Journal of Dental Hygiene

The American Dental Hygienists’ Association February 2015 Volume 89 Supplement 1 Supplement to Access Magazine

Proceedings from the 3rd North American/Global Dental Hygiene Research Conference: “Beyond the Boundaries: Discovery, Innovation and Transformation”

Bethesda, MD, October 16-19, 2014

Sponsored by the National Center for Dental Hygiene Research & Practice Herman Ostrow School of Dentistry of USC

Funded by an unrestricted educational grant from:

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 1 2 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Journal of Dental Hygiene VOLUME 89 • SUPPLEMENT 1 • FEBRUARY 2015

STATEMENT OF PURPOSE 2014 – 2015 ADHA OFFICERS The Journal of Dental Hygiene is the refereed, scientific PRESIDENT TREASURER publication of the American Dental Hygienists’ Association. Kelli Swanson Jaecks, MA, Louann M. Goodnough, It promotes the publication of original research related to the RDH RDH, BS profession, the education, and the practice of dental hygiene. The Journal supports the development and dissemination PRESIDENT–ELECT IMMEDIATE PAST of a dental hygiene body of knowledge through scientific Jill Rethman, RDH, BA PRESIDENT inquiry in basic, applied and clinical research. Denise Bowers, RDH, MSEd VICE PRESIDENT Betty A. Kabel, RDH, BS SUBSCRIPTIONS

The Journal of Dental Hygiene is published quarterly online EXECUTIVE DIRECTOR COMMUNICATIONS by the American Dental Hygienists’ Association, 444 N. Ann Battrell, RDH, BS, MSDH DIRECTOR Michigan Avenue, Chicago, IL 60611. Copyright 2010 by the American Dental Hygienists’ Association. Reproduction [email protected] John Iwanski in whole or part without written permission is prohibited. [email protected] Subscription rates for nonmembers are one year, $60. EDITOR–IN–CHIEF Rebecca S. Wilder, RDH, BS, STAFF EDITOR MS Josh Snyder [email protected] [email protected] SUBMISSIONS Please submit manuscripts for possible publication in the EDITOR EMERITUS Journal of Dental Hygiene to [email protected]. Mary Alice Gaston, RDH, MS

EDITORIAL REVIEW BOARD Celeste M. Abraham, DDS, MS Mary Jacks, MS, RDH Cynthia C. Amyot, MSDH, EdD Heather Jared, RDH, MS, BS Joanna Asadoorian, AAS, BScD, MSc, PhD candidate Wendy Kerschbaum, BS, MA, MPH Caren M. Barnes, RDH, MS Janet Kinney, RDH, MS Phyllis L. Beemsterboer, RDH, MS, EdD Salme Lavigne, RDH, BA, MSDH Stephanie Bossenberger, RDH, MS Jessica Y. Lee, DDS, MPH, PhD Linda D. Boyd, RDH, RD, EdD Deborah Lyle, RDH, BS, MS Kimberly S. Bray, RDH, MS Deborah S. Manne, RDH, RN, MSN, OCN Colleen Brickle, RDH, RF, EdD Ann L. McCann, RDH, MS, PhD Lorraine Brockmann, RDH, MS Stacy McCauley, RDH, MS Patricia Regener Campbell, RDH, MS Gayle McCombs, RDH, MS Dan Caplan, DDS, PhD Shannon Mitchell, RDH, MS Marie Collins, EdD, RDH Tanya Villalpando Mitchell, RDH, MS Barbara H. Connolly, DPT, EdD, FAPTA Tricia Moore, EdD MaryAnn Cugini, RDH, MHP Christine Nathe, RDH, MS Susan J. Daniel, BS, MS Johanna Odrich, RDH, MS, PhD, MPH Michele Darby, BSDH, MSDH Jodi Olmsted, RDH, BS, MS, EdS, PhD Janice DeWald, BSDH, DDS, MS Pamela Overman, BS, MS, EdD Susan Duley, EdD, LPC, CEDS, RDH, EdS Vickie Overman, RDH, Med Jacquelyn M. Dylla, DPT, PT Ceib Phillips, MPH, PhD Kathy Eklund, RDH, MHP Marjorie Reveal, RDH, MS, MBA Deborah E. Fleming, RDH, MS Kathi R. Shepherd, RDH, MS Jane L. Forrest, BSDH, MS, EdD Deanne Shuman, BSDH, MS, PhD Jacquelyn L. Fried, RDH, MS Judith Skeleton, RDH, Med, PhD, BSDH Mary George, RDH, BSDH, MED Ann Eshenaur Spolarich, RDH, PhD Kathy Geurink, RDH, MA Rebecca Stolberg, RDH, BS, MSDH Joan Gluch, RDH, PhD Julie Sutton, RDH, MS Maria Perno Goldie, MS, RDH Sheryl L. Ernest Syme, RDH, MS Ellen B. Grimes, RDH, MA, MPA, EdD Terri Tilliss, RDH, PhD JoAnn R. Gurenlian, RDH, PhD Lynn Tolle, BSDH, MS Anne Gwozdek, RDH, BA, MA Margaret Walsh, RDH, MS, MA, EdD Linda L. Hanlon, RDH, PhD, BS, Med Pat Walters, RDH, BSDH, BSOB Kitty Harkleroad, RDH, MS Donna Warren-Morris, RDH, MeD Lisa F. Harper Mallonee, BSDH, MPH, RD/LD Cheryl Westphal, RDH, MS Harold A. Henson, RDH, MED Karen B. Williams, RDH, MS, PhD Alice M. Horowitz, PhD Nancy Williams, RDH, EdD Laura Jansen Howerton, RDH, MS Pamela Zarkowski, BSDH, MPH, JD Olga A. C. Ibsen, RDH, MS

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 3 Inside Journal of Dental Hygiene Vol. 89 • Supplement 1 • February 2015 Features Research 9 Dental Hygiene’s Scholarly Identity and Roadblocks to Achieving It Margaret M. Walsh RDH, MS, MA, EdD; Elena Ortega RDH, MS; Barbara Heckman RDH, MS 13 Advancing the Profession JoAnn R. Gurenlian, RDH, PhD 16 Interrupting the Disease of Tobacco Addiction Charl Els, MBChB, FCPsych, MMedPsych, ABAM, MROCC 20 The Oral Microbiome and Cancer A. Ross Kerr DDS, MSD 24 Creating a Risk-Based Model for Dental Benefit Design Shannon E. Mills, DDS 27 Using Prevention and Measurement to Drive Quality Improvement Christopher J. Smiley, DDS 30 Opportunities to Increase Prevention in Dentistry Robert Compton, DDS 33 Interprofessional Practice: Translating Evidence-Based Oral Care to Hospital Care Virginia Prendergast, PhD, NP-C, FAAN; Cindy Kleiman, RDH, BS 36 Poor Oral Health Literacy: Why Nobody Understands You William Smith, EdD, PhD; Cindy Brach, MPA; Alice M. Horowitz, PhD 39 Using the Best Evidence to Enhance Dental Hygiene Decision Making Julie Frantsve-Hawley, RDH, PhD; Janet E Clarkson, BDS, PhD; Dagmar E. Slot, RDH, MSc 43 Overcoming the Fear of Statistics: Survival Skills for Researchers Karen B. Williams PhD, RDH 46 Millennials and Dental Education: Utilizing Educational Technology for Effective Teaching Christine Blue, BSDH, MS; Harold Henson, RDH, PhD 48 Getting Your Name in Print Jacquelyn L. Fried, RDH, MS; Katy E. Battani, RDH, MS

51 Becoming an Effective Journal Reviewer Ann Eshenaur Spolarich, RDH, PhD; Rebecca S. Wilder, RDH, MS 54 Successfully Navigating the Human Subjects Approval Process MaryAnn Cugini, RDH, MHP 57 Data Management 101: How to Construct and Maintain a Usable Dataset R. Curtis Bay, PhD Abstracts 59 Abstract Titles – Poster Presentations 82 Abstract Titles – Oral Free Papers Editorial 5 Foreword J. Leslie Winston, DDS, PhD 6 The 3rd North American/Global Dental Hygiene Research Conference Jane L. Forrest, RDH, EdD; Ann Eshenaur Spolarich, RDH, PhD 8 Beyond the Boundaries: Discovery, Innovation and Transformation Through Collaboration Rebecca S. Wilder, RDH, MS; Katherine Zmetana, DipDH, DipDT, EdD

4 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Foreword J. Leslie Winston, DDS, PhD Director, Global Oral Care Professional and Clinical Operations Procter & Gamble Oral Health

On behalf of Procter & Gamble Professional The conference continues to bring together Oral Health, we are pleased to support the Pro- the international dental hygiene research com- ceedings from the 3rd North American/Global munity, with original research being presented Dental Hygiene Research conference as a spe- by dental hygienists from Australia, Canada, cial supplement to the Journal of Dental Hy- the Netherlands, Portugal, South Korea and the giene. Our relationship with the National Center United States. The level of scientific exchange for Dental Hygiene Research & Practice has been is impressive, with a wide range of topics and in place for many years and we are proud to methodologies used to study problems of direct have provided three educational grants to sup- significance to dental hygiene practice and edu- port the North American/Global Dental Hygiene cation. In addition there continues to be a large Research Conferences. As a company, we are group of dental hygiene students from both un- working to help advance the profession of dental dergraduate and graduate dental hygiene pro- hygiene around the world and we are committed grams. It is essential to continue to fuel their to research and development initiatives that are energy and enthusiasm as they are a critical part relevant to the prevention of oral diseases. of the research infrastructure going forward.

We believe that in order to deliver the best For those that had the opportunity to attend oral health prevention and patient care for the the conference, we hope you enjoy revisiting the world’s consumers that the foundation needs to great research you learned about and discussed. be science based. The National Center for Den- Importantly, for those who were unable to join, tal Hygiene Research & Practice shares similar we trust that these Proceedings will help you goals with their mission to promote the public’s get a sense of the depth and breadth of top- oral health by fostering the development, imple- ics covered and learn something new from your mentation and the dissemination of oral health colleagues. We would be remiss if we did not ac- research; establishing an infrastructure to sup- knowledge the tireless work of Drs. Jane Forrest port dental hygiene research; and strengthen- and Ann Spolarich in bringing these research ing the scientific foundation for the discipline of conferences to life! dental hygiene.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 5 Editorial Jane L. Forrest, RDH, EdD Ann Eshenaur Spolarich, RDH, PhD

The 3rd North American/Global Dental Hygiene Research Conference The 3rd North American/Global Dental Hygiene In order to achieve these objectives, a program Research Conference, “Beyond the Boundaries: devoted to a wide range of topics was created. Discovery, Innovation and Transformation,” was Invited senior scientists presented their ideas and held from October 16 to 18, 2014, in Bethesda, summaries of ongoing research efforts related to Maryland. An additional half-day session was tobacco addiction and treatment, and the role of held on October 19, 2014 for educators entitled, the oral microbiome in oral cancer development. “A Practical Guide to Incorporating Research & Distinguished dental hygiene scientists discussed Evidence-Based Decision Making into the Dental the development of a scholarly identity and its Hygiene Curriculum.” The Conference provided relationship to advancing the profession. Invited an opportunity for dental hygiene researchers researchers shared their work, including an ex- from the United States, Canada, Asia, Europe amination of the relationship between preventive and Australia to convene and explore common- services and quality of care; how an interprofes- alities in their research interests, learn from each sional collaboration between nursing and dental other about new and ongoing research programs, hygiene improved health outcomes in patients in and foster future collaborations. It is our hope the ICU; and about the impact of health literacy that discussion and interest generated at the on health outcomes. Dental hygiene researchers conference provided the networking support and from around the world presented their original intellectual stimulation needed to systematically work during both poster and oral scientific ses- and purposefully move our research forward. To sions in support of national and global oral health this end, the purpose of the conference was to research agendas. Opportunities to learn about bring the international dental hygiene community this research were made through 42 poster and together to: 33 oral presentations.

• Share new knowledge obtained through re- Finally, based on the outcomes from the sec- search investigations ond conference in October 2011, a program was • Explore how to translate research to practice created to enhance training and skill develop- in a meaningful and useful manner ment on a wide range of topics. Seven different • Disseminate new knowledge gained from re- continuing education workshops were specifically search to support evidence-based practice designed on the following topics: Using Best Evi- • Increase and diversify the number of individ- dence to Enhance Dental Hygiene Clinical Deci- uals engaged in oral health research sion Making; Overcoming the Fear of Statistics; • Build collegial relationships among oral health Millennials and Dental Education: Using Technol- researchers and organizations representing ogy for Effective Teaching; Getting Your Name in academia, government and industry Print; Becoming an Effective Journal Reviewer; • Captivate, advance and nurture a cadre of Navigating the IRB; and How to Construct and dental hygiene researchers Maintain a Usable Dataset. Educators learned • Provide information about valid and useful re- best practices for how to incorporate research search tools and resources and evidence-based decision making into the • Provide workshops for ‘hands-on’ training in dental hygiene curriculum. Over 18 hours of con- scientific writing, editorial review, search- tinuing education credit were offered over the ing for best evidence, and teaching research three and a half day conference. methods • Mentor student and novice investigators in This conference has required more than a year preparation for careers in research. of planning, and we must acknowledge the contri-

6 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 butions and support that we have received from We thank the members of our Advisory Board many individuals and organizations along the for volunteering their time and talents, for facili- way. First, we thank the Canadian and American tating workshops, and for moderating sessions Dental Hygienists’ Associations for again partner- during the meeting. We also thank our volunteers ing with the National Center for Dental Hygiene for managing the registration tables and the Research & Practice to invite dental hygienists many companies who graciously donated copies from across the continent to participate in this of their research to share with all of the confer- event. We also thank the American Dental Educa- ence participants to further our knowledge and tion Association and the American Association for understanding of their products and services. Dental Research for their support and participation. Conference attendees represented 11 coun- Most importantly, we extend our deepest and tries; 34 states in the United States, 6 Canadian most heartfelt gratitude to our corporate spon- provinces, 7 European countries, South Korea, sors: The Procter & Gamble Company, Colgate- and 2 of the 6 states of Australia. There were 41 Palmolive Company, Colgate Oral Pharmaceu- international participants from 10 countries out- ticals, Philips, Johnson & Johnson, Sunstar, side of the United States; 36 graduate dental hy- Dentsply, Waterpik, and Premier. This conference giene students, 13 full-time dental hygiene clini- would not have been possible without education- cal practitioners, 126 full and part-time faculty al grants from our corporate partners, and we from universities, dental schools, and community thank them for their kindness and generosity. colleges, 3 practitioners from hospital settings, 9 representatives from health organizations, 15 Sincerely, professional association representatives, 7 journal editors, 30 dental hygienists and dentists rep- Jane L. Forrest, RDH, EdD resenting various industries, 9 independent con- Conference Co-Chair sultants, and 1 person representing the military. Ann Eshenaur Spolarich, RDH, PhD Conference Co-Chair

Advisory Board Denise Bowen, RDH, MS Linda Kraemer, RDH, PhD Chris Charles, RDH, BS Salme Lavigne, RDH, MS MaryAnn Cugini, RDH, MHP Jonathan Owens, RDH, MS Jacquelyn Fried, RDH, MS Joyce Sumi, RDH, MS Ashley Grill, RDH, MS Jeanie Suvan, DipDH, MSc, PhD JoAnn Gurenlian, RDH, PhD Margaret Walsh, RDH, EdD Harold Henson, RDH, PhD Patricia Walters, RDH, MS Alice Horowitz, RDH, PhD Rebecca Wilder, RDH, MS Janet Kinney, RDH, MS Karen Williams, RDH, PhD

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 7 Editorial Rebecca S. Wilder, RDH, MS Katherine Zmetana, DipDH, DipDT, EdD

Beyond the Boundaries: Discovery, Innovation and Transformation Through Collaboration

The 3rd North American/Global Dental Hygiene The impact of this discovery of commonalities Research Conference, held in October in Bethesda, was immediate. What followed in the meeting was Maryland, was a resounding success. It certainly a brainstorming of ways that our common research held true to its mandate to go beyond boundaries, efforts could be not only shared, but also collected in with dental hygienists from 13 countries participat- a more central manner. Participants acknowledged ing as presenters and as attendees. Discovery, in- that, although the dental hygiene research com- novation, and transformation were around every munity is relatively small, it is growing. Coordinat- corner of the conference venue and in every working our research in a purposeful way could advance shop. But the spirit that animated those conceptual our efforts maximally using the minimum resourc- goals was one of collaboration. es that are available. Working collaboratively, not in independent silos, just makes sense if we hope Nowhere was this intention observed more ex- to realize our ambitious agendas. To open lines of plicitly than at the pre-conference working meet- communication and promote cooperation it was ings of the Canadian Dental Hygienists Association’s agreed that meeting together more often would be Research Advisory Committee and the National ideal; with social technology, that shouldn’t be too Center for Dental Hygiene Research and Practice. difficult! Suggestions were made about exploring After daylong separate meetings to revise, de- the possibilities of accessing a common research velop, and discuss respective strategic plans and portal for reference and resources to help fulfill this research priorities, the groups came together with dream of active sharing and collaboration. We await representatives of the International Federation of the exciting new opportunities that may come of Dental Hygienists as well as members of the Amer- this first brief get-together. ican Dental Hygienists’ Association Council on Re- search. This meeting of national and international Not only does research give rise to clinical results minds resulted in a sharing of research agendas in the way of improved treatment, better materials, and visions of future research focus for our dental and advanced applications of technology, but it also hygiene profession. has a social impact—on access to care, education, and public and private policies on oral health. The The collective research meeting also resulted Bethesda conference brought together like minds in the recognition that our dental hygiene orga- who reiterated the value of such achievements and nizations share essentially common interests and confirmed that the world is indeed small. As oral goals. Of no surprise, global areas of concern in- health professionals, we have much in common clude oral cancer, tobacco cessation, infection con- in our research visions; what was made clear at trol, and health care for aging populations. Yet we this conference was that together we are stronger. also continue to discover, and confirm, more and Here’s to a future of continuing the discovery, in- more oral—systemic links that will have profound novation, and transformation through global col- effects on the health care professions in general. laboration. Consensus appears to be that research strategies should be both patient/client centred and popula- Sincerely, tion focused. Core professional education and continuing development, including augmented training Rebecca Wilder, RDH, BS, MS in research, are also considered of high importance. Editor–in–Chief, Journal of Dental Hygiene Katherine Zmetana, DipDH, DipDT, EdD Scientific editor, Canadian Journal of Dental Hygiene

8 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Dental Hygiene’s Scholarly Identity and Roadblocks to Achieving It

Margaret M. Walsh RDH, MS, MA, EdD, Elena Ortega RDH, MS, Barbara Heckman RDH, MS

