)3(3.8%)

Ondrugstoothbrushingfrequency# 0.907M*

3 or more per day2xperday1xperday3to6xperweek1to2xperweek<weekly

16(9.4%)47(27.5%)63(36.8%)16(9.4%)5(2.9%)24(14.0%)

8(8.7%)23(25.0%)36(39.1%)9(9.8%)2(2.2%)14(15.2%)

8(10.1%)24(30.4%)27(34.2%)7(8.9%)3(3.8%)10(12.7%)

t=t-Test;P=PearsonChiSquare;M=Mann-WhitneyUTest;M*=Mann-WhitneyUTest(basedonthe6ordinalre-sponsesonfrequencyofuse);F=Fisher’sExactTest;#User=92;##Non-user=78;###User=94

TableI:DistributionofSubjectsbyCovariatesandbyMethamphetamineUse

range17to53),85.6%weremale,81.6%wereWhite, 50.6% had never been married, 49.5%hadeithergraduatedhigh school or obtainedaGED, and 78.2% had been employed full-timepriortoincarceration(TableI).

Themain reasons for lastdentalvisitwereatoothache(55.2%),checkup(28.2%)andotherdental work (15.5%). More than half (n=101,

57.9%)hadnotbeento thedentist in thepastyearandtheaveragenumberofyearssincelastdentalvisitwas4(SD=4.3).

Most subjects usually brushed their teethonce(39.7%)ortwiceaday(35.6%);however,whensubjectswereusingdrugs,36.8%brushedonceadayandonly27.5%brushedtwiceaday.While2.3%ofsubjectsusuallybrushedlessthan




MethNon-user(n=79)n(percent) p–value

Yearssincelastdentalvisit 0.042M

123to45 to 910 to 25Neverbeen

73(42.0%)20(11.5%)22(12.6%)35(20.1%)22(12.6%)2(1.1%)

47(49.5%)10(10.5%)9(9.5%)19(20.0%)9(9.5%)1(1.0%)

26(32.9%)10(12.7%)13(16.4%)16(20.2%)13(16.4%)1(1.3%)

Reasonforlastdentalvisit 0.032P

ToothacheOtherworkCheckupNeverbeen

96(55.2%)27(15.5%)49(28.2%)2(1.1%)

62(65.3%)8(8.4%)24(25.3%)1(1.1%)

34(43.0%)19(24.1%)25(31.6%)1(1.3%)

Number of drugs <0.001F

NoneOnlyoneMultiple

12(6.9%)18(10.3%)144(82.8%)

0(0.0%)1(1.1%)94(98.9%)

12(15.2%)17(21.5%)50(63.3%)

EveruseddrugsTobacco <0.001F

YesNo

151(86.8%)23(13.2%)

92(96.8%)3(3.2%)

59(74.7%)20(25.3%)

Alcohol 0.508P

YesNo

101(58.0%)73(42.0%)

53(55.8%)42(44.2%)

48(60.8%)31(39.2%)

Marijuana <0.001P

YesNo

91(52.3%)83(47.7%)

67(70.5%)28(29.5%)

24(30.4%)55(69.6%)

Cocaine <0.001P

YesNo

41(23.6%)133(76.4%)

33(34.7%)62(65.3%)

8(10.1%)71(89.9%)

Heroin 0.032F

YesNo

6(3.4%)168(96.6%)

6(6.3%)89(93.7%)

0(0.0%)79(100.0%)

Other 0.060P

YesNo

14(8.0%)160(92.0%)

11(11.6%)84(88.4%)

3(3.8%)76(96.2%)


TableI:DistributionofSubjectsbyCovariatesandbyMethamphetamineUse(continued)

weekly, 14.0% brushed less than weekly whenon drugs.

Almost half ormore of the subjects reportedthat they ingested soda (83.3%), chips and/orsnack crackers (59.0%), cake and/or cookies(54.3%),orcandy(47.1%)atleastonceaday.Sodawas consumed3 ormore times a day by64.9%of the subjects forameanconsumptionof 15.9 times perweek.Non-soda sugarswereconsumed,onaverage,34.7timesperweek.

While themajority of subjects (82.8%) usedmultipledrugs,12didnotuseanydrugsand18usedonly1drug.Fourdrugswereusedbymorethanhalf of the subjects: tobacco (86.8%), al-cohol(58.0%),methamphetamine(54.6%)andmarijuana(52.3%).Cocainewasusedby23.6%of the subjects and heroin by 3.4%. Fourteensubjectsreportedusingothertypesofdrugs.

Bivariate analysis determined significant as-sociations between methamphetamine use andbeing White, being female, having visited the




MethNon-user(n=79)n(percent)

SugarconsumptionSoda 0.007M*

1to3xperday1to6xperweek<weekly

145(83.3%)13(7.5%)16(9.2%)

84(88.4%)4(4.2%)7(7.4%)

61(77.2%)9(11.4%)9(11.4%)

Chips/crackers## 0.339M*


102(59.0%)34(19.7%)37(21.4%)

59(62.1%)18(18.9%)18(18.9%)

43(55.1%)16(20.5%)19(24.4%)

Cakes/cookies### 0.149M*


94(54.3%)29(16.8%)50(28.9%)

57(60.6%)16(17.0%)21(22.3%)

37(46.8%)13(16.5%)29(36.7%)

Candy 0.188M*


82(47.1%)41(23.6%)51(29.3%)

49(51.6%)23(24.2%)23(24.2%)

33(41.8%)18(22.8%)28(35.4%)

Kool-Aid/lemonade 0.759M*


62(35.6%)19(10.9%)93(53.4%)

34(35.8%)9(9.5%)52(54.7%)

28(35.4%)10(12.7%)41(51.9%)

Sweetenedcereal## 0.312M*


58(33.5%)23(13.3%)92(53.2%)

35(36.8%)12(12.6%)48(50.5%)

23(29.5%)11(14.1%)44(56.4%)

Sweetrolls/cerealbars 0.391M*


55(31.6%)17(9.8%)102(58.6%)

32(33.7%)10(10.5%)53(55.8%)

23(29.1%)7(8.9%)49(62.0%)

Sweetenedcoffee/tea 0.099M*


45(25.9%)8(4.6%)

121(69.5%)

28(29.5%)5(5.3%)62(65.3%)

17(21.5%)3(3.8%)59(74.7%)


TableI:DistributionofSubjectsbyCovariatesandbyMethamphetamineUse(continued)

dentist in the previous year, having visited thedentistforatoothache,havingconsumedsodaatthehighestfrequency,usingmultipledrugs,us-ingtobacco,usingmarijuana,usingcocaine,andusingheroin(TableI).