Introduction

Dental hygiene scholarship development exists components consist of the discipline’s definition, on a continuum. At one end of the continuum, its paradigm concepts, which are the major con- scholarship begins in entry-level dental hygiene cepts selected for study, global definitions of the programs and then progresses to increasing high- paradigm concepts, and conceptual models that er levels of scholarship in research-oriented mas- shape the direction and methods of the practitio- ter’s degree programs and in research-oriented ners, educators, and researchers (Figure 1).9-11 doctoral degree programs that require learners to The dental hygiene discipline is defined as “the conduct original independent research.1 Although study of preventive oral healthcare including the nursing, physical therapy, and audiology have management of behaviors to prevent oral disease developed doctoral programs to prepare gradu- and to promote health.” This definition is unique ates to engage in discipline-specific research,2-4 because its focus is on oral disease prevention to date there are no U.S. dental hygiene doctoral and health promotion directed by the dental hy- programs. gienist.9

The question needs to be asked: Why is dental Dental hygiene’s four paradigm concepts se- hygiene so far behind other health professions in lected for study, the “Client,” the “Environment,” establishing doctoral programs to conduct rigor- “Health/Oral Health,” and “Dental Hygiene Ac- ous discipline-specific research? Could it be that tions,”12,13 are defined very broadly to allow for dental hygienists are not fully aware of the disci- the development of conceptual models about pline’s hierarchy of knowledge and of the impor- the concepts that are defined by specific -theo tance of developing a “Scholarly Identity”1 related ries. For each conceptual model, related theories to it? Could it be that there are maladaptive pat- are tested by scholars who ascribe to a particular terns of behavior among dental hygienists that conceptual model. Findings contribute to the dis- create roadblocks to moving the discipline for- cipline’s body of knowledge providing evidence ward of which we are unconscious? And, if these that influences dental hygiene practice, educa- threats are real, then what can be done to coun- tion and research. To build the discipline’s body teract them? The purpose of this paper is to chal- of knowledge, dental hygiene graduate learners lenge our thinking about these questions and to and established researchers need to develop and provide some essential information to consider in promote a dental hygiene “Scholarly Identity” answering them. Specifically, this paper will dis- in addition to mastering research-related com- cuss (1) the dental hygiene discipline’s hierarchy petencies needed for the development of dental of knowledge; (2) the dental hygiene “Scholarly hygiene scientists. Identity” and its importance to the discipline’s advancement; (3) the “Imposter” Phenomenon5,6 The Scholarly Identity1,14 and the “Queen Bee” Syndrome7 as roadblocks that may jeopardize our discipline’s ability to Dental hygiene researchers who have a schol- move forward; and (4) the role of “Followership”8 arly identity are dental hygiene scientists who: in diminishing these potential roadblocks. • Ask and answer research questions central to The Structural Hierarchy of Knowledge the discipline while reaching across disciplines • Have a sense of the dental hygiene discipline A discipline’s structural hierarchy of knowledge as a whole specifies the discipline’s unique perspective and • Incorporate the norms and values of the prac- distinguishes one discipline from another. Its titioners, and conceptualize theory central to

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 9 the discipline as the basis for further knowl- FigureFigure 1. Dental 1: Hygiene Dental’s Structural Hierarchy Hygiene’s of Knowledge Defined Structural in Broad Terms Hier- edge development archy of Knowledge Defined in Broad Terms • Have a life-long commitment to the develop- Dental Hygiene Discipline’s Definition ment of the discipline’s knowledge base1,2 • Welcome philosophical debate about the dis- Paradigm Concepts cipline Client Environment Health/oral health Dental hygiene actions • Use evidence to support their viewpoint • Report one’s own results in the context of those of others in the field as well as those of Conceptual Conceptual Conceptual Model Model Model other disciplines • Disseminate the findings of one’s work 1 through scientific publication Theory Theory Theory • Have a dedicated and passionate commit-

ment to how their science relates to our dis- Practice Practice Practice cipline’s mission, its values, and its effects on Education Education Education Research Research Research humanity.

Equating the development of a scholarly iden- accomplishments, they really are incompetent tity only with research methods, statistics, and –– and that anyone who believes otherwise has design courses in isolation from the context of been fooled. Anxiety, self-doubt, inability to ac- the dental hygiene discipline constrains the de- cept positive feedback, fear of failure, and guilt velopment of the dental hygiene scholarly iden- about success undermine their ability to function tity. Knowledge gained in research methodology at their highest level. For example, a high achiev- courses needs to be augmented with a critical ing dental hygiene leader who suffers from the knowledge of the dental hygiene discipline’s re- imposter phenomenon may not be able to find search priorities in conjunction with learning how her voice to defend her support of dental hygiene interdisciplinary approaches can be used in ad- doctoral education when confronted by skepti- dressing those priorities. Moreover, professional cal questions from members of a more dominant socialization and peer interaction are critical for group perceived as having greater prestige, pow- developing the dental hygiene scholarly identity. er and status. A dental hygiene “scholarly identity” is not realized unless a whole culture is created to promote To counteract the potential for the “Imposter and nurture it.1,14 It must be acknowledged that Phenomenon” each one of us must realistically dental hygiene doctoral educational programs are assess our traits and celebrate our individual needed to enhance the dental hygiene’s scholarly strengths and successes while forgiving our im- identity and this evolution is the essential next perfections and mistakes. Being aware of and step for continued progress in the dental hygiene sensitive to the “Imposter Phenomenon” allows discipline. one to establish control and identity driven by in- ner strength, not fear, with an on-going desire to Potential Roadblocks to Developing a improve ourselves and to be of service to others. “Scholarly Identity” and Dental Hygiene Doctoral Education The Queen Bee Syndrome, first defined in 1973, describes a woman in a position of author- Two behavior patterns prevalent among wom- ity who treats subordinates more critically if they en who have succeeded in their careers that are are female. The “Queen Bee” is one who has suc- potential roadblocks to developing a “scholarly ceeded in her career, but refuses to help other identity” and dental hygiene doctoral education women do the same.7 This phenomenon has been are the Impostor Phenomenon and the Queen documented by several studies.16 The “Queen Bee Syndrome.15 “The Impostor Phenomenon,” Bee” protects her status by developing behaviors prevalent among high achieving women, was first that are entrenched with self-centered motiva- described as the perception of oneself as having tion. “Queen Bee” leaders often shun their dental an “intellectual phoniness”.5,6 Although studies hygiene affiliation to align themselves with what report that men also experience the phenome- they perceive as the more powerful reference non, the impostor phenomenon’s characteristics group, such as dentists. These talented but mal- have a more deleterious effect upon a woman’s adaptive dental hygiene leaders often have the career. Women who experience it believe that, opportunity to support dental hygiene goals, but despite outstanding academic and professional frequently do not. For example, the “Queen Bee”

10 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 who has risen to the level of a deanship or higher Followership and who has considerable influence on academic decisions about establishment of innovative aca- Taking action to adopt effective follower char- demic programs may sabotage a proposal for the acteristics may be key to counteracting road- establishment of a doctoral dental hygiene pro- blocks to developing a “Scholarly Identity.” Fol- gram. Instead of being supportive, the “Queen lowership theory17-24 views leaders and followers Bee” is a barrier to power and achievement for as “two sides of one process, two parts of a other women, especially if they are members of whole.”24 It points out that “…performance chal- a subordinate group from which the “Queen Bee” lenges -- not position -- should determine when originally was a member. Therefore, it is critical one should follow and when one should lead.”21 that we seek and only count on her support if we The term “Followership” honors and recognizes already have received the endorsement of some- the crucial role followers play in organizational one else in the dominant culture who has more life and recognizes that followers and leaders are prestige than she. dynamic roles that can be exchanged. Much of a leader’s success depends on effective followers “Queen Bee” leadership often leads to divi- and both roles deserve equal weight. We should siveness and competition among dental hygien- no longer equate leaders with supervisors and ists and cannot be counted on to foster united followers as subordinates. efforts to develop a scholarly identity, establish dental hygiene doctoral programs, or to initiate Conclusion any changes in the system that would benefit the dental hygiene community. Dental hygien- Having a community of passionate dental hy- ists must engage in self-reflective processes and giene scholars with their doctorate in dental hy- look beyond the role of the ”Queen Bee” for other giene who will ask and answer questions related leadership styles that will complement not only to the discipline’s whole while reaching across dis- the needs of the leader incumbent, but also those ciplines for assistance is essential for our discipline of the dental hygiene profession and its members and profession to reach parity with other health and clients. Leadership behaviors needed may lie professions and to address the oral health chal- in the concept of “Followership” that is discussed lenges of our nation and elsewhere.25 below.

References

1. Walsh M, Ortega, E. Developing a scholarly 5. Clance PR, Imes SA. The impostor phenom- identity and building a community of schol- enon in high achieving women: Dynam- ars. JDH Special Commemorative Issue. ics and therapeutic intervention. Psycho- 2013:15-19. therapy: Theory, Research and Practice. 1978;15(3):241-147. 2. University of Pittsburgh. Doctor of Philoso- phy (PhD) Nursing [Internet].[cited 2013 6. Clance PR, O’Toole MA: The impostor phe- Aug 7]. Available from: http://www.nurs- nomenon: An internal barrier to empowering.pitt.edu/academics/phd.jsp ment and achievement. Women and Thera- py. 1988;6(3):51-64. 3. American Physical Therapy Association. Physical Therapist (PT) Education Overview 7. Halsey S. The queen bee syndrome. In Har- [Internet].[cited 2013 Sept 3]. Available dy ME, Conway M, eds. Role Theory: Per- from: http://www.apta.org/PTEducation/ spective for Health Professions. New York: Overview/ Appleton-Century-Crofts, 1978.

4. American Academy of Audiology. AuD Facts 8. Raffo, D. Teaching Followership in Leader- [Internet].[cited 2013 Sept 3]. Available ship Education. Journal of Leadership Edu- from: http://www.audiology.org/education/ cation. 2013; (12)1: 262-273 students/Pages/audfacts.aspx

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 11 9. Darby M, Walsh M. The Dental Hygiene 17. Collinson, D. (2006). Rethinking follower- Profession. In: Dental Hygiene Theory and ship: A post-structuralist analysis of follow- Practice. Fourth, Elsevier, St Louis, Mo, er identities, The Leadership Quarterly, 2, 2014. 179-189.

10. Walsh M. Theory development in dental hy- 18. Baker, S. D. (2007). Followership: The the- giene. Journal of the Canadian Dental Hy- oretical foundation of a contemporary con- gienists’ Association. 1991;25(1):12-18. struct. Journal of Leadership & Organiza- tional Studies, 14(1), 50-60. 11. Johnson PM. Theory development in Den- tal Hygiene. Journal of the Canadian Dental 19. Hackman, M. Z., & Johnson, C. E. (2009). Hygienists’ Association. 1991;25(1):10-21. Leadership: A communication perspective (5th ed.). Long Glove, IL: Waveland Press. 12. American Dental Hygienists’ Association (ADHA): Policy statement. Theory Devel- 20. Kellerman, B. (2008). Followership: How opment/Paradigm Concepts 6-93, ADHA, followers are creating change and changing 1993. leaders. Boston: Harvard Business Press.

13. American Dental Hygienists’ Association 21. Kelley, R. E. (1988). In praise of followers. (ADHA): Proceedings of the 68th Annual Harvard Business Review, 66(6), 142-148. Session, House of Delegates. Louisville, KY: June, 1992, and 69th Annual Session, 22. Rost, J. C. (1993). Leadership for the twen- House of Delegates, CO, June, 1993. ty-first century. Westport, CT: Greenwood Publishing. 14. Meleis, A. On the way to scholarship: From Master’s to Doctorate. J Prof Nurse. 23. Smith, D. K. (1997). The following part of 1992;8:328-334. leading. In F. Hesselbein, M. Goldsmith, & R. Beckhard (Eds.) The leader of the Fu- 15. Short Communications. Impostor phenom- ture: New visions, strategies, and practices enon and queen bee syndrome: threats to for the next era (pp. 199-207). San Fran- success. Nurse Pract. 1998 Dec; 23(12): cisco: Jossey-Bass. 68-71 24. Chaleff, I. (2009). The courageous follower 16. Dobson R and Iredale W. Office queen (3rd ed.). San Francisco: Berrett-Koehler. bees hold back women’s careers. (http:// www.timesonline.co.uk/tol/news/uk/article 25. US Department of Health and Human Ser- 1265356.ece) The Sunday Times. vices. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofa- cial Research, National Institutes of Health, 2000.

12 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Advancing the Profession

JoAnn R. Gurenlian, RDH, PhD

Introduction

In his discussion of professionalization, Green- with a focus on disadvantaged and poor popula- wood1 stated that one of the characteristics of tion groups; advocating for a common risk factor a profession was a systematic body of theory, approach to prevent oral and other chronic dis- which required the application of the scientific eases; and, to provide technical support to coun- method to the service situations encountered. tries to strengthen their oral health systems and He regarded the use of the scientific method as integrate oral health into public health.2 paramount to the development and sustenance of a profession noting that growth of the profes- From a national perspective, the oral health sion would occur with a “perpetual readiness to status of people in the United States is remark- discard any portion of the system, no matter how ably poor as illustrated in the following key bullet time-honored it may be, with a formulation dem- points.3-5 onstrated to be more valid.”1 Given the nature of this research conference, the purpose of this • Tooth decay is the most common chronic ill- paper is to address how to advance the dental ness among school-aged children hygiene profession through research. • From 2007 too 2011, the percentage of persons aged 2 years and older who had a dental In examining research needed in dental hy- visit in the past 12 months decreased by ap- giene to advance the profession, it is important proximately 6% to consider oral health status from a global and • Approximately 23% of children aged 2-11 national perspective. According to the World years have at least one primary tooth with Health Organization:2 untreated decay • In 2010, 22% of low-income adults had gone • Worldwide, 60-90% of school children and 5 years or more without a dental visit, or had nearly 100% of adults have dental caries never had a visit • Severe periodontal disease is found in 15- • Nearly half (44%) of all Medicare beneficia- 20% of middle aged (35-44 years) adults ries report no dental visit in the past year, • About 30% of people aged 65-74 have no and 22% report they have not seen a dental natural teeth provider in the last 5 years • Oral disease in children and adults is higher among poor and disadvantaged population Solutions proposed to address the oral health groups conditions of the public should be considered as • Risk factors for oral diseases include an un- one component of advancing the profession. Pro- healthy diet, tobacco use, harmful alcohol posed solutions include using professionally ap- use, poor oral hygiene, and social determi- plied fluoride gel and varnish treatments; placing nants dental sealants on permanent molars; providing early identification of those at high risk for oral Further, the WHO states that most oral diseases disease and delivery of effective interventions; require professional oral health care. However, providing access to a dental home by the time a due to limited availability or accessibility, the use child is 1 year old; addressing oral health literacy; of oral health services is markedly low among old- implementing and evaluating activities that have er people, people living in rural areas, and people an impact on health behavior; facilitating collab- with low income and education. To combat oral oration between state public health and medical health diseases and inequalities, the WHO advo- assistance departments and other groups to de- cates for stimulating the development and imple- liver preventive oral health care; and increasing mentation of community-based projects for oral the number of community health centers with an health promotion and prevention of oral disease oral health component.3,4

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 13 Table I: Research Agenda of the Patient-Centered Outcomes Research Institute8

Topic Agenda Assessment of preven- Comparing the effectiveness of safety of alternative prevention, diagnosis, tion, diagnosis, and treat- and treatment options to see which ones work best for different people with a ment options particular health problem. Comparing health system-level approaches to improving access, supporting Improving health care patient self-care, innovative use of health information technology, coordinating systems care for complex conditions, and deploying workforce effectively. Comparing approaches to providing comparative effectiveness research infor- Communication and dis- mation, empowering people to ask for and use the information, and support- semination research ing shared decision making between patients and their providers Identifying potential differences in prevention, diagnosis, or treatment ef- Addressing disparities fectiveness, or preferred clinical outcomes across patient populations and the healthcare required to achieve best outcomes in each population Accelerating patient-cen- Improving the nation’s capacity to conduct patient-centered outcomes re- tered outcomes research search by building data infrastructure, improving analytic methods, and and methodological training researchers, patients, and other stakeholders to participate in this research research.

Another avenue for advancing the profession is • Emphasize the importance of multi-disciplin- to consider the research agendas of key groups ary and translational research, seeking input and how these agendas might influence the re- from a range of social scientists and health search agenda for the discipline of dental hy- professionals giene. Three research agendas reviewed included • Develop disease prevention strategies based the WHO Global Oral Health Programme, the In- on broad social and environmental determi- ternational Association of Dental Research-Global nants of health, adopting upstream rather Oral Health Inequalities Research Agenda (IADR- than downstream strategies GOHIRA®), and the Patient-Centered Outcomes • Develop community-based regional-and Research Institute (PCORI). country-level systems for oral health promotion and healthcare; recognizing previous The WHO Global Oral Health Programme fo- experience and resource implications, and, cuses on multiple aspects of oral health research. where appropriate, emphasizing whole and Examples of topics within this agenda include the at-risk populations. following.6 The Patient-Centered Outcome Research Insti- • Modifiable common risk factors to oral health tute promotes five main areas as their research and chronic disease, particularly the role of agenda. These areas include: assessment of diet, nutrition and tobacco prevention, diagnosis and treatment options; • Oral health-general health interrelationships improving health care systems; communication • Inequality in oral health and disease and the and dissemination research; addressing dispari- impact of socio-behavioural risk factors ties; and accelerating patient-centered outcomes • Evidence in oral health care: clinical care and research and methodological research.8 These public health practice categories are further defined in Table I. • Translation of knowledge into clinical and public health practice and operational re- To advance the dental hygiene profession, it is search on effectiveness of alternative com- recommended that a new global dental hygiene munity oral health programmes research agenda be formulated based on the oral • The IADR-GOHIRA® identified ten major- ar health status of the public, proposed solutions to eas of research. A sample of their research the oral health crisis in the nation and the world, agenda follows7 and other targeted research agendas. Specifi- • Develop and implement, in partnership with cally, it is recommended that this new dental cognate evidence-based medical and dental hygiene research agenda be streamlined and fo- organizations, a knowledge base that uses a cused specifically on improving the health of the standard set of reporting criteria and includes public. Research should target the most vulner- a registry of implementation trials able populations, address risk-based health pro-

14 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 motion and disease prevention strategies (such should focus on increasing partnerships among as caries, tobacco cessation, obesity, and human inter-professional groups, agencies and policy papillomavirus infection) and health literacy, and makers to promote and sustain research initia- test new workforce models. Given the limited tives. number of dental hygiene researchers and funding options available, this research agenda should Advancing the profession of dental hygiene re- promote a coordinated, collaborative effort creat- quires new initiatives and ways of thinking that ing teams of national and international dental hy- are focused on key areas that can be effectively giene researchers that can share resources, and researched with the resources available. In do- broaden data collection using systematic metrics ing so, the profession may realize a growth in so findings are robust and meaningful. Further, the profession while simultaneously discovering this coordination of dental hygiene researchers methods that significantly improve the health of the public.

References

1. Greenwood E. The elements of professional- 5. Kaiser Commission on Key Facts. Oral health ization. In Vollmer HE, Mills DL. Preofession- in the U.S.: key facts. Available from: www. alization. New Jersey: Prentice Hall; 1966. p. kff.org/kcmu 12. 6. Petersen PE. Priorities for research for oral 2. Oral Health Fact Sheet No.318. World Health health in the 21st century-the approach of Organization [Internet]. Available from: the WHO Global Oral Health Programme. http://www.who.int/mediacentre/factsheets/ Community Dental Health 2005;22:71-74. fs318/en 7. Sgan-Cohen HD, Evans RW, Whelton H, Vil- 3. U.S. Department of Health and Human Ser- lena RS, MacDougall M, Williams DM. IADR vices Office of Disease Prevention and Health Global Oral Health Inequalities Research Promotion. Healthy People 2020 Leading Agenda (IADR-GOHIRA®): A call to action. J Health Indicators: Oral Health. U.S. Depart- Dent Res 2013;92(3):209-211. ment of Health and Human Services. 2010. 8. Patient-Centered Outcomes Research Insti- 4. Griffin SO, Barker LK, Wei L, et al. Use of den- tute. National priorities and research agenda. tal care and effective preventive services in Available from: http://www.pcori.org/con- preventing tooth decay among U.S. Children tent/national-priorities-and-research-agenda and adolescents--Medical Expenditure Panel Survey, United States, 2003-2009 and Na- tional Health and Nutrition Examination Sur- vey, United States, 2005-2010. MMWR Sur- veill Summ. 2014;63(Suppl 2):54-60.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 15 Research Interrupting the Disease of Tobacco Addiction

Charl Els, MBChB, FCPsych, MMedPsych, ABAM, MROCC

Introduction

Tobacco is the only legal consumer product Global Approaches to Tobacco Control that kills at least 1 out of 2 of its regular users when used as intended by the manufacturer.1 Although much progress has been made in There are approximately 1.1 billion smokers many countries, our current country-specific world-wide, and it is predicted that the use of prevalence rates cannot be seen as the end- tobacco could kill 1 billion people during the point for success. Increasing adult cessation is 21st century. Cigarettes contain tobacco, and considered a major determinant for reducing tobacco contains nicotine, delivered rapidly to smoking-related death and disease over the the brain when smoking tobacco. Nicotine is a next few decades.6 The first international pub- single psychoactive substance that affects the lic health treaty—the Framework Convention on brain and the central nervous system, among Tobacco Control (FCTC)7 — represents a mile- others. The disease of tobacco addiction (Nico- stone for public health. Article 14 of the FCTC tine Dependence, Tobacco Use Disorder) is rec- addresses cessation. In its MPOWER initiative, ognized as a chronic disease by most authori- the WHO describes the six key policy strategies ties including the USDHHS, Health Canada, the that have been demonstrated to denormalize many countries’ Medical Associations, and the and reduce tobacco use:1 World Health Organization; it is classified as such in major disease classification systems.2,3 M: Monitor tobacco use and prevention poli- However, not every person who uses tobacco is cies addicted to nicotine. P: Protect people from tobacco smoke O: Offer help to quit tobacco use Addiction is a Pediatric Disease W: Warn about the dangers of tobacco E: Enforce bans on tobacco advertising, pro- Tobacco addiction is a treatable disease and motion and sponsorship not simply a lifestyle choice. Addiction is a pri- R: Raise taxes on tobacco mary, chronic, neurobiological disease with genetic, psychosocial, and environmental fac- Simulation models8 examine the overall effect tors influencing its development and manifes- of tobacco control policies and other interven- tations. It is characterized by behaviors that tions on estimated population quit rates. Graph include one or more of the following: impaired 1 demonstrates some of the lost opportunities control over drug use, compulsive use, contin- for cessation interventions on primary care for ued use despite harm, and craving.3 This condi- different disciplines. tion is typically induced by repeated exposure to nicotine from tobacco, producing changes Despite the devastating health effects and in the brain’s motivational system as a con- the associated costs to society, and the avail- sequence of which a reward-seeking behavior ability of safe and effective measures to treat has become out of control.4,5 Decision-making tobacco addiction, there appears to have and behavior are subsequently influenced by emerged a plateau in tobacco control’s impact. the underlying pathophysiological changes in There are numerous plausible explanations for the brain. Ninety percent of the population will this, including lost opportunities for safe and try tobacco at least once in their lifetime, and effective interventions by health professionals. about 90% of persons who become addicted The reality is that, despite the proven benefi- will do so before the age of 18. cial impact on remedying the tobacco epidemic, treatment of tobacco use and addiction continue to be vastly neglected.9

16 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Figure 1 2008 Rate Status Quo 50% Tax Increase Smokefree Laws Media/Education

Percent Cessation Policies Cessation Policies and Promising Treatement Tobacco Control and Cessation Policies Tobacco Control and Cessation Policies and Promising Treatement

0 5 10 15 20 25

Treatment Approaches document tobacco use status and treat every tobacco user seen in a healthcare set- There is a robust body of evidence guiding ting. effective tobacco cessation, and there exists a 3. Tobacco dependence treatments are effec- wide array of internationally recognized guide- tive across a broad range of populations. lines and opportunities for intervention with to- Clinicians should encourage every patient bacco use and addiction. The US Public Health willing to make a quit attempt to use the Service-sponsored Clinical Practice Guideline counseling treatments and medications rec- update identifies the ‘5-A’ model for treating ommended in the Guideline. tobacco use and dependence.9 This includes 4. Brief tobacco dependence treatment is ef- asking about tobacco use with every patient fective. Clinicians should offer every patient at every visit, advising tobacco users to quit, who uses tobacco at least the brief treat- assessing willingness to make a quit attempt, ments shown to be effective in the Guide- assisting those willing to attempt quitting by line. offering counseling and medication, by moti- 5. Individual, group, and telephone counsel- vating future quit attempts in those unwilling, ing are effective, and their effectiveness and arranging for follow-up contacts. increases with treatment intensity. Two components of counseling are especially USDHHS Guideline Key effective, and clinicians should use these Recommendations for Tobacco when counseling patients making a quit at- Use and Dependence9 tempt: • Practical counseling (problem-solving/ The overarching goal of these recommenda- skills training) tions is that clinicians strongly recommend the • Social support delivered as a part of treat- use of effective tobacco dependence counsel- ment ing and medication treatments to their patients 6. Numerous effective medications are avail- who use tobacco, and that health systems, in- able for tobacco dependence, and clinicians surers, and purchasers assist clinicians in mak- should encourage their use by all patients ing such effective treatments available. attempting to quit smoking—except when medically contraindicated or with specific 1. Tobacco dependence is a chronic disease populations for which there is insufficient that often requires repeated intervention evidence of effectiveness (i.e. pregnant and multiple attempts to quit. Effective women, smokeless tobacco users, light treatments exist, however, that can sig- smokers, and adolescents). nificantly increase rates of long-term absti- 7. Seven first-line medications (5 nicotine and nence. 2 non-nicotine) reliably increase long-term 2. It is essential that clinicians and healthcare smoking abstinence rates: delivery systems consistently identify and • bupropion (Sustained Release [SR])

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 17 • nicotine gum Figure 2 • nicotine inhaler 100 • nicotine lozenge Smokers visited • nicotine spray 90 • nicotine patch Smokers recieved • varenicline 80 advice to quit Smokers received Clinicians should consider the use of certain 70 information about combinations of medications identified as -ef assistance fective in the Guideline. 60

1. Counseling and medication are effective 50 when used by themselves for treating tobacco dependence. The combination of Percent 40 counseling and medication, however, is more effective than either alone. Thus, cli- 30 nicians should encourage all individuals making a quit attempt to use both counsel- 20 ing and medication. 2. Telephone quitline counseling is effective with diverse populations and has broad 10 reach. Therefore, both clinicians and healthcare delivery systems should ensure patient 0 access to quitlines and promote quitline Doctor Dentist Pharmacist use. 3. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use Figure 3: Safety Sensitive Algorithm the motivational treatments shown in the Guideline to be effective in increasing future quit attempts. 4. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in the Guide- line as covered benefits.

Consistent with the FCTC Article 14,7 Canada released its first federally funded set of Clinical Practice Guidelines through the Canadian Ac- tion Network for the Advancement, Dissemina- tion and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT).11 Given the high level of co-occurrence of mood symptoms in persons who use tobacco and/or stop its use, the basic algorithm included in CAN-ADAPTT allows integrated and brief screening of mood in the treatment of tobacco use and addiction.

Among those who currently smoke tobacco, approximately 70% would like to stop and about half of these will try to quit at least once this year.10 The use of short-term, acute care models to manage chronic, non-communicable

18 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 diseases is theoretically inconsistent. Hyper- sive progress over decades, existing smoking tension, hypercholesterolemia, obesity, diabe- rates (as an endpoint) cannot be regarded as tes, depression, chronic obstructive lung dis- a success. Yet the problem of tobacco does not eases and addiction are some diseases that have to be an intractable one. It has been es- often require repeated interventions. Following timated that some of the greatest declines in a short-term approach for tobacco-addicted in- smoking-related death over the next few de- dividuals is equally illogical and compromises cades will come from increasing adult cessa- the chances of long-term cessation success. tion. Tobacco (nicotine) addiction is a chronic Evidence-based smoking cessation is both safe disease amenable to treatment. Health pro- and effective and appears to be one of the most fessionals are ideally placed to make a sub- robust and clinically meaningful interventions stantial difference, utilizing Clinical Practice healthcare professionals could offer. Guidelines.12 Despite the highly significant health threat of tobacco, the existence of ro- Conclusion bust interventions, and the desire of most individuals to quit, opportunities continue to be Tobacco use remains the leading prevent- neglected. Evidence tells a vivid and chilling able cause of death and disease worldwide story of the dire and urgent need to support and, having taken into consideration impres- cessation.12

References

1. World Health Organization. WHO report on the 8. Levy DT, Mabry PL, Graham AL, et al. Reaching global tobacco epidemic, 2008: The MPOWER healthy people 2010 by 2013—a SimSmoke package. Geneva: Author; 2008. simulation. Am J Prev Med. 2010;38:S373-81.

2. American Psychiatric Association. Diagnostic 9. US Department of Health and Human Ser- and statistical manual of mental disorders, vices. The health consequences of smoking: text revision, 4th ed. Washington DC: Author; a report of the Surgeon General. Atlanta: US 2000. Department of Health and Human Services, Centers for Disease Control and Prevention, 3. World Health Organization. ICD-10: Interna- National Center for Chronic Disease Preven- tional statistical classification of diseases and tion and Health Promotion, Office on Smoking related health problems, tenth revision. Ge- and Health; 2004. neva: Author; 2007. 10. Leatherdale S, Shields M. Smoking cessation: 4. West R. Theory of addiction. Alcohol Alcohol. intentions, attempts and techniques. Statistics 2006;42(2):161-3. Canada: Health Reports. Catalogue no. 82- 003-XPE. Ottawa: Statistics Canada; 2009. 5. Heather N. A conceptual framework for ex- plaining drug addiction. J Psychopharmacol. 11. CAN-ADAPTT. Canadian smoking cessation 1998; 12:3-7. clinical practice guideline. Toronto: Cana- dian Action Network for the Advancement, 6. McLellan A, Lewis D, O’Brien C, Kleber H. Drug Dissemination and Adoption of Practice-independence, a chronic medical illness: im- formed Tobacco Treatment, Centre for Addic- plications for treatment, insurance, and out- tion and Mental Health; 2011 [accessed Au- comes evaluation. JAMA. 2007;284:1689-95. gust 21, 2014]: Available from: https://www. nicotinedependenceclinic.com/English/CAN- 7. World Health Organization: Framework Con- ADAPTT/Pages/Home.aspx vention on Tobacco Control. URL [accessed: August 21, 2014]: http://www.who.int/fctc/ 12. Els C, Kunyk D, Selby P. Disease Interrupted en/ (Book) 2012, 2nd Print: Laval Press, 2014: [accessed August 21, 2014]: Available from: http://www.pulaval.com/produit/disease-interrupted-tobacco-reduction-and-cessation

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 19 Research The Oral Microbiome and Cancer

A. Ross Kerr DDS, MSD

Introduction

The human microbiome is defined as the col- initial landmark study has explored the human lective genomes of the microbes (composed of bacteriome in health by sampling multiple habi- bacteria, bacteriophages, fungi, protozoa and tats (ie: oral, gut, urogenital and skin sites) over viruses) that live inside and on the human body, two time points in a cohort of more than 240 and there are approximately 10 microbes and “healthy” adults.1,2 An analysis of bacterial di- 100 microbial genes for each human cell and versity was performed using complex method- gene respectively. Collectively the human ge- ology including 16S ribosomal RNA gene profil- nome and microbiome is known as the metage- ing and shotgun metagenomic sequencing.3 In nome. The oral microflora comprises a number general, the results showed that there is con- of specific ecological surface niches (biofilms) siderable intra- and interpersonal variation in that evolve from birth through to death: initial- the composition of the microbiome, yet despite ly as populations adherent to mucosal surfaces such complexity, sophisticated data analysis passed on from maternal flora, to tooth-adherent incorporating demographics (eg. gender, edu- populations following eruption of the dentitions, cation levels), life-style factors (eg. diet) and and with changes in both supra- and subgingi- environmental exposures (eg. breast feeding), val niches (ie dental plaque/biofilm). In diseases has allowed a distillation into distinct groups or states, there is a shift in the equilibrium away communities within habitats that share similar from the dynamic synergistic interplay of these signatures. Further investigation is needed to healthy oral microbial populations towards a establish if these communities predict risk of narrower diversity of healthy populations in an- disease.4 tagonistic interplay with pathologic populations, and coupled with variable inflammatory host im- In general, the oral microbiome is diverse, mune responses. The structure and function of and oral wash samples (surrogates for the oral the oral microflora (and associated microbiome) flora) from 20 healthy subjects analyzed using has been investigated in numerous oral diseases high-throughput methods revealed the presence caused by bacteria, fungi and viruses (eg. peri- of 5 major phyla (Firmicutes, Proteobacteria, odontal diseases) and the systemic diseases Bacteroidetes, Actinobacteria, and Fusobacte- linked to chronic infections (eg. diabetes mel- ria) and that Streptococcus, Veillonella, Lep- litus, cardiovascular disease, and cancer). The totrichia, Prevotella, and Haemophilus genera purpose of this lecture is to provide an updat- were the most abundant.5 In an effort to discern ed understanding about the oral microbiome in differences across the different oral niches, a health and disease, with a particular emphasis landmark HMP study has explored the microbi- on the relationship with cancer, not only oral and ome of samples collected from 9 distinct oral/ pharyngeal cancers, but also other cancer sites. pharyngeal sites: saliva, supragingival plaque, subgingival plaque, keratinized gingiva, buccal Our understanding of the microbiome has mucosa, tongue dorsum, hard palate, palatine been limited by our inability to detect impor- tonsils, and posterior pharyngeal wall. Similar tant microbial populations using culture-based phyla were represented in these samples, and methods. Advances in high-throughput genome statistical analysis allowed a distillation into sequencing led the National Institutes of Health three distinct community groups: (NIH) to launch the Human Microbiome Project (HMP) as an extension of the Human Genome • Group 1 (buccal mucosa, keratinized gin- Project (see http://commonfund.nih.gov/hmp), giva, and hard palate) demonstrated a pre- catalyzing multiple studies to explore the di- dominance of organisms from the phylum versity of the microbiome across different body Firmicutes (with a very high proportion [ap- habitats in both health and disease states. An proximately 50%] from the genus Strepto-

20 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 coccus) followed in relative abundance by the microbiome. Human papillomavirus commu- the phyla Proteobacteria, Bacteroidetes and nities across various habitats in healthy patients either Actinobacteria or Fusobacteria have also recently been described.9 • Group 2 (saliva, tongue, tonsils, and posterior pharyngeal wall) demonstrated a de- In terms of the functional attributes of the creased relative abundance of Firmicutes oral microbiome in health, little is currently un- compared to Group 1 replaced by increased derstood and more studies are needed to iden- levels of four phyla: Bacteroidetes, Fusobac- tify the significance of the communities (ie. the teria, Actinobacteria and the candidate phy- metaproteome or metametabalome). Tech- lum TM7, and with a predominance of Strep- niques such as shotgun metagenomic sequenc- tococcus (approximately 20%), followed by ing data provides some insight into the meta- approximately equal abundance of the gen- bolic pathways, and as an example, bacterial era Veillonella, Prevotella, Neisseria, Fuso- small sugar transporters were shown to be of bacterium, Actinomyces and Leptotrichia particular abundance in the oral cavity sites. • Group 3, (the sub- and supra-gingival plaque biofilm) showed the greatest bacterial diver- There is a large literature exploring the oral sity and had a further decrease in Firmicutes microbiome in various disease states and a dis- compared to Groups 1 and 2, with a marked cussion of this literature is beyond the scope of increase in the relative abundance of Actino- this lecture. In terms of cancer however, it was bacteria and with a similar profile of genera the discovery of the association of Helicobacter as Group 2 plus Corynebacterium, Capnocy- pylori infection with gastric adenocarcinoma that tophaga, Rothia and Porphyromonas6 spawned an exploration for other cancer-infec- tious disease associations. Epidemiologic stud- Further analysis of these groups revealed a low ies have long reported an alleged association of but non-zero abundance of known bacterial periodontal diseases and tooth loss with cancer, pathogens in the oral cavity habitat were also and there is data to support an association with consistently detected in these healthy subjects, oral, esophageal, gastric, and pancreatic can- namely Treponema, Aggregatibacter, Porphy- cer, even after controlling for confounding fac- romonas, and Tannerella species. Also, com- tors such as tobacco use.10,11 More recently, the parison of the supra-gingival and sub-gingival principal periodontal pathogen Porphyromonas sub-sites epitomized niche specialization and gingivalis has been identified as a biomarker confirmed the physiological distinctions known for orodigestive tract cancer death (colorectal between these two sites: with facultative anaer- and possibly pancreatic cancer).12 Recent mi- obic and obligate anaerobic genera populating crobiome studies lend support for the associa- the supra-gingival and subgingival sites respec- tion of upper digestive tract flora with gastric tively. and esophageal cancers.13 There is also some evidence to support associations between both Despite the focus on the oral bacteriome, oral fungal and viral organisms and cancer. As the diversity of both the oral mycobiome and an example, human papillomavirus 16 (HPV-16) virome, and their interplay with bacterial com- infection is an established cause for the majority munities has been explored. In a study of 20 of oropharyngeal squamous cell carcinomas.14 healthy individuals sampled by an oral rinse at baseline, 85 genera and 101 fungal species were The mechanisms by which oral bacterial flora detected. Candida species were the most fre- might cause carcinogenesis are hypothetical, quently obtained genera, isolated from 75% of particularly for sites distant to the oral cavity, all study participants, followed by Cladospori- and may include local activation of carcinogens um (65%), Aureobasidium, Saccharomycetales by oral microbes (eg. conversion of ethanol to (50% for both), Aspergillus (35%), Fusarium acetaldehyde),15 or release of pro-inflammatory (30%), and Cryptococcus (20%), suggesting mediators that can dysregulate cellular cycling, that fungi play an important role, not only in dis- disrupt signaling mechanisms, and act as tumor ease states but also in the healthy microbiome.7 promoters.16 The oral virome is mainly comprised of “com- mensal” bacteriophages mirroring the diversity Early studies using culture-dependent assays of the oral bacteriome rather than pathogenic concluded that oral squamous cell carcinomas eukaryotic viruses.8 Bacteriophages are involved (compared to normal tissues with the same pain the exchange of genetic material and hence tient) have a significantly increased abundance provide another intricate layer of complexity to of both aerobic and anaerobic bacteria with in-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 21 creases in Veillonella, Fusobacterium, Prevotella, sue.18 Recently, a cohort of oral cancers and Porphyromonas, Actinomyces and Clostridium premalignant oral lesions matched with normal (anaerobes), and Haemophilus, Enterobacte- contralateral tissue sites from the same patient riaceae and Streptococcus species (aerobes). were profiled by sequencing 16S rDNA -hyper In addition, approximately 30% of cancers were variable region amplicons. In cancer samples, shown to harbor Candida albicans, but not at the abundance of the phyla Firmicutes (espe- control sites.17 The oral microbiome in oral squa- cially Streptococcus) and Actinobacteria (espe- mous cell carcinomas has been recently studied cially Rothia) were significantly decreased rela- using culture-independent assays. In one pi- tive to contralateral normal samples. Significant lot study, the microbiome in a series of 10 oral decreases in abundance of these phyla were ob- tongue/floor of mouth cancers was compared to served for pre-cancers, but not when compar- that of normal tissue in the same patients using ing samples from contralateral sites (tongue and a 16s rRNA assay coupled with denaturing gra- floor of mouth) from healthy individuals.19 dient gel electrophoresis (DGGE). Streptococcus intermedius was present in 70% of both cancer In summary, technological advances have and normal tissues. Streptococcus sp. oral taxon provided insights about the structure of the oral 058, Peptostreptococcus stomatis, Streptococ- microbiome in health and, to a lesser extent, in cus salivarius, Streptococcus gordonii, Gemella disease. Further research is needed to explore haemolysans, Gemella morbillorum, Johnsonella the functional implications of the oral microbi- ignava and Streptococcus parasanguinis were ome in terms of diagnosis and risk assessment highly associated with the cancers and Granu- of disease (ie. cancer), or possibly therapeutic licatella adiacens was prevalent the normal tis- strategies to restore the health of the oral eco- system.