Eighteen participants had no teeth with un-treateddentalcariesand32hadnomissingteeth.Users had significantly higher numbers of cari-ousteeth(p=0.020),carioussurfaces(p=0.018)andmissingteeth(p=0.009)thanthosewhohadneverusedmethamphetamine(TableII).

Thesignificantbivariateassociationsbetweeneach covariate and the dependent variables of

cariousteethandsurfacesareasfollows.Dentalcariesweresignificantlygreateramongthoseus-ingmethamphetamine(cariousteeth:p=0.020;surfaces:p=0.018),beingWhite(cariousteeth:p=0.016; surfaces: p=0.014), consuming sodamorefrequently(cariousteeth:p=0.000;surfac-es:p=0.002),brushingonceadayorlesswhenon drugs (carious teeth: p=0.031; surfaces:p=0.050), and visiting the dentist for a tooth-ache or other work (carious teeth: p=0.030;surfaces: p=0.005). The number of missingteethwassignificantlygreateramongthoseus-ing methamphetamine (p=0.009), being older(p=0.000),beingmale(p=0.021),beingmarried(p=0.000), not visiting the dentist in the past


Variable Mean SD Median Q1 Q3 p-valueMDecayedteeth 0.02

TotalUserNon-user

6.97.85.8

5.86.25.1

674

332

10108

Decayedsurfaces 0.018TotalUserNon-user

17.520.413.9

17.419.214.1

141511

564

232820

Missingteeth 0.009TotalUserNon-user

4.24.73.7

4.33.94.7

343

121

674

M=Mann-WhitneyUTest;SD=StandardDeviation;Q1=25thPercentile;Q3=75thPercentile

TableII:SummaryStatisticsforOralHealthVariablesandStatisticalSignificancebyMethamphetamineUse

year (p=0.004), and visiting the dentist for atoothacheorotherwork(p=0.000).

Regression analyses to control for covariatesinassessingtheeffectofmethamphetamineuseondentalcariesshowedasignificantinteractionbetweenmethamphetamineuseandrace/ethnic-ity(cariousteeth:p=0.039;surfaces:p=0.023)and a significant interaction between metham-phetamine use and tooth brushing frequencywhen on drugs (carious teeth: p=0.044; sur-faces:p=0.035)(Table III).AmongNon-Whitestherewere significantlymore carious teethandsurfacesinmethamphetamineusers(n=6)com-paredtonon-users(n=26)(Bonferroniadjustedp=0.014 and p=0.011, respectively). However,no significant effect of methamphetamine wasseen among Whites (carious teeth Bonferroniadjusted p=0.367; carious surfaces Bonferroniadjusted p=0.287) (Table IV). Likewise, amongthosewhobrushedtheir teeth less thanonceadaywhenondrugs,thereweresignificantlymorecariousteethandsurfacesinmethamphetamineusers (n=25) compared to non-users (n=20)(Bonferroniadjustedp=0.007andp=0.003,re-spectively). There was no significant effect ofmethamphetamineoncarious teethandsurfac-es (Bonferroni adjusted p=0.216 and p=0.221,respectively) among those who brushed theirteethat leastonceadaywhenondrugs(TableIV).Othersignificantcovariatesfordentalcarieswere reason for lastdentalvisit (carious teeth:p=0.025;surfaces:p=0.011)andsoda(cariousteeth:p=0.026;surfaces:p=0.030).Thosewhovisitedthedentistforatoothacheorotherworkand thosewhomore frequentlyconsumedsodahadmorecariousteethandsurfaces(TableIII).

Formissing teeth, regressionanalyses toas-sesstheeffectofmethamphetamineuseshowedasignificantmethamphetamineandrace/ethnicityinteraction(p=0.028)(TableIII).Thisinteractionindicatedthattheeffectofmethamphetamineonmissing teethdifferedwithin race/ethnicity cat-egories,withsignificantlymoremissingteethinWhiteswhousedmethamphetamine(n=89)thaninWhiteswhodidnot(n=53)(Bonferroniadjust-ed p=0.038). Therewas no significant associa-tionbetweenmethamphetamineuseonmissingteeth among Non-Whites (Bonferroni adjustedp=0.431)(TableIV).Othersignificantcovariateswere age (p=0.0001) and reason for last den-talvisit(p=0.0001).Beingolderandvisitingthedentistforatoothacheorotherworkresultedinmoremissingteeth(TableIII).

Discussion

Previousstudiesreportedalowerpercentageofmethamphetamineuserswhobrushedtheirteethat least daily when on drugs (35.3 to 41%)30-33 thanfoundinthisstudy(72.8%).Onlyonestudyreported a significant bivariate relationship be-tween methamphetamine use and tooth brush-ingwhenondrugs.32Whilethisstudydidnotfindsignificant bivariate relationships betweenmeth-amphetamine use and usual tooth brushing and methamphetamineuseand toothbrushingwhenondrugs,itdidfindasignificantbivariaterelation-shipbetween toothbrushingwhenondrugsanddentalcaries.Additionally,multivariateanalysisofthisdataindicatedthatmethamphetamineusere-sults in statisticallymoredental caries for thosewhobrushlessthanonceadaywhenondrugs.


VariableDecayedTeeth DecayedSurfaces MissingTeeth

b SE p–value b SE p–value b SE p–valueIntercept 0.698 0.645 0.281 0.405 1.096 0.712 -0.237 0.342 0.489Methamphetamineuse -0.066 0.268 0.806 -0.145 0.456 0.751 0.314 0.132 0.019Cocaineuse -0.038 0.230 0.869 -0.043 0.392 0.912 -0.060 0.123 0.625Marijuanause 0.076 0.214 0.722 0.234 0.363 0.520 0.155 0.113 0.174Tobaccouse -0.051 0.288 0.860 -0.362 0.489 0.461 0.153 0.153 0.322Alcoholuse -0.145 0.197 0.462 -0.237 0.334 0.479 -0.104 0.104 0.316Sex(male) 0.427 0.274 0.122 0.521 0.466 0.265 -0.083 0.146 0.571Age 0.010 0.015 0.494 0.041 0.025 0.104 0.032 0.008 <.000Race/ethnicity(Non-White) -0.624 0.290 0.033 -1.093 0.493 0.028 0.385 0.154 0.013Nevermarried(other) 0.074 0.261 0.777 0.114 0.444 0.798 -0.052 0.138 0.707Married(other) -0.063 0.265 0.812 0.033 0.451 0.941 0.078 0.141 0.584Lastvisittodentist(>1year) 0.279 0.202 0.170 0.450 0.343 0.192 -0.185 0.108 0.088Reasonforlastvisittodentist(toothache/other) 0.499 0.220 0.025 0.965 0.374 0.011 0.500 0.117 <0.000

Ondrugstoothbrushingfrequency(<1/day) -0.200 0.322 0.536 -0.463 0.548 0.400 0.160 0.111 0.151

Soda 0.030 0.014 0.026 0.051 0.023 0.030 0.008 0.007 0.254Non-sodasugars 0.002 0.004 0.598 0.005 0.007 0.475 0.000 0.002 0.858Methamphetamine*race/ethnicity 1.204 0.579 0.039 1.645 0.718 0.023 -0.684 0.308 0.028

Methamphetamine*Ondrugstoothbrushingfrequency 0.856 0.422 0.044 2.097 0.985 0.035 – – –

Rsquared 19% 21% 41%

Table III: Regression Coefficient Estimates and Statistical Significance of the FittedModelswithInteractionEffectsforEachOralHealthVariable

SE=StandardError

Previousmethamphetaminestudiesdidnot in-clude reason for dental visit,which this analysisfoundwasrelatedtobothdentalcariesandmiss-ingteeth.Inthisstudy,subjectswhosawtheden-tistfortoothachesorothertreatmenthadpooreroralhealththanthosewhosawthedentist foracheck-up.Inadditiontotheadvancedstageofdis-ease,thelargenumberofmissingteethfoundintheseprisonersmay reflect thecultureofdentalcare.39

In 3 previous studies, consumption of sodavaried from 35.3%30 to 94%32 among metham-phetamine users. This study found that 92.6%ofmethamphetamineusersconsumedsoda.Mo-rioetal foundasignificantdifference inpercentconsuming soda betweenmethamphetamine us-ers andnon-users, aswas found in this study.32

However, Cretzmeyer et al31 and Brown et al30 didnot.Thisanalysisfoundthatthefrequencyofsodaconsumptioncorrelatedwithdentalcaries,as

didRaveneletal,7butCretzmeyeretal31 did not. Whencovariateswerecontrolled,sodaconsump-tionremainedsignificantlyrelatedtodentalcaries.Noneoftheothersugarvariablesstudiedindividu-ally or as a combined frequency correlatedwithmethamphetamineuseorwithdentalcaries.Sug-arvariables,includingsodaconsumption,werenotrelated to missing teeth.

Inadditiontothisstudy,Cretzmeyeretalweretheonly ones to investigate the relationship be-tweenageandoralhealth.31 Although they found that methamphetamine users were significantlyyounger than their other-substance-abuse com-parison group, logistic regression indicated thatagewasnot related tooralhealth. In thisstudyagewasnotrelatedtomethamphetamineusenortodentalcaries;however,agewasrelatedbivari-atelyandmultivariatelytomissingteeth,withold-erinmateshavingmoremissingteeth.


OralHealthMeasures Interaction

User Non-userp–valueB

n mean SE n mean SE

Decayedteeth

Methamphetamine*race/ethnicityNon-Whites 6 9.7 3.0 26 3.1 0.9 0.014Whites 89 6.8 1.0 53 5.2 1.2 0.367Methamphetamine*OndrugstoothbrushingfrequencyLess than onceaday 25 10.1 2.1 20 3.7 1.2 0.007

Onceadayor more 70 6.6 1.4 59 4.4 0.9 0.216

Decayedsurfaces

Methamphetamine*race/ethnicityNon-Whites 6 26.8 8.4 26 8.0 2.3 0.011Whites 89 18.7 2.8 53 13.9 2.9 0.287Methamphetamine*OndrugstoothbrushingfrequencyLess than onceaday 25 28.2 5.9 20 9.4 2.9 0.003

Onceadayor more 70 18.0 3.8 59 12.0 2.4 0.221

MissingteethMethamphetamine*race/ethnicityNon-Whites 6 2.1 0.8 26 3.5 0.7 0.431Whites 89 3.2 0.5 53 2.1 0.4 0.038

B=BonferroniAdjustedMethodMeansandStandardErrors(SE)ComputedbyBackTransformation

TableIV:EffectofMethamphetamineonOralHealthVariablesBasedonEstimatesfromtheRegressionModels

Although methamphetamine users commonlyuseotherillicitdrugs,40previousresearchers7,30-33 didnotinvestigatethem.Inthisstudy,whileuseof tobacco, marijuana, cocaine and heroin weresignificantly correlated with methamphetamineuse, none of these drugs correlated with dentalcaries andmissing teeth. Additionally,multivari-ateanalysescontrolledforthese4drugsandnonewas found to be related to the oral health vari-ables. However, polydrug use was high and thissampleof174subjectswasnotadequatetocon-siderall the interactioneffectsof thedrugswithmethamphetamine.