References

1. Huttenhower C, Gevers D, et al (The Human 6. Segata N, Haake SK, Mannon P, et al. Com- Microbiome Project Consortium). Structure, position of the adult digestive tract bacterial function and diversity of the healthy human microbiome based on seven mouth surfaces, microbiome. Nature 2012;486(7402):207- tonsils, throat and stool samples. Genome 14. Biol 2012;13(6):R42.

2. Methe BA, Nelson KE et al (The Human Mi- 7. Ghannoum MA, Jurevic RJ, Mukherjee PK, et crobiome Project Consortium). A framework al. Characterization of the oral fungal micro- for human microbiome research. Nature biome (mycobiome) in healthy individuals. 2012;486(7402):215-21. PLoS Pathog 2010;6(1):e1000713.

3. Li K, Bihan M, Yooseph S, Methe BA. Analyses 8. Abeles SR, Pride DT. Molecular Bases and of the microbial diversity across the human Role of Viruses in the Human Microbiome. J microbiome. PLoS One 2012;7(6):e32118. Mol Biol 2014.

4. Ding T, Schloss PD. Dynamics and associa- 9. Ma Y, Madupu R, Karaoz U, et al. Human pap- tions of microbial community types across the illomavirus community in healthy persons, human body. Nature 2014;509(7500):357- defined by metagenomics analysis of human 60. microbiome project shotgun sequencing data sets. J Virol 2014;88(9):4786-97. 5. Ahn J, Yang L, Paster BJ, et al. Oral microbiome profiles: 16S rRNA pyrosequencing 10. Meyer MS, Joshipura K, Giovannucci E, and microarray assay comparison. PLoS One Michaud DS. A review of the relation- 2011;6(7):e22788. ship between tooth loss, periodontal disease, and cancer. Cancer Causes Control 2008;19(9):895-907.

22 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 11. Fitzpatrick SG, Katz J. The association be- 15. Meurman JH, Uittamo J. Oral micro-organ- tween periodontal disease and cancer: a re- isms in the etiology of cancer. Acta Odontol view of the literature. J Dent 2010;38(2):83- Scand 2008;66(6):321-6. 95. 16. Meurman JH. Oral microbiota and cancer. J 12. Ahn J, Segers S, Hayes RB. Periodontal dis- Oral Microbiol 2010;2. ease, Porphyromonas gingivalis serum anti- body levels and orodigestive cancer mortal- 17. Nagy KN, Sonkodi I, Szoke I, Nagy E, ity. Carcinogenesis 2012;33(5):1055-8. Newman HN. The microflora associated with human oral carcinomas. Oral Oncol 13. Yu G, Gail MH, Shi J, et al. Association be- 1998;34(4):304-8. tween upper digestive tract microbiota and cancer-predisposing states in the esophagus 18. Pushalkar S, Ji X, Li Y, et al. Comparison of and stomach. Cancer Epidemiol Biomarkers oral microbiota in tumor and non-tumor tis- Prev 2014;23(5):735-41. sues of patients with oral squamous cell carcinoma. BMC Microbiol 2012;12:144. 14. D’Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavi- 19. Schmidt BL, Kuczynski J, Bhattacharya A, rus and oropharyngeal cancer. N Engl J Med et al. Changes in abundance of oral micro- 2007;356(19):1944-56. biota associated with oral cancer. PLoS One 2014;9(6):e98741.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 23 Research Creating a Risk-Based Model for Dental Benefit Design

Shannon E. Mills, DDS

Introduction

For generations, Americans have been ex- determinants of future disease, which is then horted to “see your dentist twice a year.” This converted to a numerical score or descriptive cultural icon is deeply embedded in the minds ranking (e.g. low, moderate or high risk). Most of the American psyche. Although the earliest risk assessment tools use paper checklists that origin is in dispute, this advice was featured in guide the user to determine the patient’s risk for toothpaste advertising in the 1950s and was lat- oral disease and assist oral healthcare provider adopted by both the dental profession and the ers in developing prevention-based treatment dental benefits industry. The influence that this plans. cultural meme continues to exert on the dental profession, the dental benefits industry and Electronic risk assessment technologies have the public is profound. Despite advancements in advantages over paper forms including more understanding the pathophysiology, epidemiol- accurate data entry, automated calculation of ogy and systemic implications of oral disease,1,2 scores, customized reports based on each indi- standard dental benefit designs help perpetuate vidual’s risk factors, and secure transmission to the archetype of the biannual dental visit where third party payers. Electronic risk assessment many patients receive the same preventive ser- reports can also be stored for later review by vices at the precise frequencies allowed by their the dentist to create a chronological record of dental plan. an individual’s oral health status. Risk assessment data can be used to create population Both dental insurers and clinicians benefit health reports for employer groups which can from the simplicity of this approach. Patients reveal whether or not treatment being provided and dentists tend to “follow the benefits” spelled for patients matches a population’s oral health out in the plan design. Claims submission and risk profile. processing are simplified when most beneficia- ries have the same benefits, helping to control The growing evidence of relationships be- the costs for administration. When the risk for tween oral and overall health and evidence oral disease is not considered, the result can that improving oral health can help employers be a trade-off between administrative efficiency lower medical claims expenses has encouraged and effectiveness in improving oral healthcare many dental benefit companies to provide ad- outcomes. The “standard” benefit can encour- ditional preventive services, such as prophylaxis age overtreatment for the healthiest individu- and periodontal maintenance for members with als and discourage recommended treatment for medical conditions including diabetes, heart dis- those at greater risk. ease and pregnancy. However, providing these services on the basis of a medical diagnosis may Strategies for disease prevention and man- miss the chance for primary prevention of dental agement have been developed based on the caries and periodontal disease. Patients should concept of individual risk assessment.3-6 Risk not have to wait until they get sick before they assessment tools use standardized questions receive benefits for the oral preventive care they to identify factors such as medical history, car- need to stay healthy. ies and restoration history, diet, oral hygiene practices, family history, and clinical informa- Stand-alone dental benefit carriers face a tion such as pocket depth, clinical attachment common dilemma: how can they provide well- loss, bleeding, and tooth loss, that influence the ness programs for purchasers and their insured likelihood that a person will develop the target members that would match the promises made condition. The information is weighted based on by competing multi-line carriers to reduce median estimated value that these factors have as cal costs without access to medical claims data

24 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 and diagnostic coding? Northeast Delta Dental’s Employers can also use an online oral health choice was to create an oral health and wellness self-assessment tool to gain insights into the program focused on primary prevention of caries population health of their employees and their and periodontal disease as opposed to medical families by aggregating the risk and disease diagnoses. We believe that the use of predictive data into the data hub to create a population risk assessment for oral disease to authorize oral health report that estimates the prevalence guideline-based preventive benefits could - en of caries, periodontal disease, and oral can- courage the delivery of care matched to indi- cer risk among the insured population, as well vidual needs, and actively engage patients and as the number of smokers and persons in the providers to change behaviors and adopt clinical population with chronic disease who also have best practices to improve health outcomes. greater risk for periodontal disease. When dental claims data and population health risk pro- We developed a set of “enhanced” preventive files are compared, areas where the treatment dental benefits which were mapped as closely as being provided does not match a population’s possible to the preventive best practice guide- oral health risk profile can be determined. These lines from the American Dental Association7 and “gaps to fill” can help focus efforts to improve the American Academy of Pediatric Dentistry8 patient self-management and the utilization of for dental caries; and the American Academy preventive benefits by dentists through - out of Periodontology for periodontitis.9 Eligible pa- reach and engagement. tients who have been assessed by their dentist using a standardized electronic risk assessment To gain the most from their dental benefits tool and found to be at moderate to high risk for and achieve optimal oral health, members must caries or periodontal disease are pre-authorized be engaged and empowered with personalized, for preventive benefits including topical fluoride objective and actionable information and retreatment and sealants without age limitation, sources. The oral health risk assessment data up to four prophylaxis and periodontal mainte- hub also provides a communication module that nance visits per year, and oral health counsel- uses patient-provided data to send individual- ing. Northeast Delta Dental chose a commer- ized, HIPAA compliant text and e-mail messag- cially available clinical risk assessment software ing to engage individual members based on their platform which provides fully automated risk unique oral health and personal profile. assessments for caries, periodontal disease and oral cancer for this purpose.10 Conclusion When data is entered by the patient or the Northeast Delta Dental has developed a com- dental office, it is uploaded to the risk assess- prehensive oral health and wellness program for ment software company’s HIPAA compliant da- employer groups based on an understanding that tabase where the patient’s risk and disease se- “one size does not fit all” when it comes to dental verity scores are calculated. Risk profile reports benefits. The program provides evidence-based are automatically sent securely to the patient or preventive dental benefits matched to each pa- dental office. The data is also downloaded to a tient’s individual needs in order to improve oral proprietary data integration hub jointly devel- healthcare outcomes for individuals and popula- oped by Northeast Delta Dental and the risk as- tions. The program provides employers with an sessment software vendor. The data integration objective analysis of the oral health status of their hub securely aggregates both self-assessed and covered populations, and recommends strate- clinically generated risk assessment data and gies to close gaps that may exist between the can automatically authorize guideline-based preventive oral health care their employees are enhanced benefits in the dental insurance com- receiving and best practices for oral prevention. pany claims processing system. To be eligible The program engages and empowers patients to for enhanced benefits, qualifying members also take steps to achieve their personal best oral and use the data hub to register for an oral health overall health, and encourages dentists to use and wellness score which allows us to engage evidence-based preventive benefits matched to members to optimize self-management for their the needs of their patients to deliver evidence- oral health. based oral preventive care.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 25 References

1. Borgnakke WS, Ylostalo PV, Taylor GW, Gen- 6. Martin JA, Page RC, Loeb CF, Kaye EK. Re- co RJ. Effect of periodontal disease on dia- duction of tooth loss associated with peri- betes: systematic review of epidemiologic odontal treatment. Int J Periodontics Restor- observational evidence. J Clin Periodontol ative Dent 2011;31(5):471-9. 2013;40 Suppl 14:S135-52. 7. Beauchamp J, Caufield PW, Crall JJ, et al. 2. Genco RJ, Borgnakke WS. Risk factors Evidence-based clinical recommendations for periodontal disease. Periodontol 2000 for the use of pit-and-fissure sealants: a 2013;62(1):59-94. report of the American Dental Association Council on Scientific Affairs. J Am Dent As- 3. Bader JD, Perrin NA, Maupome G, Rush soc 2008;139(3):257-68. WA, Rindal BD. Exploring the contributions of components of caries risk assessment 8. American Academy of Pediatric Dentistry guidelines. Community Dent Oral Epidemiol CoCA. Guideline on Caries Risk Assessment 2008;36(4):357-62. and Management for Infants, Children, and Adolescents. 2010. 4. Domejean S, White JM, Featherstone JD. Validation of the CDA CAMBRA caries risk 9. Krebs KA, Clem DS, 3rd, American Academy assessment--a six-year retrospective study. of P. Guidelines for the management of pa- J Calif Dent Assoc 2011;39(10):709-15. tients with periodontal diseases. J Periodon- tol 2006;77(9):1607-11. 5. Fontana M, Young DA, Wolff MS. Evidence- based caries, risk assessment, and treat- 10. Page RC, Martin JA, Loeb CF. The Oral Health ment. Dent Clin North Am 2009;53(1):149- Information Suite (OHIS): its use in the 61, x. management of periodontal disease. J Dent Educ 2005;69(5):509-20.

26 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Using Prevention and Measurement to Drive Quality Improvement

Christopher J. Smiley, DDS

Introduction

The term “quality” can mean many things to tient adherence with recommended care, each many people. In healthcare, we speak of “qual- of which can improve care outcomes.6 ity of care” to mean “the degree to which health services for individuals and populations increase Within oral healthcare, the “triple aim” can the likelihood of desired health outcomes and be best achieved through a focus on prevention are consistent with current professional knowl- consistent with evidence-based guidelines pub- edge.”1 In order to drive quality improvement, lished by the National Guideline Clearinghouse, the Centers for Medicare & Medicaid Services the American Academy of Pediatric Dentistry (CMS) is pressing forward with the “triple aim” and the American Dental Association’s Center goals of: 1) better individual health care, 2) for Evidence Based Dentistry.7 A focus on pre- better population health, and 3) lower per-cap- vention can improve health outcomes as shown ita costs called for in health reform’s Affordable in several evidence-based guidelines and can Care Act.2 CMS’ Quality Road Map promotes a also lower per capita costs over time. However, vision for “The right care for every person every in order to improve, we must measure the de- time” with a goal of making care: safe, effec- gree to which our dental care system supports tive, efficient, patient-centered, timely and eq- the provision of preventive services. uitable: indicators of quality for care delivery.3 In 2009, the Children’s Health Insurance Pro- An assumption in healthcare was that clinical gram Reauthorization Act (CHIPRA) called for judgment was sufficient to guide wise decision the Secretary of Health and Human Services to making. This emphasis on the art of medicine establish an evidence-based pediatric quality was grounded in a tradition that education, the measures program for primary and specialized knowledge of pathophysiology, and sufficient pediatric health care professionals, including clinical experience were all that was needed to dental professionals. A measure is a mathe- develop sound treatment recommendations.4 matical ratio expressed as a percentage, with The result of basing care on such personal opin- exclusions of patients who should not be incor- ion is wide variations in clinical practice where porated for various reasons. An example would the most effective treatment is not always used be a measure for placement of sealants on first and ineffective treatments often persist. Such molars. This could be described as the num- issues are indicators for a healthcare delivery ber of patients with sealants ages 6 to 8 years system of poor quality. To address the goal of who have had a restoration in the past three quality through the delivery of effective care, years divided by the total number of patients Eddy and others postulated that what happens in the measured population ages 6 to 8 years to patients should be based upon “evidence” to who have had a restoration in the past three produce recommendations that are valid, reli- years. Included are those at risk for decay, as able and objective.5 indicated by restorative history, while exclud- ing children whose adult molar teeth have not The goal of Patient Centered Care (PCC) is an erupted.8 Measurement allows for tracking the important component of prevention. Prevention success in delivering care to those in need and of adverse outcomes is enhanced when patients it can be benchmarked to incentivize care de- comply with treatment recommendations, pre- livery. scriptions, homecare and post-operative instructions. Studies show that PCC results in To promote quality measurement, CMS en- increased patient satisfaction and improved pa- couraged the establishment of the Dental Qual-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 27 ity Alliance (DQA) in 2010. The DQA is a multi- The rapidly changing landscape of healthcare stakeholder alliance from across the oral health financing will result in greater reliance on quality community, including federal agencies, payers, measures. Employers and purchasers will drive professional associations and public represen- accountability through measurement. Consum- tation, with a mission to advance the field of ers and providers are often fearful that plan de- performance measurement to improve oral sign will focus on cost containment at the ex- health, patient care, and safety.9 In 2012, the pense of improving utilization and prevention. Dental Quality Alliance (DQA) approved its first Measurement will identify when plan design re- fully tested set of ten measures: Dental Caries stricts access to care or impedes improvement in Children: Prevention and Disease Manage- of oral health, patient care and safety. ment.10 These were developed over two years after rigorous testing. These DQA measures are Often measures are designed for reporting us- validated at the program and plan level and are ing administrative enrollment and claims data. meant for the purpose of holding health plans This can pose issues with transparency as many accountable for utilization and quality. administrators view this to be proprietary data. A solution seen in several states is the creation Through a consensus process of its stake- of “All Payer Claims Databases” (APCD).15 These holders, the DQA builds measures that are evi- APCD may help address concerns for transpar- dence- based.11 An example would be the DQA’s ency, as well as the call for “continuous learn- sealant and fluoride measures. These are built ing health systems” through the application of off of anticipated outcomes found in the ADA’s its data to a “dashboard of measures” to show evidence-based clinical recommendations.12 how our providers, health systems and plan ad- Measuring the delivery of care with proven out- ministrators are achieving measurement goals comes will promote utilization of these services and improving the health and safety for covered and raise the level of oral health for the target- populations. ed population. Tracking measurement performance will provide administrators with the tools Clinicians interested in elevating the qual- that they need to be confident that their plans ity of care in their practice can adapt measure are designed to promote quality. concepts for individual use. Using sealants as an example, clinical software systems can gen- Measuring the delivery of preventive services erate a list of children ages 6 to 8 years that with an anticipated outcome for at-risk patients have had a filling in the past three years and will drive quality improvement. For example, those who have had sealants placed. Monthly reduction of caries incidence in children and ad- tracking of performance becomes an exercise of olescents after placement of resin-based seal- data analysis. A more basic approach could use ants ranges from 58.6 percent at four years, a spreadsheet where individual providers track and rises to 76.3 percent during this period patients seen at preventive visits who are at el- when reapplied as needed.13 Use of the DQA’s evated risk for decay and are in need of seal- sealant measure will provide assessment of a ant care. Regular reporting of results within a plan’s performance that those covered indi- practice can provide incentive for utilization of viduals are receiving this evidence-based pre- preventive services and enhance overall quality ventive service. Failure to achieve anticipated of care. outcomes could signal administrators that flaws exist within their system that impacts the deliv- Assuming that a covered population remains ery of quality care. with a plan long enough to reap the benefit, access to preventive services and the delivery of The Institute of Medicine in its 2012 report that care will improve oral health and decrease “Best Care at a Lower Cost. The Pathway to health care costs by reducing the need for more Continuously Learning Health Care in Ameri- costly care in the future. This is most likely to ca” called for “continuous learning health sys- occur when evidence-based preventive services tems.”14 Measures are an integral component are targeted effectively to at-risk groups and in- of this concept due to the cyclic nature of evi- dividuals. The transparent use of measures will dence, leading to anticipated outcomes, which provide the incentive for the use of preventive lead to clinical guidelines for care decisions services to drive quality improvement and build which are then measured. Once measured, the evidence on the effectiveness of these interven- realized outcomes create new evidence and the tions for the development of future care recom- process revolves. mendations.