The findings that methamphetamine’s effectson dental caries aremoderated by tooth brush-ingwhenondrugs,andthatthereasonfordentalvisitinfluencesbothcariesandmissingteeth,sug-gest intervention points. One interventionwouldfocus on preventive behaviors. For persons withfewdentalcaries,secondarypreventivemeasureswouldcompriseappropriatetraditionalhomecareand routine dental visits. However,many of theprisonersinthisstudyareatthetertiarylevelandmay requireprescription strengthfluoride tooth-

paste, frequentprofessional cleaningsandelimi-nationofsoda.Sincemethamphetamineusemayaltersalivasothat it ismoreacidicandhas lessbufferingcapacity, saliva testingandappropriateneutralizing and re-mineralizing agents shouldbe considered.7 Drugs used to treat drug abuse shouldnothavehighsugarcontent.

Researchers have found that habituated oralhealthbehaviorscanwithstandchangesinaper-son’s social environment, and this underscoresthe importance of primary prevention.41 Had the methamphetamine users in this study had well-establishedoralcarehabitstheywouldhavemain-tainedtheirusualhighertoothbrushingfrequen-cyandregulardentalvisitswhenondrugs.Thiswouldhavereducedthenumberandsizeofcari-ous lesions for theprisonerswhousedmetham-phetamine.Givenwhatisknownaboutdevelopingdental health habits, primary prevention shouldstart at birth.42-45

Changing adults’ health behavior is not easy,nor is altering dental procedures in institutions.Research on dental hygienists’ role in providing


preventiveservicestodrugusershasnotbeenre-ported.However,givenadministrativesupportforestablishingpoliciesandfunding,theseinterven-tionsarewithinthescopeofdentalhygieneprac-ticeandthuscouldbeprovidedcost-effectivelybydental hygienists. It is likely that dental hygien-ists,especiallythoseemployedinrehabilitationorcorrectional facilities, could advocate for restric-tions onaccess to sodas andother sugar intakesimilartothosefordiabeticprisoners,forshorterintervalsforprophylaxesandclosersupervisionofpersonal oral hygiene.

Anotherinterventiontoconsiderwouldbeden-tal screenings for high school seniors, especiallyin stateswheremethamphetamineuse ispreva-lent.Inthenewlyadmittedprisonersinthisstudy,byage18,63%ofthishighriskgrouphadtriedmethamphetamine. Thus, such a dental screen-ingprogrammaynotonlyleadtoearlydetectionofdentalcariesandthepreventionofdestructivecariesbutmayalsoleadtoearlyidentificationofdrug use.

Whiletheseinterventionsareprimarilydirectedatdentalcaries,theyalsowouldaddressmissingteeth. Osborn found that approximately 86% ofprisoners ages 25 to 40 needed teeth extracteddue to dental caries; for those younger than 25andthoseolderthan40,65%neededextraction.46

Alimitationofthisstudywhichmayhaveinflu-enced the resultswas that the number ofmiss-ing teeth attributed to dental diseasemay havebeenover-estimatedbecausethereasonforteethbeingabsentwasnotascertained. Inaddition todentaldisease,teethcouldhavebeenmissingduetotraumaandorthodonticcare.Salivesuggestedthat the higher mean number of missing teeth in theprisonershestudied,ascomparedtoanation-alsample,mayhavebeenduetotrauma.47

Additionally,therewere3variableswhichwerenotcapturedcompletely: theupper limitofsodaconsumption, the lower limit of tooth brushingwhenondrugsanda completehistoryofdentalcaries (because filled teeth were not charted aspartoftheoralexaminationattheIMCC).Howev-er,itisunlikelythattheselimitationsoncomplete-nessalteredthefindingsofthisstudy.

Sincethedatawerecollected16yearsago,thisraisesthequestion:Arethedatastillpertinentto-day?Theauthorsbelieve theyare for anumberof reasons.Methamphetamineusestill createsameaningful and growing burden on health carefacilities and penal institutions in Iowa.2,3 Meth-amphetamineusedin2014inIowaispurerthan

thatwhichwasusedin1998.3Whethermorepuremethamphetaminewouldresultinhigherlevelsofdecayisunknown.Ifitdid,methamphetamineus-erswould be further differentiated fromnon-us-ers.Theresearchmethodologyusedinthisstudyis consistent with current approaches and theSubstanceAbuseandMentalHealthServicesAd-ministration’smeasurementofmethamphetamineuse.40ThedentalevaluationsareconductedinthesamemannerattheIMCC,anddentalcariesandmissing teethare still commonmeasuresoforalhealthstatus.Dentalcariespreventiveandtreat-mentprocedureshavechangedlittlesince1998.

Theprisonpopulationwasselectedbecausetheauthorsexpectedthatprisonerswouldhavemoreoral disease and more use of illicit drugs thanthegeneral population.Additionally, this popula-tionwas accessible andwas not expected to beaffected by socially-correct answers. Conductingthestudywithintheconfinesofthisparticularpe-nalinstitutionrestricteddatacollectiontoinmatesevaluated by the staff dental hygienist and pre-cludedusingmorethanoneexamineraswellasconductingintra-examinerreliabilitytests.

Thesettingdidallowfornon-threatening,con-fidential and routine implementation of the per-sonal interviews. The structure of the interviewandsequencingofitemsweredonetobeconsis-tent,clear,andeasytoanswer,toenhancerecallandunbiasedresponses,andtogiveequalatten-tiontoalldrugs.Whileself-reportedinformationisoftenconsideredsuspect, it isthemostcommonmethodology to obtain personal information and itisthemostpracticalintermsofprivacyandex-pense.Donovanconcludedthatself-reporteddrugusecanbeaccurateiftheforegoingtechniquesofinterviewdesignandimplementationareutilized.48

Futurestudiesareneededtoelucidatetheroleof methamphetamine use on oral health status. Largesamplesizesareneededtostudymainef-fectsregardinguseofotherdrugsandtotesttheinteractioneffectregardingrace/ethnicityfoundinthisstudyamongthesmallnumber(n=6)ofNon-Whiteusers.Additionalresearchusingusersandnonuserscouldtestthevalidityofanecdotalinfor-mationregardingtheuniquelocationandappear-ance of methamphetamine-associated caries. Inadditiontocomparingusersandnonusers,quan-tityandfrequencyofmethamphetamineuseandoral health should also be investigated. Anotherareaofresearchwouldbetodevelopandtesttheeffectiveness of interventions regarding oral hy-giene, professional care, and soda consumptionfor methamphetamine users.