28 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 References

1. Lohr KN (ed). Health, Healthcare and Quality 9. American Dental Association. Dental Qual- of Care. In: Medicare: A Strategy for Quality ity Alliance. 2012. Available at: http://www. Assurance. National Academies Press. 1990, ada.org/en/science-research/dental-quality- p.21. Available at: http://www.nap.edu/ alliance/#mission Accessed October 6, 2014. openbook.php?record_id=1547&page=19#p 2000a5059970019001 Accessed October 6, 10. American Dental Association. Dental Quality 2014. Alliance. Dental Caries in Children: Preven- tion & Disease Management. 2012 Available 2. Berwick DJ, Nolan TW, Whittington J. The at: http://www.ada.org/en/science-research/ triple aim: care, health, and cost. Health Af- dental-quality-alliance/dqa-measure-activi- fairs. 2008:27(3):759-769. ties/measure-sets Accessed October 6, 2014.

3. CMS QUALITY IMPROVEMENT ROADMAP. 11. American Dental Association. Dental Qual- Available at: http://www.cms.gov/Medicare/ ity Alliance. Procedure Manual for Perfor- Coverage/CouncilonTechInnov/downloads/ mance Measure Development: A Voluntary qualityroadmap.pdf Accessed October 6, Consensus Process. April 23, 2013. Available 2014. at: http://www.ada.org/~/media/ADA/Sci- ence%20and%20Research/Files/042213_ 4. Evidence-Based Medicine Working Group. Measure_development_Procedure_Manual. Evidence-based medicine. A new approach to ashx Accessed October 6, 2014. teaching the practice of medicine. J Am Med Assoc. 1992 Nov 4;268(17):2420-5. 12. American Dental Association Council on Sci- entific Affairs. Professionally applied topical 5. Eddy DM. Evidence-based medicine: a unified fluoride. Evidence-based clinical recommen- approach. Health Affairs 2005:24:9-17 dations. J Am Dent Assoc. 2006;137:1151- 1159. 6. Hirsh AT, Atchison JW, Berger JJ, Waxenberg LB, Lafayette-Lucey A, Bulcourf BB, Robin- 13. American Dental Association. Evidence-based son ME. Patient satisfaction with treatment clinical recommendations for the use of pit- for chronic pain: predictors and relation- and-fissure sealants. A report of the Ameri- ship to compliance. Clin J Pain. 2005 Jul- can Dental Association Council on Scientific Aug;21(4):302-10. Affairs. J Am Dent Assoc. 2008;139:257-268.

7. ADA Center for Evidence Based Dentistry. 14. Institute of Medicine. Best Care at Lower Cost. Clinical Recommendations/Guidelines. Avail- The Path to Continuously Learning Health able at: http://ebd.ada.org/en/evidence/ Care in America. Recommendations. Avail- guidelines Accessed October 6, 2014. able at: http://www.iom.edu/~/media/Files/ Report%20Files/2012/Best-Care/Best%20 8. Smiley C. Quality measurement in your of- Care%20at%20Lower%20Cost_Recs.pdf Ac- fice.J Mich Dent Assoc. 2012 Jul;94(7):30. cessed October 6, 2014.

15. All Payer Claims Database Council. 2014 Available at: http://apcdcouncil.org Accessed October 6, 2014.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 29 Research Opportunities to Increase Prevention in Dentistry

Robert Compton, DDS

Introduction Figure 1: Radiograph of Interproximal Caries According to the CDC, between 12.1% and 41.9% of the American population ages 5 years and older (depending on age and income level) has untreated dental caries. In addition, the per- centages of those who have restorations vary from 44.5% to 92.6%. Children at or below the federal poverty level (and most likely Medicaid eligible) have the highest untreated dental caries rates for children, at 25.4%. Yet nationally, only 46.9% of children receiving Medicaid, on average, were able to access any dental care in 2013. Limited Medicaid budgets often lead to Medicaid fees that are below the cost of providing surgical treatment to repair the damage caused by caries. However, it is possible to provide effective preventive treatment by dental hygienists or other health professionals at lower costs before the motivational interviewing, behavior modification disease progresses to an irreversible state which and simple goal setting. Parents are taught the necessitates surgical repair. causes of tooth decay. Most are not aware that the apple juice they put in a Sippy Cup has a pH The construct of classifying health services of 3.5% or that milk in a bottle at bedtime dam- into three levels of prevention to differentiate ages their child’s teeth. Goal setting asks parents them from curative treatment was developed by to pick just one risky behavior they can work on Leavell and Clark in 1965.3 More recently, Jekel during the next month, such as putting water defined the levels of prevention as listed in Table in the Sippy Cup or the bedtime bottle. Or they 1.4 may choose to add a protective factor, like brushing the child’s teeth with a smear of fluoridated Our knowledge about dental disease and how toothpaste. BCH found that it was able to reduce to prevent it has increased significantly, which the risk status of children from high risk to mod- opens opportunities to provide beneficial care to erate risk after three of these visits. many people who otherwise would not receive it and who would ultimately suffer the consequenc- Secondary prevention is employed after the es of untreated disease. The DentaQuest Insti- patient has developed a carious lesion but before tute has been partnering with Boston Children’s it has cavitated. Figure 1 shows several inter- Hospital (BCH) since 2008 on an Early Childhood proximal carious lesions. The upper bicuspids ap- Caries Collaborative that makes extensive use of pear to have demineralization that extends into primary, secondary and tertiary prevention. The the dentin and probably have cavitated. They will ECC Collaborative’s protocol includes perform- most likely require surgical repair. However, the ing a risk and behavior assessment to determine lower bicuspids show examples of demineraliza- which risky behaviors parents are doing and tion that do not appear to be into dentin. A pa- whether they are using protective factors.5 When tient with only early stage demineralization could it comes to the determinants of health, we know be managed medically rather than surgically by that behavior may contribute 40%, while health applying topical fluoride and prescribing 1.1% care services may only contribute 10%.6 Chang- sodium fluoride or calcium phosphate/fluoride ing behavior can have a profound affect, and the enhanced toothpaste to remineralize early stage clinical staff in the collaborative was trained in lesions. The resulting remineralization would be

30 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Table I: Levels of Prevention4

Level of Stage of Disease Definition (Jekel, 2007) Prevention Keeps the disease process from becoming established by eliminat- ing causes of disease or increasing resistance to disease. Primary Pre-disease but prevention refers to health promotion, which fosters wellness in Primary at-risk general and thus reduces the likelihood of disease, disability, and premature death in a nonspecific manner, as well as specific protection against the inception of disease. Interrupts the disease process before it becomes symptomatic. Secondary prevention refers to the detection and management of Presymptomatic Secondary presymptomatic disease, and the prevention of its progression to symptomatic disease. Limits the physical and social consequences of symptomatic disease. Tertiary prevention refers to the treatment of symptomatic disease in an effort to prevent its progression to disability, or pre- Symptomatic Tertiary mature death. [Tertiary tends to apply to chronic diseases, such as diabetes, which cannot be cured but can be managed to prevent them from progressing to more serious conditions]

better quality care than a restoration, because the to be managed in a clinical setting. This tertiary fluoride would incorporate into the tooth - struc prevention reduced the need to treat the children ture and the pH would have to drop significantly in the operating room by 48% at BCH. This is a before that area would demineralize. On the oth- better experience of care since the use of general er hand, placing a restoration would increase the anesthesia in young children has inherent risks. probability that the area would need retreatment Plus, the protocol reduced reported pain by 38%, at some point in the future. At BCH the result again a better experience of care. The new ECC of behavior modification and goal setting along protocol was able to reduce the average cost of with frequent application of fluoride varnish and care for their population of children by 37% in home fluoride toothpaste was a reduction in new the first year.7 cavitation of 65%.5 Both of these procedures can be performed by non-dentist health profession- The primary focus of the Patient Protection and als, achieve better health outcomes and cost less Affordable Care Act (PPACA) is to bring down the than placing restorations. escalating costs of health care that are threatening the American economy and to improve the In addition to these primary and secondary quality of care. The goal of the Triple Aim is to preventive treatments, BCH used tertiary pre- simultaneously improve the health outcomes for vention on cavitated lesions. Many very young a population, improve the patient’s experience of children are treated at BCH because their disease care, and to lower the per capita cost of care.8 is so extensive that they cannot be managed in BCH with its ECC protocol was able to achieve the a clinical setting and they are referred for oper- Triple Aim. But one of the challenges to spreading ating room (OR) treatment under general anes- this protocol is the fact that Medicaid and com- thesia. Because of the high demand at BCH, the mercial insurers do not cover many of these pro- waiting time for the OR (prior to adoption of the cedures. They do not pay for disease manage- ECC protocol) was between six and nine months ment or motivational interviewing even though – plenty of time for caries to advance into the they both can achieve dramatic results. Usually pulp or cause the child considerable pain. they will pay for only two fluoride treatments in a twelve month period, and the ECC protocol may The ECC protocol includes removing caries call for three or more. Many do not cover interim with hand instruments without local anesthesia, therapeutic restorations. These benefit programs applying fluoride varnish and placing an interim are hesitant to cover additional services because therapeutic restoration (ITR) of glass ionomer. of the potential to provide them to children who This stabilizes the infection and reduces pain, and are not at high risk and thus would drive up cost many of these children were subsequently able without providing additional health benefit.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 31 However, a new opportunity may be develop- ate. Had BCH been part of a Patient-Centered ing. The PPACA encourages the formation of Pa- [Health] Home that qualified to share savings, tient-Centered Medical Homes (PCMH) and other they could have received substantial payment for Accountable Care Organizations with the belief achieving their outcomes. Before adopting the that they can control costs and improve quality.9 ECC protocols, the average cost to the hospital A PCMH is: of providing care was $2,023 per child, and after adopting the protocol, it dropped to $1,271, for “A primary care practice that gives patients the a savings of $752 per child.7 For their popula- individualized care and support they need to stay tion of 395 children, they lowered their costs by healthy…the patient, the primary care physician almost $300,000. Had they received just 20% of and a medical team work together to develop that expense, they would have more than cov- and implement a plan of care for the patient that ered their costs of disease management and ex- details the patient’s optimal medication use, diet, tra fluoride, earned additional revenue while also exercise, behavioral health treatments, etc. to saving the Medicaid program money. get and keep the patient healthy.”10 It is possible to expand the use of primary, These types of Patient-Centered Health homes secondary and tertiary prevention to achieve im- can include dental professionals and could poten- proved health outcomes, better patient experi- tially cover other populations besides Medicare ence of care and lower cost of care, which could recipients. They can share in savings they cre- allow existing benefit dollars to cover more patients and increase access.

References

1. Centers for Disease Control and Prevention. 6. McGinnis JM, Williams-Russo P, Knickman NCHS Data Brief. Selected Oral Health Indica- JR. The case for more active policy attention tors in the United States, 2005-2008. Avail- to health promotion. Health Aff (Millwood) able at: http://www.cdc.gov/nchs/data/data- 2002;21:78-93. briefs/db96.htm Accessed October 6, 2014. 7. Samnaliev M, Wijeratne R, Wunhae GK, et 2. Centers for Medicare & Medicaid Services, An- al. Cost-effectiveness of a disease manage- nual EPSDT Participation Report, CMS 416 (Na- ment program for early childhood caries. J tional), Fiscal Year 2013. Available at: http:// Publ Health Dent. 2014 Jul 12. doi: 10.1111/ www.medicaid.gov/Medicaid-CHIP-Program- jphd.12067. [Epub ahead of print] Information/By-Topics/Benefits/Early-and- Periodic-Screening-Diagnostic-and-Treatment. 8. Berwick DM, Nolan TW, Whittington J. The html Accessed October 6, 2014. triple aim: care, health, and cost. Health Aff. 2008;27:759-769. 3. Leavell, HR and EG Clark. Preventive Medicine for the Doctor in His Community. McGraw-Hill 9. Deloitte Center for Health Solutions. Issue Book Company.New York. 1965. Brief: Value-based purchasing: a strategic overview of health care industry stakehold- 4. Jekel, JF, DL Katz, JG Elmore, and DMG ers. Available at: http://www.deloitte.com/ Wild. Epidemiology, Biostatistics, and Pre- assets/Dcom-UnitedStates/Local%20As- ventive Medicine. W.B. Saunders Company. sets/Documents/Health%20Reform%20Is- Philadephia. 2007. sues%20Briefs/US_CHS_ValueBasedPurchas- ing_031811.pdf Accessed October 6, 2014. 5. Ng MW, Torresyap G, White A, et al. Disease management of early childhood caries: results 10. Robert Wood Johnson Foundation. The ROI of a pilot quality improvement project. J Health for Patient-Centered Medical Home Payment. Care Poor Underserv. 2012;23: 193-209. February 2013. Available at: http://www. rwjf.org/en/research-publications/find-rwjf- research/2013/02/payment-matters--the-roi- for-payment-reform.html Accessed October 6, 2014.

32 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Interprofessional Practice: Translating Evidence- Based Oral Care to Hospital Care

Virginia Prendergast, PhD, NP-C, FAAN and Cindy Kleiman, RDH, BS

Introduction

Oral Hygiene in Hospital Settings that must be addressed before oral care efficacy trials can be implemented. A diagnosis of ventilator-acquired pneumonia (VAP) is made when an intubated, mechanically Oral hygiene for intubated patients may be ventilated patient is diagnosed with pneumonia hindered by the presence of the oral endotra- 48 hours after admission. VAP has been associ- cheal tube, oral gastric tubes, bite blocks, and ated with poor oral hygiene, and this link has the adhesive tape that secures such devices. galvanized healthcare workers and researchers As a result of restricted access to the oral cav- to explore effective methods of oral hygiene to ity, nurses may delay tasks such as toothbrush- reduce rates of VAP and other nosocomial in- ing, which creates a worsened pathogenic state fections.1 Oral care regimens to improve oral within the patient’s mouth. health have been well established in the out- patient setting, but such standards are not as The Center for Medicare and Medicaid Ser- consistent in critically ill hospitalized patients. vices has restricted or ceased payment for in- While intensive care unit (ICU) nurses rate oral fections acquired in a hospital setting, and ap- care as important, most oral care practices in proximately 99,955 beds are dedicated to ICUs the ICU are inadequate. Protocols usually con- in the U.S. Thus, evidence to support the safety sist of foam sticks, standard toothpastes, and a and efficacy of oral hygiene for the critically ill saline rinse. Although the American Association patient must be demonstrated to reduce the risk of Critical Care Nurses (AACN) has advocated of hospital-associated infection and VAP. toothbrushing and declared it to be one of the standards of critical care, less than 44% of criti- Translating Oral Hygiene into Practice: cal care nurses report brushing teeth.2 Results of a Randomized Controlled Trial (RCT) Toothbrushing has been described as the single most important oral hygiene activity,3 Recognizing the need for more research on and toothbrushing twice daily reduces oral de- oral hygiene and associated VAP, we performed bris and biofilm. Over the past decade, electric an RCT to monitor changes in ICP and cerebral toothbrushes have been shown to be superior perfusion pressure (CPP) while providing oral to manual toothbrushes in biofilm reduction and care. Over a two-year period, we compared improved gingival health. The benefits of oral variations in oral health during intubation to care for critically ill, intubated patients have changes in oral and respiratory nosocomial colo- been conceded by healthcare professionals.4 nization among intubated neuroscience ICU pa- Studies that have been conducted to examine tients. this link are important but inadequate. One reason that critical care nurses in the neurosurgi- Patients were randomized to one of two cal field may be reluctant to perform consistent groups: those who would receive a standard toothbrushing for intubated patients is the con- oral care protocol, and those who would receive cern that toothbrushing may contribute to in- a comprehensive oral care protocol. The tools creased intracranial pressure (ICP). Therefore, used for the standard oral care protocol included some nurses prefer foam swabs to toothbrush- a manual pediatric toothbrush, standard foam- es, despite the fact that toothbrushing is the ing toothpaste, and water-soluble lubricant. standard of care recommended by the AACN.5 The equipment provided for the comprehensive Patient safety is a critical aspect of oral health protocol group consisted of a tongue scraper, a

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 33 power oscillating rotating toothbrush with a non- non-foaming toothpaste, and oral moisturizers foaming toothpaste, and a moisturizing agent. were found to be the most effective tools for oral Both groups received the assigned oral care pro- hygiene during intubation period as evidenced tocol twice daily, with toothbrushing lasting two by BOE item scores of tongue, teeth, gingiva, minutes per occasion. Chest radiographs and and mucous membranes. Previously unreported oral and sputum cultures were obtained upon in critical care oral protocols, the tongue scraper admission to the ICU and were repeated every was effective in preserving tongue hygiene as 48 hours while the patient remained intubated. noted by the BOE item scores and supported by Oral health was measured according to the Bed- the reduction in odor compared to the standard side Oral Exam (BOE), and these scores were protocol (odor was included as a new measure- recorded on the day of enrollment in the trial, ment parameter on the BOE). the day of extubation, and 48 hours after extubation. Among patients who received comprehensive oral care, there was a trend of a decreased con- An interim safety analysis was performed version to oral nosocomial colonization. The inci- upon 47 adult neuroscience ICU patients with dence of VAP, though equivalent in both groups, an ICP monitor. ICP and CPP (cerebral perfusion reflected a decreased trend among patients re- pressure) were recorded before, during, and af- ceiving comprehensive oral care. Because the ter oral care over the first 72 hours of admission. study was underpowered, larger studies are Of 807 ICP and CPP measurements obtained be- needed to further investigate the benefits of fore, during, and after oral care, there were no comprehensive oral care, and further studies significant differences in ICP (P=0.72) or CPP are needed to assess the long-term impact of (P=0.68) between toothbrushing methods. In oral hygiene on oral health and patient comfort. the absence of preexisting intracranial hypertension, toothbrushing was safely performed in Hospital-wide Changes in Oral Hygiene intubated neuroscience ICU patients. The results of this study, combined with other Oral health deteriorated in both groups, but evidence of the benefits of oral care, were the key differences existed between the deteriora- motivation for changes in oral care practices tions. In the standard oral care group, the BOE at St. Joseph’s Hospital and Medical Center in total score and all eight categories significantly Phoenix, Arizona. An Oral Health Initiative Com- deteriorated (Friedman Test p<0.001, Bonfer- mittee comprised of experts representing clini- roni correction) and did not return to baseline cal and management areas was established. after extubation. Large effect sizes were pres- Members of this multidisciplinary committee ent at all three timepoints in this group. In the reviewed results of the RCT and protocols and comprehensive oral care group, total BOE de- ultimately elected to incorporate the BOE and teriorated during intubation (Friedman Test comprehensive oral care protocol for all patient p<0.004) but returned to baseline status after units. The comprehensive oral care protocol was extubation. There was no significant deterio- further refined based on BOE scores and subse- ration in the ratings on tongue, mucous mem- quently referred to as the Barrow Oral Care Pro- branes, gingiva, or teeth over time in the com- tocol (BOCP).All medical and nursing commit- prehensive oral care group. Oral colonization tees hospital-wide agreed to the implementation upon admission was noted in 25% of patients in of the BOCP. each protocol. Although there were trends of reduced oral and respiratory nosocomial coloniza- Using a descriptive case design for implemen- tion among those in the comprehensive oral care tation and evaluation of oral assessments and group, no significant differences were noted be- oral hygiene, we explored quality improvement tween groups. Incidence of VAP was equivalent data for incidence of VAP and the cost effective- (p=0.61) for the standard and comprehensive ness of oral hygiene supplies using the expand- groups at day six. ed range of oral hygiene products. Incidence of VAP and the cost of oral care supplies before Discussion and after implementation were compared in the Trauma ICU over a 2-year period. The comprehensive oral care protocol demonstrated superiority to current published stan- The incidence of VAP fell significantly from dards for ICU oral care protocols as measured by 4.21 to 2.1 per 1000 ventilator days (p=0.04). the BOE. The tongue scraper, power toothbrush, Average monthly costs for oral care products

34 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 used in 2011 were $4000.00. After implementa- ditionally, the treatment setting is not conducive tion of the BOE and BOCP, the average monthly to provision of detailed oral care, as the patients cost in 2012 was $1453.00, a savings of 65%. are in a bed, not a reclining dental chair. Heavier Cost-effective, comprehensive oral care appears patients are in a wider bed, which makes it dif- to help reduce VAP, and the BOE and BOCP re- ficult for the nurse to reach the mouth. main in place at our institution. Healthcare professionals who recognize and Current Practices and Future advocate for systemic oral health protocols for Recommendations hospitalized patients and the success of our research have called attention to oral health and Although nurses are responsible for conduct- hygiene practices. Some facilities have em- ing assessments and performing interventions ployed an inpatient registered dental hygien- for other body systems, such as hemodynamic ist to assess and perform complex oral hygiene monitoring and administration of blood pres- assessments, thereby meeting the demand for sure medications, oral health assessments and cost-effective oral health assessments and re- research-based oral care practices are not rou- ducing the rate of nosocomial infections. Our tinely performed. Oral assessments are done in institution plans to collaborate with local dental dental settings every day, by both dentists and hygiene schools to establish student rotations as hygienists. When dental professionals adminis- part of the students’ curricula. ter these assessments, they use a wide variety of tools, including mouth mirrors, periodontal Though advancements in oral health have probes, loupes, headlights, digital radiography, dramatically improved in the United States over and cancer screening equipment. Generally, the the past 25 years, the need for further collabo- nurses who perform oral assessments have nei- ration among health providers in dentistry, med- ther the tools nor the training to do so effec- icine and allied healthcare providers is critical.6 tively. Comatose or intubated patients are often Such collaboration is fundamentally important unable to indicate whether they are in pain or in healthcare settings, where the status of oral describe discomfort, and the tubes make it chal- health has gained heightened awareness to pre- lenging to thoroughly examine the mouth. Ad- vent disease.

References

1. Scannapieco FA, Bush RB, Paju S. Associa- 4. Ames NJ. Evidence to support tooth brushing tions between periodontal disease and risk in critically ill patients. Am J Crit Care. May for nosocomial bacterial pneumonia and 2011;20(3):242-250. chronic obstructive pulmonary disease. A systematic review. Ann Periodontol. Dec 5. Nurses AAoC-C. Oral Care in the Critically Ill: 2003;8(1):54-69. Practice Alerts. 2006. Available at: http:// www.aacn.org/AACN/practiceAlert.nsf/vw- 2. DeKeyser Ganz F, Fink NF, Raanan O, et doc/pa2Oral Accessed October 6, 2014. al. ICU nurses’ oral-care practices and the current best evidence. J Nurs Scholar. 6. Haden NK, Catalanotto FA, Alexander CJ, et 2009;41(2):132-138. al. Improving the oral health status of all Americans: roles and responsibilities of aca- 3. P. S. Oral hygiene. In: Davies A, Finlay I, demic dental institutions: the report of the eds. Oral care in advanced disease. New ADEA President’s Commission. J Dent Educ. York: Oxford University Press; 2005. May 2003;67(5):563-583.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 35 Research Poor Oral Health Literacy: Why Nobody Understands You

William Smith, EdD, PhD, Cindy Brach, MPA, Alice M. Horowitz, PhD

Introduction

It’s Our Problem, Not Theirs tion to End Confusion.1 The following decade saw the achievement of many milestones that Health literacy has been consistently defined marked health literacy’s ascendency in both the as the degree to which individuals have the ca- public and private sectors.2 pacity to obtain, process and understand basic health information needed to make appropriate The year 2010 was a banner year for U.S. health decisions and services needed to prevent health literacy policy. First, the Patient Protec- or treat illness.1 In this session, we examined tion and Affordable Care Act (ACA) was passed the mistaken interpretation of the word “individ- in March. According to HHS’ Deputy Assistant uals” to be limited almost exclusively to citizens Secretary for Health, “Health literacy is in the and patients. This misinterpretation may seem ACA because health policy makers recognized logical if we define health literacy as “knowing that activated and informed patients are on the medical jargon.” However, true health literacy critical path to increasing access to coverage and reflects a relationship of respect between the managing costs- the goals of the ACA. Health citizen and the caregiver in which the caregiver literacy is mentioned dozens of times, directly has the responsibility to listen and understand or indirectly, in the ACA because policy makers the citizen. The caregiver must also have the understand health care cannot be reformed in “capacity to obtain, process and understand” any meaningful way without health literate pa- what the patient says and needs. In addition, as tients.”3 we apply health literacy to the entire communication context of health information, we face Second, the National Action Plan to Improve a similar confusion. The problem with health Health Literacy was launched in May, 2010.4 The pamphlets, fact sheets, and websites is not only product of a public-private collaboration that the reading level of citizens, but also the ability puts forth seven goals, the National Action Plan of the authors to understand to whom they are includes a myriad of strategies for achieving talking and how they must present information those goals and creating a health literate soci- so that it is not only clear, but credible. This ses- ety. This roadmap reflects the current empha- sion focused on the mutuality of health literacy, sis on the need to tackle system-level changes on the responsibilities and competencies that that make it easier for people to navigate, un- caregivers and professional health communica- derstand, and use information and services to tors need to foster effective health literacy, and take care of their health. HHS has not only in- on the new measures of health literacy we need tellectual leadership in making the conceptual to capture this perspective. case for health literacy, but has also furthered research, trained professionals, and otherwise Teetering at the Tipping Point: U.S. encouraged adoption of evidence-based health Government Efforts to Promote a literacy practices. Health Literate Society Third, the Plain Language Act signed into Health literacy has been identified as a prior- law in October, 2010 made all federal agencies ity area for national action in the United States, practice what they preached. The law, which is first by the Department of Health and Human not limited to health care, requires each feder- Services (HHS) as an objective for Healthy Peo- al agency to use plain writing in every covered ple 2010 (HHS, 2000), and again in the Institute document. of Medicine report Health Literacy: A Prescrip-

36 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 As the decade progresses, health literacy is We collaborated with state medical and den- becoming infused with other health and health tal professional societies to conduct surveys and care improvement priorities. For example, focus groups of 4 provider groups (dentists, health literacy is explicitly recognized as an as- dental hygienists, physicians and nurse practi- pect of being culturally competent in HHS’ newly tioners) to determine what they know and do enhanced National Standards for Culturally and about preventing dental caries among children 6 Linguistically Appropriate Services in Health and years of age and younger. We found that all pro- Health Care.5 The U.S. government continues to vider groups could improve their understanding make an extensive effort to promote a health of caries prevention and early detection. We also literate society. conducted a phone survey of Maryland adults to determine what they know and do to prevent It Is Our Problem and We Have Some caries and their opinions regarding the commu- Solutions! The Maryland Model of nication skills of their dental providers.6 To ob- Oral Health Literacy tain more in depth information, we conducted 6 focus groups, two in Spanish and four in Eng- In 2007, the State of Maryland was in the lish, with low income adults with young children. limelight concerning children’s dental health. Collectively, we found adults greatly lacking in This was a result of the tragic death of Deamonte their understanding of caries prevention. Most Driver, a 12 year old who died from an untreated assumed that early childhood caries is inevita- dental infection. The leadership of the state re- ble and must simply be endured. Partnering with sponded immediately and charged a taskforce the Office of Oral Health, Department of Health (Dental Action Committee [DAC]) to provide a and Mental Hygiene, we also conducted surveys blueprint for action to address the lack of ac- and focus groups with Women, Infants and Chil- cess to dental care for low-income children. One dren’s Programs (WIC) and Head Start directors of the seven recommendations of the DAC re- and staff to help us understand what they know port was for the design and implementation of a and do about caries prevention. statewide unified oral health education program aimed at policy makers, parents, health care Based on these findings, we then conducted providers and the public. Our overarching goal health literacy environmental scans in 26 of the was to decrease dental caries disparities among 32 community-based dental clinics in Maryland.7 Maryland’s children and youth. The approach The purpose of these scans was to determine is based on the PRECEDE-PROCEED model, a the overall user friendliness of the health facil- comprehensive approach to planning health ini- ity. Based on the information from our statewide tiatives. This is an essential first step towards assessment, we identified gaps in knowledge, creating a sustainable multi-sectorial state pro- understanding and practices regarding caries gram dedicated to improving and promoting oral prevention among the public and all provider health literacy that contributes to the state’s ca- groups. To help close these gaps, we created pacity to ensure that no more Maryland children English and Spanish language evidence-based succumb to the ravages of dental caries. tools to address them. We developed educational interventions for gravid women, parents Specifically our objective was to determine of young children, and health care provider what parents and caregivers, and health care groups, which we share with others. We also professional workers know and do about tooth provide in-service training upon request to WIC, decay and its prevention. In addition, we want- Head Start and the Area Health Education Cen- ed to know what, if any, communication skills ters. Although our focus is on dental caries pre- health care providers use on a routine basis, and vention and early detection, the model could be equally important, know what the public thinks used for other content areas. about their health care providers’ communication skills.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 37 References

1. Institute of Medicine of the National Acad- 5. U.S. Department of Health and Human Ser- emies. Health Literacy: A prescription to end vices. OPHS, Office of Minority Health.- Na confusion. National Academies Press. Wash- tional standards for culturally and linguisti- ington DC, 2004. cally appropriate services in health and health care. Washington DC 2001. http://www. 2. Parker R, Ratzan SC. Health Literacy: a second minorityhealth.hhs.gov.assets/pdf/checked/ decade of distinction for Americans. Journal of finalreport.p Accessed 10/8/2014. Health Communication, 2010:15(Suppl 2)20- 33. 6. Horowitz AM, Maybury Catherine, Kleinman DV, Radice SD, Wang MQ, Child W. Health liter- 3. Parekh A. 2010: The year of health IOM 2011. acy environmental scans of community-based Health Literacy implications for health care re- dental clinics in Maryland. Am J Public Health. form: A workshop Summary. Washington, DC: 2014;104:e85-e93. The National Academies Press. 7. Horowitz AM, Kleinman DV, Wang MQ. What 4. U.S. Department of Health and Human Servic- Maryland adults with your children know and es. The National action plan to improve health do about preventing dental caries. Am J Public literacy. 2010 http://www.health.gov/commu- Health. 2013;103:e69-e76. nication/hlactionplan/ Accessed 10/8/2014.

38 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Using the Best Evidence to Enhance Dental Hygiene Decision Making

Julie Frantsve-Hawley, RDH, PhD; Janet E Clarkson, BDS, PhD; Dagmar E. Slot, RDH, MSc

Introduction Figure 1 An evidence-based approach to healthcare of- ficially started in the early 1990s with leaders such as Dr. David Sackett and Archie Cochrane, although roots of this movement can be traced to earlier times. This approach has continually been implemented in all areas of healthcare, including dentistry. The American Dental Asso- ciation (ADA) definition of Evidence-based Den- tistry can be adapted as “an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dental care professional’s clinical expertise and the patient’s treatment needs and preferences.”1 This definition includes the three critical realms: the science, the clinician’s judgment, and the individual patient’s needs and preferences.

Using evidence-based decision making (EBD) provides specific and individualized health care that is based on the most robust scientific evi- Figure 2: Sample PICO Question dence. Much debate has occurred around the role of each of these realms, but Dr. Sacket For patients with an orthodontic appliance, described it best when he said, “External clini- would the addition of professional fluoride var- cal evidence can inform, but can never replace, nish, when compared to home fluoride tooth- individual clinical expertise.” Dr. Victor Montori, paste use alone, reduce caries incidence? another leader in the evidence-based healthcare P: orthodontic patients movement, gave a clear assessment of the role I: professional fluoride varnish plus home of research when he stated that, “The better the fluoride toothpaste research, the more confident the decision,” but C: home fluoride toothpaste he also stated that “Evidence alone is never suf- O: caries incidence ficient to make a clinical decision.” The key take- home message is that evidence and science in- Step 1. Make the question forms, but never replaces, clinical decisions. This may seem like an easy thing to do, and Learning how to use evidence in making we have much experience in asking all types of healthcare decisions is a skill learned which is questions. However, developing a strategic clini- perfected over time. As describe in Figure 1, cal question does take skill and practice. The ad- there are 5 steps in applying EBD. This presen- vantages of framing a clinical question is that it tation and manuscript will review these 5 steps helps define exactly what information you are and will give the reader insights as to how to seeking and helps you know when you’ve found obtain the skills necessary to successfully imple- the answer. It also helps to define search terms ment each step. and develop a successful search strategy.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 39 Table I: Sources of Pre-Appraised Evidence: Guidelines and Critical Summaries

Organization Website Evidence Type American Dental Association’s Evidence-based Guidelines Center for Evidence-Based http://ebd.ada.org Summaries of systematic reviews Dentistry (Free) Evidence-based Guidelines Translating Research Into Practice http://www.tripdatabase.com/ Summaries of clinical studies and (Free) systematic reviews Scottish Dental Clinical http://SDCEP .org Evidence Based Guidelines Effectiveness Programme (Free) Database of Abstracts of Reviews http://www.crd.york.ac.uk/CRD- Summaries of clinical studies and of Effects (DARE) (Free) Web/ systematic reviews National Guideline Clearinghouse http://www.guideline.gov Evidence-based Guidelines (Free) http://www.journals.elsevier.com/ Journal of Evidence-based Dental Summaries of clinical studies and journal-of-evidence-based-dental- Practice (subscription) systematic reviews practice/ Evidence-Based Dentistry Journal http://www.nature.com/ebd/in- Summaries of clinical studies and (subscription) dex.html systematic reviews

A PICO question format is typically used, summaries of research. Some resources for pre- where P refers to the population, I refers to the appraised evidence are free others require a Intervention about which we are seeking scien- subscription examples are found it Table I. tific information, C is the comparison group – usually a placebo or current standard practice, A second strategy typically employed if an an- and O is the outcome being evaluated. Figure 2 swer to the PICO(S) question is not identified provides an example of a PICO question. In this through searching for pre-appraised evidence is example, lack of a defined question might lead to search databases for systematic reviews (Fig- one to consider a much larger patient population ure 3) and clinical studies. PubMed is an open or use a wider pool of outcome measures. How- access database with handy multiple online tu- ever, using the PICO question helps us to nar- torials. One very useful PubMed feature is the row our search to those patient populations with Clinical Queries Search that will enable the user orthodontics and narrow our outcome measure to quickly identify both systematic reviews and to caries incidence. This provides framing and clinical studies. focus for our clinical question. More recently, an S has been added to PICO, creating PICOS, is The Cochrane Collaboration is another online order to focus the question even more. It can be source of systematic reviews. The Cochrane Col- used for the type of study or for the setting for laboration is an independent, non-profit, non- which the question is needed. governmental organization consisting of worldwide volunteers. The collaboration was formed Step 2. Access the Evidence to organize medical research information in a systematic way to facilitate the choices that This part of EBD would undoubtedly be quite health professionals, patients, policy makers and a challenge without the capacity to do electronic others face in health interventions according to searches of multiple databases. There are dif- the principles of evidence-based medicine. They ferent approaches to search online for evidence, conduct high quality systematic reviews, and and this is another skill that is acquired over time. many consider Cochrane systematic reviews to One approach is to seek pre-appraised evidence be the gold standard. The Cochrane Oral Health first. This refers to evidence where an individual Group (COHG) is one of 53 groups around the or organization has evaluated and summarized world and has responsibility for preparing, main- evidence. The advantage of this approach is that taining and disseminating systematic reviews of it is typically quicker and provides concise in- randomized controlled trials in oral health. The formation in a user-friendly format. Examples COHG has 1,400 members from over 40 coun- include evidence-based guidelines and critical tries who contribute in different ways. The COHG

40 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Figure 3: What is a systematic review?