Conclusion

Theeffectofmethamphetamineuseonmissingteeth wasmoderated by race/ethnicity; whereastheeffectofmethamphetamineuseondentalcar-ies was moderated by race/ethnicity and toothbrushing when on drugs. Methamphetamine usetogetherwithpoororalhygieneresultedinsignifi-cantlymoredentalcaries.Asisevidentfromthisstudytherelationshipbetweenmethamphetamineuseandoralhealthiscomplex.Thefindingsfromthis study suggest that it may be possible to miti-gate oral health problems associatedwithmeth-amphetamineusethroughpreventiveoralhygieneprograms.Theavenuesforfurtherresearchstatedabovewould add to the limitedbodyofworkonthe relationship of methamphetamine use and oral healthandwouldelucidatetheroledentalhygien-istscouldplayinreducingdentaldiseaseinmeth-amphetamine users.

E. Marcia Boyer, PhD, is the former Adjunct As-sistant Professor, Department of Preventive & Community Dentistry, College of Dentistry, The University of Iowa. Nancy Jean Thompson, PhD, is

AcknowledgmentsTheauthorswishtothank:R.D.Axelson,PhD,

AssociateProfessor,DepartmentofSociology,Di-rector, Center for Social Research, North DakotaStateUniversity;K.Kelly,PhD,AssociateResearchScientist, Department of Occupational and En-vironmentalHealth,College of PublicHealth, theUniversityofIowa;J.Yang,PhD.AssociateProfes-sor,DepartmentofPediatrics,CollegeofMedicine,TheOhioStateUniversity;andsecretarialandre-searchassistant support from theDepartmentofCommunityandBehavioralHealth.

an Associate Professor, Department of Community and Behavioral Health, College of Public Health, The University of Iowa. Tracy J. Hill, RDH, BS, BA, is a dental hygienist at the Iowa Medical Classifi-cation Center, and an Adjunct Instructor at both Kirkwood Community College and The University of Iowa College of Dentistry. M. Bridget Zimmerman, PhD, is a Clinical Professor and Associate Director, Biostatistics Core, Institute for Clinical & Transla-tional Science, Department of Biostatistics, College of Public Health, The University of Iowa.


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Dental caries is the most preva-lent and untreated chronic diseaseof children in the U.S.1 Early child-hood caries (ECC), formerly knownas baby bottle decay, affects theprimary dentition of those less than 72monthsofage,andcurrentlychil-drenages2to5haveapproximately30%untreateddentaldecay.2,3 It is estimatedthat17millionlow-incomechildren received no dental care in2009.4 Dental caries is prevalent inchildrenfromlow-incomehouseholdsand minority populations.1,4

ECCisamajorpublichealthprob-lem,andif leftuntreatedcancausepain,infectionandswellingfromab-scess,eatingproblems,andestheticconcerns.1-4 Untreated dental cariescanleadtolossofschooltime,learn-ingdifficulties,impairednutritionandhealth,andinseverecasescanresultin life-threatening infection.3 Eachyear childrenmiss 51million hoursofschoolduetodentalrelatedprob-lems.4 Hospitalization for treatmentundergeneralanesthesiaismostoftennecessarytotreatsevereECC.3

MajorriskfactorsforECCareminorityracialsta-tus and low family income,poor access to dentalcare,andmothers’poorknowledgeaboutthe im-portanceoforalhealth.1,5Poororalhealthbehaviorsof themothers and their young children are alsofactors indevelopingECC.6Frequentexposurestosweeteneddrinksandmilkinbabybottlesandsip-pycups,aswellasnursingduringsleephavebeenlinkedtothedevelopmentofsevereECC.7 Studies findthatECCcanhaveanoverallnegativeeffectonthe oral health related quality of life of preschoolchildren.8 Toddlers affected by ECC tend to growslower than caries-free toddlers, may be under-weightduetodifficultyeatingandaremorelikelytohavedentalproblemsasadults.9

KnowledgeandBehaviorsRegardingEarlyChildhoodCariesAmongLow-IncomeWomeninFlorida:APilotStudyMaryamRahbari,BA,RDH,MPH;JaanaGold,DDS,PhD

AbstractPurpose:Thisstudyevaluatedtheoralhealthknowledgeandbe-haviorsinpregnantwomenandmothersofyoungchildreninrela-tiontoearlychildhoodcariestoassesstheneedforaneducationaloral health program.Methods:Interviewswereconductedfromasampleof103Med-icaid-eligible participants;56pregnantwomenand47motherswithchildrenundertheage6inFlorida.Thedatawerecollectedusing a 4-page questionnaire with closed-ended questions andanalyzedusingSAS/STAT9.22.Results: Overall,79of101studyparticipants(78%)didnotre-ceiveanydentalcareduringpregnancy.Therewasasignificantre-lationshipbetweenthefrequenciesofmother’stoothbrushingandhowfrequentlytoddlers’teethwerebrushed(C=0.29;p=0.04),andthemothers’self-reportedoralhealthratingsandhowfre-quentlytheybrushedtheirtoddlers’teeth(r2=0.29;p=0.03).Conclusion:Mothers’oralhygienehabitsaresignificantlyrelatedto the oral hygienehabits of their children.Oral health educa-tion,duringandafterpregnancy,wouldbebeneficialtopromotehealthiermouthsforthemothersandtheirchildren.Keywords:dentalcaries,earlychildhoodcaries,WIC,oralhealthThis study supports the NDHRA priority area,Health Promo-tion/Disease Prevention: Investigatetheeffectivenessoforalself-carebehaviorsthatpreventorreduceoraldiseasesamongallage,socialandculturalgroups.

Research

Introduction

SinceECCisprevalentamongchildrenbetween2 to 5 years old of low socioeconomic status,10 a specialsupplementalnutritionprogramforWomen,Infants and Children (WIC) can provide a targetgroupforpreventivedentalservices.WICprogramsareofferedthroughcountyhealthdepartmentsandprovidenutritiousfoods,nutritionalcounselingandreferralstohealthcareandsocialservicestolow-income pregnant, postpartum and breastfeedingwomen,aswellaschildrenuptoageof5.10 Studies findthatoralhealthliteracylevelsinWICmothersare a significant factor in the oral health of theirchildren.11,12Investigatorsreportthatchildrenwhoseekpreventivedental care at anearly agehavefewer dental problems as children and are morelikelytocontinuetheutilizationofpreventivecarein the future.13,14Newmotherswholackknowledgeabout oral health and proper oral hygiene are more


likely to have young children with ECC than newmomswith better dental hygiene habits and oralhealthknowledge.15

Manywomenarealsounawareoftheeffectsoftheiroralhealthbehavioronthemselvesandtheirbabies prior to, during and after pregnancy.16 Al-though dental care during pregnancy is safe andcan prevent long-term health problems for bothmotherandchild,manywomendonotseekdentalcareduringpregnancyandmanydentistsareun-comfortable treating pregnant patients.17-23 Short-ageofdentalprovidersforMedicaidpopulationsisamong the challenges concerning dental care formothers and pregnant women. Other challengesinclude state budget cuts toMedicaid dental pro-grams,fewerdentistshavingexperiencewithMed-icaid population and pregnant women, no-showrates,andlowreimbursementsandscopeofdentalcoverage.20 Oraldiseasesmayaffectthehealthofawomanandanunbornchild.18 Although the Semi-nole County Health Department offers full dental servicesfreeofchargetoMedicaidrecipientsuptoage21,itisimportanttounderstandthebehaviorandknowledgeofMedicaid-eligiblepatientsinrela-tiontodentalcariestopromotepreventivedentalcareandreducetheneedforfuturetreatment.

ThepurposeofthisstudywastoevaluatetheoralhealthknowledgeandbehaviorsamongMedicaid-eligible pregnant women and mothers of youngchildreninrelationtoearlychildhoodcaries,andtoassesstheneedforaneducationaloralhealthpro-graminSeminoleCountyHealthDepartmentclinicsin Florida.


Results

Subjects

This studywasapprovedbyanA.T.StillUni-versityInstitutionalReviewBoard.Studysubjectswere recruited from 3 separate departments:pre-natal clinic, the primary clinic and theWIC’smandatorybreastfeedingclassesat theSeminoleCounty Health Department in Florida. Informed consentwasobtainedfromparticipantswhofilledoutthestudysurvey.Inclusioncriteriawerepreg-nantwomenandmothersofchildrenunderage6,enrolled in theWIC program, and were enrolledinMedicaidorMedicaideligible.Womenwereap-proachedbytheresearcherintheclinicsandaskedto participate in the study. The exclusion criteriawere participants with private dental insurance,hadchildrenolderthan6ordidnotqualifyforgov-ernmentassistedprogramsorMedicaid.Atbase-line, there were 103 participants, 56 pregnantwomenand47non-pregnantmothers,with55ofthewomenwithchildrenunderage6.

Data Collection

The data for this study was collected using a4-pagequestionnaireinpaperformatwithclosed-endedquestionsadministeredtopregnantwomenandmothers (n=101) of children under the ageof 6. Pregnant, first timemothers were given aquestionnaireregardingtheirownoralhealthandmothersofchildrenunderage6weregivenanad-ditional survey about their children’s oral health.The questionnaire was modified from other oralhealth questionnaires used for similar studies.24 Nopersonalidentifyinginformationwascollected.SinceallwomenwereinlowSESandeducationallevelinthisclinic,educationwasnotindicatedasan important additional variable to be included.Therewasnocompensationforparticipatinginthissurvey.The informationcollectedwasaboutpar-ents’ oral health knowledge, attitudes, behaviorsandbeliefs.Thequestionnairealsoevaluatedthechild’sdiet, frequencyofdentalvisitsandbottle-feedinghabits.Toassessoralhealthbehaviorofthemothers,participantswereaskedtoselectanswerstobehavior-relateditems,suchas:“Howoftendoyoubrushyourteeth?”and“Howoftendoyoure-ceiveroutinedentalcare?”Responseitemsinclud-ed“onceperday,”“twiceperday,”“afewtimesperweek”and “never.”Similar questionswereaskedtoassessoralhealthbehaviorofthetoddlers,suchas:“Howoftendoyoubrushyourtoddler’steeth?”or “How often does your toddler receive routinedentalcare?”SimilarresponseitemsarereportedinTableI.Aftercompletionoftheoralhealthques-tionnaires,participantswereprovidedoralhygieneeducationandmaterial.Referrals to participatingadult Medicaid dental homes were also availableuponrequest.

Data Analysis

Datafromthequestionnairewereevaluatedus-ingSAS9.3.Mantel-Haenszelchi-squarestatisticswereusedtodeterminetherelationshipbetweenmothers’ oral health behavior and children’s oralhealth behavior using mid-ranks. Associationswereconsideredstatisticallysignificantatp<0.05.