• Systematic reviews have increasingly replaced traditional narrative reviews and expert com- mentaries as a way of summarizing research evidence. • High quality systematic reviews seek to: • Identify all relevant published and unpublished evidence • Select studies or reports for inclusion • Assess the quality of each study or report • Synthesize the findings from individual studies or reports in an unbiased way • Interpret the findings and present a balanced and impartial summary of the findings with due consideration of any flaws in the evidence

Table II: Questions to be asked when applying evidence into practice

Primary Question Sub-question Are the studies well designed and executed? 1. Are the results valid? What are the types of studies used? What is the certainty of the effect? 2. What are the results? What is the magnitude of the effect? Is the population similar? 3. Can the results be applied to my patient? Is the provider similar? Is the setting similar? always welcomes new members, and increasing Step 4. Applying the Evidence the membership of this group is a priority. In- creasingly, reviews are conducted on topics rel- Guidelines will provide clinical recommenda- evant to hygienists and therapists. For more in- tions, and clinical judgment along with patient formation please email [email protected] preference will influence whether they are- ad or visit http://ohg.cochrane.org. opted. For individual studies, there are three primary questions that need to be answered Step 3. Appraising the evidence when determining whether evidence should be applied in practice (Table II). Each has sub- Knowing that not all research is of equal qual- questions that will help you to determine if the ity, it is important to critically appraise published evidence is sufficient to enable you to apply it research to understand each study’s strengths in practice. Answering these questions will help and weaknesses. This entails careful consider- determine if the study results are trustworthy ation of the study methods, which is typically (Are the results valid?), the anticipated outcome the least read part of journal articles. It is criti- of implementing the intervention (What are the cal to first understand the study methods and certainty and magnitude of the results?), and if quality before one can begin to consider the sig- this outcome can be expected with your patients nificance of the results. This, too, is a skill that (Can the results be applied to my patient?). is developed over time. Fortunately, there are multiple checklists that can help one consider Step 5: Assessing the Outcome the important factors to appraise for each study design. Web links to such tools are available One of aims of EBD is critical thinking. Step 5 through the Resources page of the ADA’s EBD is to evaluate the applied evidence in the spe- Website under the title of “Critical Appraisal and cific clinical situation. This includes determin- Evidence Analysis.” ing which course of action is best and evaluating how well the whole process worked. Did the One of the advantages of seeking pre-ap- product or treatment work for this patient in this praised evidence, as described in the first search situation? Was the intended outcome achieved? strategy above, is that there is no need to con- Did the evaluation or treatment method help duct a formal critical appraisal because this is this patient? How much time did the process included in the critical summary or guideline take, and even more important, was the cost development process. Furthermore, these docu- efficient? Is the magnitude of the benefit of the ments are developed by individuals with exper- additional treatment substantial, and is it worth tise in EBD and critical appraisal. the extra cost and time?

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 41 Conclusion steps of an evidence-based approach to healthcare will help any practitioner effectively imple- An evidence-based approach to healthcare ment science in practice: requires incorporating the most current and comprehensive scientific evidence, the clini- 1. Ask the question cian’s judgment, and the patient’s needs and 2. Access the evidence preferences to make individualized healthcare 3. Appraise the evidence decisions. This will likely require developing new 4. Apply in practice skills, or enhancing existing skills, to effectively 5. Assess the outcome and efficiently use evidence in practice. The 5

References

1. American Dental Association. Policy State- 2. Hemingway P, Brereton N. What is a system- ment on Evidence-Based Dentistry. August atic review? Available at: http://www.medi- 29, 2013. Available at: http://www.ada.org/ cine.ox.ac.uk/bandolier/painres/download/ en/about-the-ada/ada-positions-policies- whatis/syst-review.pdf Accessed October 7, and-statements/policy-on-evidence-based- 2014. dentistry Accessed October 7, 2014.

42 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Overcoming the Fear of Statistics: Survival Skills for Researchers

Karen B. Williams PhD, RDH

Introduction One of the most common complaints I hear sality. We can, however, estimate the probability from clinician-researchers is that statistics are (p) that observed differences between groups difficult to understand and apply. Misstatements are based on “chance” using the null hypothesis. such as “differences were highly significant, with p=0.008” or “our study proved X causes Y” re- Getting significant differences (p<0.05) is in- inforce common misperceptions associated with fluenced by three factors: magnitude of effect, statistics. These statements illustrate 2 common sample size, and variation in the data. Because fallacies. The first is that smaller p values can be sample size influences p value, a small p cannot interpreted as a larger effect, and, that a small be simply equated with large effect size. Results p value is evidence of “truth.” In order to under- from a study with 1,000 subjects will always stand why these assumptions are fallacies, it is have a much smaller p value than one with 100 important to know what the p value represents. subjects, given the same magnitude of difference between groups. Power of a statistical test The accepted convention for separating po- - the likelihood of rejecting the null hypothesis tential explanations (X causes Y) from chance when there is a real difference - is influenced by happenings is testing the null hypothesis. One the number of observations/sample size. can think of testing the null hypothesis as a ”rit- ualized exercise of devil’s advocacy.”1 The null Effect size is about actual differences. It can hypothesis is an artificial argument – that any be determined from raw data (e.g., difference difference between treatment groups is due to between group means) or standardized (raw ef- chance, assuming that the treatment has no fect size divided by the standard deviation). It effect. Researchers hope that this likelihood is is helpful for researchers to think about raw ef- small. The p value derived from statistical test- fect size as the minimally important difference ing is an estimate – the probability that, assum- (MID), that is clinically meaningful. The stan- ing the intervention is not effective, that treat- dardized effect size, which takes into account ment groups are different simply due to chance the variance, can be interpreted as a measure variation. If a small p value (conventionally of “importance”. Thus, it gives an objective esti- <0.05) is obtained, then the researcher rejects mate of the strength of association between the the assumption of difference due to chance and outcome and intervention/treatment. Common accepts the alternative - that differences are effect size measures include r2, eta square, odds likely due to the treatment. ratio and Cohen’s d.

Groups can differ simply due to chance. Two Statistical Decision Making common sources that contribute to this are sampling error and measurement error. Sampling So, why do clinicians often equate a statisti- error occurs when groups are inherently differ- cally significant p value with truth about causal- ent by chance. Random assignment can reduce ity? Humans innately have a need for certainty. this error, but does not ensure group equiva- When individuals feel uncertain or there are lence with respect to all factors that might influ- multiple cues that need to be considered simul- ence the outcome. Measurement error can exist taneously, individuals often rely on one-dimen- depending on how, when, where and by whom sional rule-based decision making.2 Such is the outcomes are measured. Either source of error case with statistical analysis and interpretation.3 can introduce doubt as to whether change in the Several researchers have criticized this “fan- outcome (Y) is solely attributable to the inter- tasy” of statistical testing as proving effective- vention (X). Thus, it is not possible to prove cau- ness, and have called for logical interpretation

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 43 of data along with use of the p value, effect size pact over time estimate and replication of findings.4,5 • Not all subjects were available for all observation periods or differentially dropped from CONSORT Guidelines and Improved CON- the study (missing data). SORT guidelines now encourage researchers to • There were too few subjects to capture a dif- provide information about the MID when pub- ference if it existed or there were so many lishing. They also suggest that MID be defined in subjects that even a trivial difference would advance and used as the effect size for design- be statistically significant. ing clinical trials.6 Despite changes in publication standards and improved statistical techniques Statistical Tests as Part of a Logical available, clinicians and researchers still tend to Argument fear statistics and make rash judgments about the meaningfulness of statistics. One of the most compelling books in print today is Statistics as Principled Argument.1 Abel- Therefore, the remainder of this paper will son argues for use of applied logic and good discuss issues that may help demystify statis- judgment along with hypothesis testing to make tical testing and provide clinician-researchers good decisions about study results. Psycholo- with realistic strategies for improving the quality gists have shown that people are highly sus- of one’s own research efforts. ceptible to confirmation bias. Confirmation bias results when people selectively focus on infor- The Logic of Establishing Causality mation that reinforces preexisting ideas, thus resulting in overestimating the influence of sys- Establishing the causality between an inter- tematic factors (like an imposed treatment) and vention and outcome requires that 5 tenets be underestimating influence of alternative expla- met. First, there must be a logical or biologically nations, including chance. This may cause in- plausible relationship between the cause and the dividuals to conclude that an intervention is ef- outcome. Second, exposure to the cause must fective, especially if there is a p value from a precede development of the outcome. Third, statistical test of <0.05, without thoughtful con- there has to be evidence of strength of associa- sideration of other factors. tion. Fourth, and critically relevant to both proper design and statistical testing, is that there Since very few clinical researchers have the has to be a lack of competing explanations for depth of understanding that underlies the field the results. Last, evidence must be replicated. A of methods and biostatistics, they are likely un- single study does not provide sufficient evidence aware of how a conceptual model, study design to support causality. and measurement can be used to their maximal benefit to answer meaningful research- ques Study design is critical to making causal tions. Actively seeking out a consultation with a statements. Having a comparison group (or bet- biostatistician with experience in the broad field ter yet, a control group if possible) is necessary of health-related research is one of the most ef- to tease apart whether any observed changes fective ways to overcome a fear of statistics. are attributable to the treatment/intervention. While the statistical test (and associated p val- Getting a Statistical Consult ue) can give us an estimate of chance differences, it alone is insufficient. One must consider Obtaining a statistical consult during the de- why treatment versus comparison groups might sign phase of a study is one of the best ways (or might not) differ. Some common reasons in- to maximize efficiency in the research process. clude: Many institutions have statistical consultation services or individuals who can provide these • Individuals in the respective groups looked consults. Find someone at your institution who similar but differed in subtle ways that were is knowledgeable with whom you can discuss undetectable but important. your project. • Changes observed over time could be natural occurrences (e.g. aphthous ulcers and Once identified, prepare for the consulta- healing) tion in advance. Be prepared for the questions • Measurement was flawed or unequally- im that the statistician might ask about previous plemented research. In the literature, be attentive to how • Study length was insufficient to capture im- results may have changed over time. An inter-

44 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 esting observation about study results is that ables that should be controlled either by design effects often decrease over time. Lehrer sug- or statistically. Make sure you leave with an un- gests that “truth wears off” over time because derstanding of how design, measurement and our illusions about the meaningfulness of vari- statistical analysis fit together. Once you have ous research questions declines over time.7 Be- drafted your proposal, get confirmation from the ing able to articulate this trend will be important consultant that you have “gotten it right.” for study design and power analysis. Getting the right estimate for sample size initially improves Make sure you discuss how to set up your data the likelihood of getting meaningful results. for analysis. The statistical analysis plan, design of the study, capture of confounders, number In advance, draft an abstract that summarizes and type of outcome measures, and statistical your proposed project using the PICO format.8 software will dictate the appropriate format. Un- less you are completely comfortable with statis- (P) Population: Who is the population being tical software and the analysis plan, do not do studied? this on your own. There is nothing more frus- (I) Intervention: What is the intervention or trating than to have all of your data entered, exposure variable? only to find it is not in an analyzable format. (C) Comparison or Control Group: What is the most appropriate comparison or control Conclusion group? (O) Primary Outcome Measure: What out- Most importantly, leave your apprehension at comes are feasible to measure? the door and look at the consultation as a unique opportunity to engage in creative planning. Sta- A good consultation will usually result in modify- tistics are wonderful tools, but only if used cor- ing some aspects of your original research plan. rectly. Statistical analysis programs manage the So, be prepared to capture recommendations ei- computational aspects but do not overcome bad ther in writing or audio recording. Clarify issues design and incorrect analyses. Approach the re- that are confusing at that time. A good consul- search process just as you would plan a trip to tant will help identify potential confounding vari- a foreign country and you can avert the fear of statistics and pain of failure.

References

1. Abelson RP. Statistics as Principled Argu- 6. Zwarenstein M, Treweek S, Gagnier J, Alt- ment. New York, Taylor and Francis Group, mam DG, Tunis S, Haynes B, Oxman AD, Mo- Psychology Press. 1995. her D. Improving the reporting of pragmatic trials: an extension of the CONSORT state- 2. Erick J, Boomer J, Smith J, Ashby F. Informa- ment. BMJ 337: 1-8, 2008. tion-integration category learning and the human uncertainty response. Mem Cogn. 7. Lehrer J. The truth wears off: Is there some- 39: 536-554, 2011. thing wrong with the scientific method? New York Times. Available at: http://www.newy- 3. West CP, Ficalora RD. Clinician attitudes to- orker.com/reporting/2010/12/13/101213fa_ wards biostatistics. Mayo Clinic Proceedings. fact_lehrer Accessed August 2011. 82(8); 939-943, 2007. 8. Duke University. Asking a Well-Built Clini- 4. Carver RP. A case against statistical signifi- cal Question. Introduction to Evidence- cance testing. Harvard Educ Review. 48(3): based Practice. Available at: http:// 378-399, 1978. guides.mclibrary.duke.edu/content. php?pid=431451&sid=3529524 Accessed 5. Carver RP. A case against statistical sig- August 20, 2014. nificance testing, revisited. J Experimental Educ. 61(4): 287-292, 1993.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 45 Research Millennials and Dental Education: Utilizing Educational Technology for Effective Teaching

Christine Blue, BSDH, MS and Harold Henson, RDH, PhD

Introduction Millennials arrived on campus in the year 2000 did. Since their arrival on the college campus in and will continue to be part of the college campus 2000, faculty have been trying to figure out how for the next decade. Their unique characteristics, to manage the amount of involvement and feed- diversity and expectations for the learning envi- back these students demand. ronment are transforming the college classroom and challenging faculty to examine traditional Millennials are high achievers and are focused pedagogy as well as the learning environments on grades and performance.4 This generation offered to students.1 Attitudes, beliefs and values wants a clear, structured academic path and sees are influenced by the people, places and events a college education as an expensive consumer in our history, and therefore uniquely shape each good. This mind-set translates tuition into a col- generation. Like generations before them, these lege degree and good grades. In the classroom, influences establish different motivation levels, students will often dismiss homework as “busy work ethics, and worldviews that impact teaching work” when it has no relevance to personal goals. and learning. This presentation will aid in under- In college, Millennials are finding that self-esteem standing generational differences and may help cannot deliver their expected success and many dental educators improve their teaching effective- are showing signs of stress, anxiety, and hence, ness. the rise in academic and mental health resources on today’s college campus. Millennials have and will continue to influence higher education first, as students, then as facul- Leisure time is a priority for Millennials. When ty. Millennials bring a new generational personality these students were growing up, they were highly to the college campus which includes optimism, scheduled with traveling sports teams, music les- structure, team orientation, and a confidence that sons, camps and organized playgroups. As col- some believe borders on entitlement.2 Millennials lege students, they have less “free time” than any are used to being engaged with adults, and have other generation of students due to time com- strong bonds with their parents who throughout mitments to school, sports, social activities, work their lives have told them they were special and and volunteerism. Technology allows Millennials to included them in decision-making. Consequently, stay connected and has blurred the lines between most have the same values as their parents, re- work and life. They stay in uninterrupted contact spect authority and are rule-followers.2 Millennials with the world around them and consequently, the had less academic demands in high school than workday is no longer nine to five, thus motivating previous generations and, upon arriving to cam- Millennials to desire work/school-life balance.3 pus, expect the same minimal demands in college. Faculty have found that these students have unre- An abundance of information has focused on alistically high expectations of success combined the traits of Millennials; however, less has been with a surprising low level of effort on their part.3 published on teaching methodology that aligns with the way Millennials learn. Interestingly, many Millennials exude confidence and are extremely components of Millennials’ ideal learning environ- optimistic. The majority of Millennials are person- ment – less lecture, active learning approaches, ally happy and excited about their future as they use of multimedia, collaborating with peers – are believe they will correct the ills of society.2 Tan- some of the same pedagogical approaches re- gible achievements and rewards are important to search is showing to be effective.4,5 them and they expect praise and encouragement from their college professors, as all of their lives First, because of their highly scheduled child- they have heard “good job” for most of what they hood, their need for structure carries over into the

46 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 classroom. The more structured and planned the teams, school and volunteer projects, Millennials course, the more secure and satisfied this student know how and when to work with other people will be. This generation prefers to know the facts very effectively.2 Accustomed to teaming-up, and does not like ambiguity. A common question these students desire collaborative learning in of this cohort is, “What do I need to know?” Millen- the classroom. Millennial health care students are nial students expect emphasis on core knowledge primed for health care reform which emphasizes and skills and expect frequent formative feedback team-based care and interprofessional education. on their performance, as well as frequent review Their desire for connection extends to faculty as sessions. Frequent formative feedback has shown well. Having been raised by caring parents and to improve the learning process, and literature other adults, Millennials want faculty to get to suggests people learn when they actively monitor know them and care more about how their pro- their learning and reflect on performance.5 fessors interact with them than about what their professors know.4 In addition to their focus on what information they need to know, Millennial students want to Technology is perhaps the most distinguishing know why they need to know it. Their desire for characteristic of the millennial generation. For this learning to be relevant and related to their ex- generational cohort, personal computers have al- periences cannot be underestimated.4 However, ways been there and are as ubiquitous and com- this student has difficulty seeing the big picture mon as a coffee pot. Millennials expect a multi- and thinking independently and will rely on the media enriched environment in the classroom. instructor to make a connection between their life Interestingly, professors who use multimedia and course material. Teaching methods emerging (YouTube, movie clips, etc.) saw better student from constructivist theory support the way Mil- test scores on quizzes and examinations.5 lennnials want to learn, including active learning strategies such as cases, cooperative learning, They expect that there will be communication group projects or skill demonstration. Millennials with faculty via e-mail and have access to online also desire variety in the classroom and interest- resources. Faculty will need to serve as a facilita- ingly, research has demonstrated people learn tor in order for students to collaborate with each best when they receive the new materials mul- other. It is important for faculty to “frame” the tiple times but in different ways.5 Service-learning course and supplement student interactions by in education grew out of constructivist theory as providing resources and opportunities. Addition- well, and when paired with structured reflection ally, faculty need to develop a conceptual ratio- has been demonstrated to improve students’ aca- nale for incorporating technology into their teach- demic, personal, social and citizenship skills. ing, identifying how it fits with their philosophy of teaching and learning. In other words, technology Millennials’ penchant for connection is mani- should not be used for its own sake but rather only fested in the classroom in several ways. After if it enhances teaching and learning.6 many years of collaborating at day care, sports

References

1. Pew Research Social and Demographic 4. Price C. Why don’t my students think I’m Trends. Millennials in adulthood:Detached groovy? The New “Rs” for Engaging Mil- from institutions, networked with friends. lennial Learners. Available at: http://www. March 2014. Available at: http://www.pew- drtomlifvendahl.com/Millennial%20Charac- socialtrends.org/2014/03/07/millennials-in- turistics.pdf Accessed October 8, 2014. adulthood Accessed June 11, 2014. 5. Wilson M, Gerber LE. How generational 2. Strauss W, Howe N. Millennials rising: The theory can improve teaching: strategies for next generation. New York: Vintage Books; working with millennials. Currents in Teach- 2000. ing and Learning. 2008;1(1)29-44.