Allwomenwho consented to this surveywereinterviewed. A sample of 103 participants com-pleted thequestionnairesbut only101question-naireswereincludedinanalysis.Incompleteques-tionnaires(n=2)wereremovedfromtheanalysis.Mostoftheparticipantswere21to30yearsofage(65%).DistributionoftheageoftheparticipantsispresentedintheTableII.Therewere56pregnantparticipants (55%) at the time of the study, but


only22participants(22%)hadadentalvisitdur-ingpregnancy.Fifty-fivemothers(54%)hadchil-drenundertheageof6.Intotal,79participants(78%) did not receive dental care during preg-nancy.Multiplereasonsweregivenfornothavingdental visits during pregnancy, which included:“didnothavedentalpainorproblems”(27%),“noinsurance” (14%), “inability to pay” (5%), “weretoldnottogotothedentist”(8%),“wereafraidofthedentist”(9%)or“couldnotfindadentistwhotreatedpregnantpatients”(8%).Overhalfoftheparticipants(53%)didnotprovideareasonfornotvisitingadentistduringpregnancy(Figure1).

Of all participants (n=101), only 7 rated theiroralhealthasexcellent(7%),51asgood(50%),34asfair(34%)and9ratedtheiroralhealthaspoor (9%). Over half of mothers (58%) report-edtobrushtheir teeth2ormoretimesperday,with fewer than30%usingdentalflossonceperday (Table I). Therewasa significant correlation(r2=0.27;p=0.008)betweenhowthemothersrat-ed their oral health and howoften they brushedtheirteeth.Mother’sreportedoralhealthwassig-nificantly positively associated with the reportedflossing(r2=0.35;p<0.001),andtherewasasig-nificant correlation between mother’s perceivedoralhealthandthefrequencyoftheirdentalvisits(r2=0.32;p=0.002).

Thequestionsregardingthechildren’soralhealthhabitsincludedthefrequencyofbrushingandden-talvisits,aswellasthetoddler’sbottlecontents.Twenty-fouroutof51mothers(47%)reportedtobrushtheirtoddler’steethtwiceperday,20moth-ersbrushedonceaday(39%),5fewtimesaweek(10%) and only 2 mothers never brushed theirtoddler’steeth(4%).Therewasasignificantposi-tiverelationshipbetweenamother’steeth-brush-ing frequency and the teeth-brushing frequencyof the toddler performed by the mother (r2=0.29;p=0.04).Therewasasignificantpositiverelation-shipbetweenthemother’sself-reportedoralhealthratingandtheteeth-brushingfrequencygivenbythe mother to the toddler (r2=0.29;p=0.03).

Although46(90%)motherswithchildrenunderage6respondedthatitisimportantfortoddlerstoreceive routine dental check-ups, only 14 (27%)admittedthattheirtoddlersreceiveroutinedentalcheck-ups 2 times a year.Motherswho reportedtheir oral health as fair or poor corresponded tobrushingtheirtoddler’steethlessfrequently.

Inresponsetoquestionsregardingbottle-feed-inganditscontents,themajorityofmothers(42,82%)reportedthattheydonotputtheirchildrentobedwithabottle.Ofthemothersthatrespond-

CaregiverFrequencyNumbers(n=101)

FrequencyPercent

OralHealth• Excellent• Good• Fair • Poor

751349

6.93%50.50%33.66%8.91%

BrushingFrequency• Afewtimesperweek• Aboutonceaday• Twoormoretimes

per day

43860

3.96%37.62%59.41%

FlossingFrequency• Never• Lessthanonceperweek

• Oncetosixtimesperweek

2350

27

22.77%49.50%

26.73%

MouthwashandDentalRinseFrequency• Never• Lessthanonceperweek

• Oncetosixtimesperweek

• Atleastonceperday

1528

27

29

14.85%27.72%

26.73%

28.71%RoutineDentalCare• Never• Lessthanonceper

year • Onceperyear• Twoormoretimes

per year • Onlywhenexperienc-

ing dental problem

1325

2117

21

12.87%24.75%

20.79%16.83%

20.79%

DentalCareDuringPregnancy• Yes• No

2279

21.78%78.22%

*IfNot,Why?• Iwasnothavingden-

tal problems• Idonothavedentalinsurance

• Ican’taffordtogotothe dentist

• Iwastoldnottogoto the dentist during pregnancy

• I am afraid to go to the dentist

• Ican’tfindadentistwhotreatspregnantwomen

• No reason

27

14

5

8

9

8

53

26.73%

13.86%

4.95%

7.92%

8.91%

7.92%

52.48%

TableI:Caregivers’OralHealthCharacter-isticsandBehavior

*Multipleanswerswereselectedbyparticipants


Age n=101 PercentUnder18 4 3.96%18 to 20 16 15.84%21 to 25 30 29.70%26to30 35 34.65%31 to 35 5 4.95%36andolder 11 10.90%

TableII:AgeDistributionofParticipantsed to bottle-feeding during the day, 43 selectedmultipleanswers.Theliquidofchoiceselectedforbottlefeedingduringthedayincluded:water(29,67%),milk(28,65%)andjuice(23,53%).

Bivariateassociationbetweenthemothers’oralhealthrating,thefrequencyoftoothbrushingandthe frequencyof tooth brushing of their toddlersshowedasignificantpositiveassociation.Motherswho rated their oral health as good or excellentbrushedandflossedtheirteethandtheirtoddler’steethmorefrequentlythanmothersthatratedtheiroralhealthasfairorpoor.Thefrequencyofmoth-ers’brushing,flossing,mouthwashuseanddentalvisitsshowedapositivecorrelationwith theself-reported oral health rating (r2=0.39;p<0.001).

DiscussionThe oral health of infants and toddlers is depen-

dentonmothers’knowledgeoforalhealthandoralhygienebehavior.6In2000,theSurgeonGeneral’sReportonOralHealth inAmericastressed itwasnecessary forparents tobe familiarwith the im-portanceandcareofchildren’sprimaryteeth,andtotakeappropriateactionstopreventECC.25

Theprimaryfindingof this studywas that themothers’oralhygienehabitsandfrequencyofden-tal visits are significantly related to the oral hy-gienehabitsandfrequencyofdentalvisitsoftod-dlers.Studiesshowthatperceptionoforalhealthis of higher level thanperception of oral diseasewhich can influence a person’s behavior to seekdentalcare.26,27 Questionnaires regarding pregnant womanandmothersof youngchildren can showthe levelofdentalandoralhealthawareness.26,27 This study found a positive correlation betweentheself-perceivedoralhealthofmothersandtheiroralhygienehabits.Thisstudysupportsthefind-ingsofapriorstudythatpoororalhealthbehav-iorscanbecontributingfactorstopoororalhealthinadultsandtheirchildren.6Goodoralhealthbe-haviorisdependentonindividual’sunderstandingoforalhealthandtheirabilitytoactontheinfor-mation.11Ithasbeenshownthatfrequentuseofdentalcarecanprovidehigherknowledgeoforalhealth for this population.11Studiesconductedontheeffectivenessofmotivationalinterviewingwithregularreinforcementsofdentalcariespreventioninpregnantmothersandmothersof infants,hasshownpromise inreducingearlychildhooddecayby the time children reached age 2 years.25,28,29 Thus, oral health education of WIC participantsdesignatedtocatertopatientswitha lower leveloforalhealthliteracyisanimportantfactortopre-ventECC.Ithasbeenshownthatchildrenwhosemothersemphasizeoralhealthhavefewercavities

thanchildrenwithoutproperoralhygienehabitsathome.6,15Becauseparentsareresponsiblefortheoralhygienehabitsanddietofyoungchildrenathome,parentalknowledgeoforalhealthandoralhygienehabitsareofgreatimportance.6

Oralhealthknowledge,attitudesandbehaviorsofMedicaidparentslargelyaffecttheiruseofpre-ventivedentalcare.30 Although these parents be-lieveit is importantfortoddlerstoreceivedentalcare,theymaynotplacehighvalueonreceivingpreventivecare.Studiessuggest that the rateofno-showsormissedappointmentsamongMedicaidpatientsisalargecontributingfactortolackofMed-icaid dental providers.14,20 Many Medicaid partici-pantsequatelackofdentalpaintoahealthymouthanddonotseekcareunlesstreatment isneededfor immediate pain relief.14 Another contributingfactorforlackofdentalcareutilizationmaybetheshortageofMedicaidprovidersinthearea.20,21Pooraccesstodentalcare,knowledgeandbehaviorofmothers,aswellasconsumptionofsugarydrinksinthefirstfewyearsoflife,arecontributingfactorstoECCinMedicaidchildren.6,12,14,15,19

Earlypreventivevisitsaremoreeffectiveinchil-drenathigherrisk,andbecausechildrenofMedic-aidandWICareathigherriskforECC,promotingearlyvisitsshouldbepracticedbyWICstafforpe-diatricMedicaidhealthcarephysicians.11,24Preven-tion of ECC can be provided by promoting goodoral hygiene habits, good nutrition, establishingofadentalhomeatanearlyageandpreventivepracticessuchasapplicationsoffluoridebyhealthprofessionals.13Prenatalandpostpartumcounsel-ingofmothersonoralhealthisnecessarytopro-motehealthydentalbehaviors that continue intothe adulthood ofMedicaid-enrolled children. Alsopromotingdentalcareforpregnantwomenisim-portantduetothestrongrelationshipbetweenoralhealthstatusofthemotherandchild.

The limitationof this study is thatparticipantswereselectedfrom1publichealthdepartmentin1stateandonlyEnglishspeakingcaregiverscom-pletedthequestionnaire.BecauseECCisaffected


ConclusionThisstudyreportsthatmothers’oralhygienehab-

itswere related to theoralhygienehabitsof theirchildren, andmany pregnant women do not havedentalcareduringtheirpregnancies.Theseresultssupporttheneedforpreventiveoralhealtheducationprogramforpregnantwomenandmothersofyoungchildren.However,oralhealtheducationalonemaynotbeeffectiveenoughsoincludingotherpreventiveapproaches, such as fluoride varnish applications,andfindingadentalhomeisimportantinreducingdisease burden in low-income risk populations. Acomprehensive preventive approach and an inter-professionalcollaborationwithotherhealthcarepro-fessionalscouldbethefuturemodeltohelpimproveoralhealthofthisvulnerablepopulation.

AcknowledgmentsThe authors thank Vanessa Kvam, Biostatisti-

cian,OfficeofResearchSupportA.T.StillUniver-sity,forhercontributionandassistanceinthedataanalysis. We thank the Seminole County HealthDepartment’sWICandthePrimaryClinicforallow-ingustousetheirfacilities,aswellasthewomenwhoparticipatedinthestudy.

Iwasnothavingdental problemsIdonothavedentalinsuranceIcannotaffordtogo to the dentistIwastoldnottogotothedentistduringpregnancyI am afraid to goto the dentistIcannotfindadentistwhotreatspregnantwomen

No reason

Figure1:ReasonsforNotReceivingRoutineDentalCareDuringPregnancy

*Multipleanswerswereselectedbyparticipants

bymanydifferentsocialandenvironmental risk factors,this survey may not be apredictorofallMedicaidandWIC participants.14 Otherlimitations of this surveywere the possible volun-teerbiassincewomenpar-ticipated voluntarily and arelativelysmallsamplesize.Our study sample was aconveniencesamplefrom1clinicconsistingself-report-eddata,whichwasnotcon-firmedbyclinicaldata.Thisstudyisthefirstoralhealthstudy of Seminole County WICparticipantsanditsre-sultscanbeusedtoevalu-ate the need for preven-tivedentalprogramforthispopulation. Further research isnecessary tobet-terunderstandthefactorsrelatedtooralhealthofchildrenandwomenenrolledintheWICprograms.

Maryam Rahbari, BA, RDH, MPH, is a registered dental hygienist currently practicing dental hygiene in a private dental practice in Lake Mary, Fla. Jaana Gold, DDS, PhD, is an Associate Professor in the Col-lege of Graduate Health Studies at the A.T. Still Uni-versity, MPH dental emphasis program and Adjunct Associate Professor at the University of Florida, Col-lege of Dentistry, Department of Community Den-tistry and Behavioral Sciences.


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