3. Twenge JM. Generational changes and their 6. Wilson, ME. Teaching, learning, and millen- impact in the classroom: teaching genera- nial students. New Directions for Student tion me. Medical Educ. 2002;43:398-405. Services, 2004: 59–71. doi: 10.1002/ss.125

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 47 Research Getting Your Name in Print

Jacquelyn L. Fried, RDH, MS; Katy E. Battani, RDH, MS

Introduction The conduct of research and the dissemina- to the guidelines of their publication of choice. tion of resulting relevant findings create a pro- Specific elements of research papers most often fession’s body of knowledge. For dental hygiene include the following: title, abstract, introduc- to advance, a cadre of adept researchers must tion/literature review, methodology, discussion, be developed. These researchers must have the findings, references and appendices, figures and skill sets that enable publication of their work. tables. A scientific, cogent yet attention-grab- The main goals of this workshop were to suc- bing title that reflects the content of the manu- cessfully instill the self-confidence and impart script must be developed. Tips for title creation the knowledge necessary for iterant scientific were delineated, and examples of titles were writers to publish in a peer-reviewed journal. critiqued and modified. Participants reviewed Designed to be interactive, participants applied abstracts and identified whether required parts basic principles of scientific writing and the writ- were included or omitted. How to organize and ing process through self-assessment exercises write the body of the paper, congruent with the and individual or group opportunities that al- paper’s abstract, was addressed. Identifying lowed attendees to critique and create workable the elements of the methodology section and documents. The dual emphases of helping writ- providing examples of how to group and pres- ers write well and write well scientifically were ent results were addressed through group ac- intertwined in group activities. tivities. The challenges associated with the discussion section and relationships to the results Scientific writing is a unique approach to shar- were discussed. Writers sometimes have a ten- ing information. Several characteristics differen- dency to restate results in discussions and offer tiate it from other styles. Scientific writing must discussion points in the results section. Paring be systematic as it reflects information that was down discussions can be challenging in scientific obtained through a systematic process. While writing. Not all results merit discussion. Similar providing the readership with new findings and findings may be summarized and described in ideas, scientific writing is expected to reflect an a single paragraph. Researchers often tend to economy of words, a neutral tone, lucidity and overstate their findings. Limitations associated precise wording. The need to link thoughts to with sample sizes, research design and control each other, present a logical progression of ideas, of extraneous variance must be addressed when and methods for emphasizing organization of findings are discussed. content and logical flow were highlighted. For example, a literature review must precede from The formal stages of the writing process were the general to the specific to arrive at a focused presented. Specific phases include invention research question or hypothesis. This same flow (pre-writing), development of a thesis state- of ideas, i.e., from a broad introduction to speci- ment, outlining, writing the first draft, revising ficity, should be apparent in each paragraph of a and polishing. Since writers process and utilize paper. Participants assessed sample papers that information differently, their approaches to put- required changes in organizational flow. -De ting pen to paper differ. Less formalized ap- termining the relevance of inclusions also was proaches but useful steps in the writing process examined. Attendees critiqued writing samples include examining the purpose of the paper, how and were asked to identify superfluous informa- it will be achieved and brainstorming. Pre-writ- tion. Participants’ self-assessed and modified ing may include a random collection of thoughts their own writings to reinforce organization and and ideas that adhere to no particular order. economy of words. Jotting down or typing random ideas when they enter the writer’s mind is a commonly used and Scientific writers must address the required helpful way to stimulate thinking. components of a research paper and adhere

48 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 The benefits of outlining were emphasized. Overreliance on spell check was discouraged as Outlining promotes a hierarchical and system- a word may be spelled correctly but still used atic approach to writing. To promote order and inaccurately in a sentence. organization, participants were advised to begin each paragraph with a topic sentence and Knowing the prospective audience helps the ensure that paragraph content supported and writer decide what information to include in the elucidated introductory sentences. Participants research report. An article directed toward a created thesis statements to begin paragraphs narrow audience will have a different perspec- and then outlined the subsequent related con- tive than one submitted to a journal that is rel- tent. Attendees shared their pre-inventive stag- evant to a broad range of disciplines. Regardless es and writing approaches. They discussed ways of the audience, findings and conclusions must to improve their processes of writing, and the be stated clearly with as few words as possi- facilitators and other attendees offered sugges- ble. Referencing content is critical in scientific tions. Other thoughts related to the writing pro- writing. A fatal flaw and reason for article- re cess were shared. Participants were advised that jection is plagiarism. Quoted material must be writing takes time and editing and re-editing are acknowledged. The use of secondary sources is continual processes; and, that many authors prohibited. Returning to the original reference is advise taking breaks during the actual writing required as the author who first cites the article, of the paper to clear their minds and enable a i.e., the secondary source, may tweak an origi- return to work with a fresh perspective. During nal statement inadvertently and that thought editing and reediting, attendees were advised to could be more distorted in subsequent itera- seek input from other accomplished writers, re- tions. A return to an original document ensures searchers and objective parties. that both the original intent of a statement or finding and the details of the citation- areac Major grammar and punctuation pitfalls and curate. Publishing is not a perfect art so errors scientific writing taboos were discussed. Scien- can occur. A repetition of the same citation error tific as opposed to narrative writing, employs no could indicate the author’s use of a secondary superlatives, is preferably stated in the voice of source; i.e., copying the inaccurate secondary third person, and uses active, not passive verbs. source’s reference information. Authors are re- Contractions must be avoided and acronyms quired to adhere to the referencing guidelines cannot be used until the proper name for a term of the publication to which they are submitting. has been previously spelled out in the text. In- Any questions about guidelines should be direct- cluding vocabulary that is difficult to understand ed to the journal of interest. in an effort to sound intellectual is discouraged. Flowery prose must always be avoided. Begin- Attendees received a list of resources to uti- ning statements with terms such as “there is” lize as they develop their writing skills. A key or “it is important that” dilute the power of a tool for perfecting one’s writing skills is read- thought. Subject and verb agreement and paring and studying published work. Published allelism of subjects and possessive pronouns, reports particularly in peer-reviewed journals common grammatical errors, were cited. Par- have undergone rigorous reviews so using them ticipants were advised to be mindful of creating as a guide can be advantageous. Publications a need to know, beginning with the manuscript also can serve as springboards for developing title, maintaining an optimal rate to impart in- research ideas. Practicing writing is another formation, avoiding ambiguity and jumping to way to develop skills and build self-confidence. conclusions (particularly in the discussion and To quote Dr. Seuss, “So the writer who breeds conclusions sections). During the writing pro- more words than he needs is making a chore for cess, writers were advised to utilize a thesaurus the reader who reads.” In conclusion, rewriting and dictionary (electronically or hard copy) and remains the best form of writing. to take advantage of spell and grammar checks.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 49 References

1. Calfee RC and Valencia RR. APA guide to 6. Pyrczak F and Bruce RR. Writing Empirical preparing manuscripts for journal publica- Research Reports. 6th ed. Glendale, CA: tion. Washington, DC: American Psycholog- Pyrczak Publishing; 2007. ical Association. 1991. 7. Strunk W and White EB. The Elements of 2. Harris RA. Writing with Clarity and Style. Style. 4th ed. Needham Heights, MA: Allyn Los Angeles, CA: Pyrczak Publishing; 2003 and Bacon; 2000.

3. Manning T, Algozzine B, and Antonak R. 8. Truss L. Eats, Shoots & Leaves: Illustrated Guide for Preparing a Thesis or Disserta- Edition. New York, NY: Gotham Books, 2008 tion. Morgantown, W. VA: PNG Publications; (US, Special Edition). 2003. 9. Turabian KL. A manual for writers of term 4. OWL, On-line Writing Lab, Purdue Universi- papers, theses and dissertations. 7th ed. ty. Available at: http://owl.english.purdue. Chicago. University of Chicago Press; 2007. edu/ Accessed October 8, 2014. 10. Watkins R, Watkins FW, amd Hiers J. Practi- 5. Pan ML. Preparing Literature Reviews: qual- cal English Handbook. 11th ed. Stamford, itative and quantitative approaches. 3rd ed. CN: CENGAGE Learning; 2009. Glendale, CA: Pyrczak Publishing; 2008.

50 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Becoming an Effective Journal Reviewer

Ann Eshenaur Spolarich, RDH, PhD, Herman Ostrow School of Dentistry of USC and Rebecca S. Wilder, RDH, MS, University of North Carolina School of Dentistry – Chapel Hill

Introduction Peer review is a time-honored process that to identify and discuss strengths and weak- uses editors and experts to evaluate the sci- nesses of a given paper, minimizing time spent entific merit of 1) manuscript submissions to searching for minor strengths in a paper that is journals; 2) abstracts and papers submitted for obviously weak and should be rejected and the consideration for presentation at professional tendency to obsess over minor weaknesses in meetings; and, 3) grant applications requesting a paper that is otherwise strong.3 The review funding of research projects. For journal sub- should be conducted efficiently and returned missions, the process is used to ensure a level of back to the editor promptly to avoid unneces- confidence in the rigor of the research process sary delays between time of submission and no- utilized to conduct a scientific investigation and tification to authors. the accuracy of the study findings and conclusions presented. Papers published in peer-re- Zucker states that reviewers make two com- viewed journals are assumed to have a higher mon mistakes.3 First, reviewers often request level of quality than those published elsewhere. that authors conduct additional work and/or For non-scientists, peer-reviewed publications submit additional data as a contingency for pub- remain the “gold standard” as credible, trusted lication. Reviewers should not approach a man- sources of information.1 uscript review thinking about how they would have conducted the study. A request for ad- Challenges ditional data should not be made lightly, as it places considerable burden on the authors. It is Finding individuals to serve on editorial re- important to remember that submitted manu- view boards can be challenging for editors. An scripts represent a body of work that has been editorial by William Perrin explored the issues completed; therefore, if the stated conclusions that editors face in finding individuals who will in the paper are not supported by the work de- agree to serve as reviewers.2 A primary difficulty scribed, then the reviewer should recommend to encountered is that often the leading recognized the editor that the paper be rejected. Second, experts in a given field who are best suited to reviewers may fail to consider whether the paper review the paper are “too busy” with their own is appropriate for publication based upon how work, requiring editors to then move down the well the paper aligns with the stated goals and list of choices to locate individuals who have requirements of the journal. A reviewer needs to enough knowledge of the subject matter to re- decide whether a paper that is well-written and view the paper. The worst case scenario for the novel should be accepted if the paper has not editor is having to reach out to reviewers who been constructed according to stated guidelines. are not experts in the subject area or not as closely related to the field, increasing the likeli- Reviewers also should consider the amount hood that the quality of the review will be less of work that will be required by the author to than desired.2 Neither editors nor authors ben- revise the paper to meet posted journal stan- efit from the outcomes of this process. dards.3 For example, if a manuscript far exceeds the word count allowed by the journal, the re- Reviewer Responsibilities viewer may recommend that the authors either substantially reduce the word count, or submit The primary responsibilities of a reviewer are to another publication that will accept longer pa- to inform the editor about whether a manuscript pers. The reviewer should clearly communicate is acceptable for publication and to provide the these concerns with the editor early in the re- author with an understanding about how to im- view process to come to a consensus about how prove the submission. Reviewers should be able to advise the author about needed revisions.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 51 Other skills and knowledge are required to clear what are priority areas for revisions and become an excellent journal reviewer. The fol- what are suggested changes to improve the lowing is a list of important aspects of reviewing manuscript. In addition, justify statements for peer-reviewed journals: with references and logical arguments.4 Even if the reviewer recommends that the 1. All reviewers should be familiar with the paper should be rejected, a thorough review guidelines to authors. Knowing the suggest- with some encouragement and advice will ed word count, format for references, tables, help the author improve future research and figures, etc. is essential. writing efforts. 2. Respond to the request to review a paper. 7. Submit the review to the editor on time. Reviewers are asked to evaluate papers If the situation changes and more time is based on their specific expertise. Editors needed, communicate with the editor to en- may have limited numbers of reviewers with sure a timely review process for the authors. the expertise needed for a particular paper. 8. After the first reviews are submitted to the If reviewers fail to respond, it delays the en- authors, resist the temptation to add addi- tire process for the authors and the editorial tional requests in subsequent reviews that staff. Even responding with a “No” will help are not related to the original revisions. the process move forward. Authors become frustrated if they have re- 3. Start the review process with an optimistic sponded to all of the recommended revisions point of view. Many reviewers find ways to only to have others added in the second or reject a paper expecting authors to convince third round. them otherwise. Good reviews help authors improve their work even if their papers are Other Considerations not accepted for publication. Reviews that “tear a paper apart” are not useful to the ed- Serving as a reviewer is an expectation of all itor, author or reputation of the journal. The scientific professionals, and this responsibility review should provide a balance between should be included in job descriptions for faculty positive feedback and critical assessment of and as a requirement for tenure.2 It also is an what needs to be accomplished to improve honor and privilege to contribute to the profes- the paper. The best reviews provide critical sion by supporting and improving the peer re- commentary with concrete recommenda- view process. However, it is becoming increas- tions ingly more difficult to serve as a reviewer, as 4. Provide reviews that are tactful, construc- fields of study are becoming more specialized, tive and as professional as possible. Wording scientific technology is increasingly complex, such as “Who cares?”, “This sentence makes and research projects cross multiple disciplines. no sense”, “I disagree with this statement”, For interdisciplinary projects, it is not realistic “This is bad” can be reworded so the author to expect two or three people to have expertise does not become defensive and overlook the in all aspects of the project. When a reviewer is valuable insight of the reviewer. One might asked to look at a paper that is outside of his ex- wish to approach every review as if it were pertise, the nature of the question asked by the a graduate student who needs to be men- reviewer changes from, “Is this paper a signifi- tored. Also, be a role model of good writing cant contribution to the literature” to “Is there by providing reviews that are free of typos anything about this paper that makes me feel and spelling errors. uncomfortable?”5 While the reviewer is expected 5. Most reviewer evaluation forms have a sec- to detect notable design flaws in a paper, it may tion where reviewers can provide confidential not be as easy to do if the reviewer has not en- comments to the editor. Do not make sub- gaged in a similar type of work or if the reviewer stantive points about a paper unless those is unaware of subtleties, such as cultural differ- comments also are shared with the authors. ences or variances due to study setting, that It is frustrating to editors if the confidential might be inherently important to project design comments are more crucial than what will and related outcomes. be shared with the authors. It also can place the editor in an awkward position if the deci- Further compounding these challenges is the sion regarding the manuscript does not coin- notion that faculty feel increasingly pressured to cide with the review. publish, who then choose to “split” their work 6. Reviews need to be prioritized. It should be across multiple papers, submitting pieces of the same study to several journals with the hope of

52 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 improving the odds of getting a paper accepted activity among the metrics used to determine for publication. The increased number of sub- eligibility for academic advancement. Finally, missions and the finite number of available re- new software systems used to track manuscript viewers overloads the peer review system. When submissions and corresponding documentation there are fewer reviewers available to look at a can be used to archive reviews, which can be paper, the process of review is delayed, limiting used for reviewer training and evaluate reviewer the dissemination of new knowledge in a timely performance across time.6,7 manner.5

To entice more individuals to participate in Conclusion peer review, individuals need to find a balance between the demands of the typical academic Serving as a reviewer for a peer-reviewed workload and the time needed to serve in this ca- scientific publication can be a challenging yet pacity. Some have examined how best to reward rewarding experience. Professionals seeking the efforts of those who dedicate their time and an appointment as a reviewer or membership talents as reviewers, especially for those who on an editorial review board must be willing consistently provide thoughtful, comprehensive to dedicate time and expertise and be willing and quality reviews. If serving as a reviewer be- to be constantly educated about how to becomes a stated expectation for faculty promo- come a better reviewer. Conducting reviews in tion and tenure, then a method to measure and a positive manner with a spirit of professional- document performance is required to help en- ism will assist in encouraging and mentoring sure that participation will “count” as a scholarly the future investigators in the field.

References

1. McNutt M. Improving scientific communica- 5. Salisbury MW. Is peer review broken? Genome tion. Science 2013;342:13. Technology 2009;volume:38,39,4143,45.

2. Perrin WF. In search of peer reviewers. Sci- 6. Metz MA. Rewarding reviewers. Science ence 2008;319:32. 2008;319:1335.

3. Zucker RS. A peer review how-to. Science 7. Marchionini G. Rating reviewers. Science 2008;319:32. 2008;319:1335-1336.

4. Iyengar R, Diverse-Pierluissi MA, Jenkins SL, et al. Integrating content detail and critical reasoning by peer review. Science 2008;319:1189-1190.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 53 Research Successfully Navigating the Human Subjects Approval Process

MaryAnn Cugini, RDH, MHP

Introduction

In order to successfully navigate the human autonomy. Autonomy refers to a person’s subject approval process in clinical or behav- ability to make sound decisions. In re- ioral research, one needs a good understand- search, an autonomous person must be ing of the ethical principles guiding the con- able to consider the potential harms and duct of research involving human subjects. benefits, analyze the risks associated with Federal and international codes and guidelines the proposed research and make a deci- exist which frame the context of ethical re- sion in his own best interest. This includes search. These codes and guidelines include the ability to read and understand the in- The Nuremberg Code (1949), the Declaration formed consent document. of Helsinki (1964-2000), The Belmont Report (US, 1979), Council for International Orga- In 2000, Emmanuel et al proposed a framework nizations of Medical Sciences (CIOMS) and/ of seven ethical principles for clinical research World Health Organization (WHO) Internation- studies, believing that informed consent is not al Guidelines (1993, 2002) and the ICH/GCP sufficient to ensure ethical research. Expand- International Conference on Harmonization – ing on the three basic principles described Good Clinical Practice (EU, 1996). above, this framework adds the principles of social or scientific value – meaning that some There are three ethical principles that guide enhancement of health or knowledge must be all research involving human subjects – benef- derived from the research and scientific valid- icence, justice and respect for persons. (Bel- ity, that the proposed research has a rigor- mont Report, CIOMS/WHO). ous scientific methodology including statistical tests that produce reliable and valid data. • Beneficence refers to the ethical obligation to maximize benefits and minimize harm. In the U.S., the Office of Human Research In effect ‘do no harm’. Assessment of risk Protections (www.ohrp.gov) in the Depart- falls under this principle. Risk in this con- ment of Health and Human Services provides text is defined as the probability that cer- leadership and structure for overseeing the tain harm will occur to subjects from par- rights and welfare of subjects participating in ticipation in research. It is the obligation of research conducted by or supported by the investigators to minimize this potential by US Department of Health and Human Services selecting optimal study designs and inter- (HHS). These guidelines and policies are pub- ventions for their research. lished in the Code of Federal Regulations (CFR) • Justice is the ethical obligation to treat 45 CFR part 46. The Food and Drug Admin- each person (population) equitably and istration (FDA) regulates human subjects in equally. In this principle, distribution of the clinical investigations involving drugs, biologi- benefits and burdens or risks of research to cal products and medical devices. FDA regula- participants and populations should be dis- tions are published in 21 CFR parts 50, 56, tributed fairly among diverse populations. 312, and 812, covering not only protection of Justice protects the vulnerable populations human subjects, but also regulations for Insti- from exploitation and protects of the rights tutional Review Boards (IRB) and other areas and welfare of vulnerable persons. in the review process. • Respect for Persons incorporates two ethical considerations – respect for autonomy Most academic institutions have ethics or and protection for persons with reduced human subjects committees that review proj-

54 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 ects involving the participation of human sub- revisions to the Human Research protocol jects as research subjects for both behavior- and/or study materials, e.g., consent form. al and interventional studies. Independent, Human Research may not commence until central IRBs also exist to serve those com- the IRB grants final approval. If the Princi- panies or investigators not affiliated with an pal Investigator accepts the required modi- academic or medical institution. IRBs such as fications, s/he should submit the revised the Western Institutional Review Board (www. materials to the IRB within the timeframe wirb.com) and The New England Institutional specified. If all requested modifications are Review Board (www.neirb.com) may review made, the IRB will issue a final approval pharmaceutical or clinical protocols for studies notification letter after which time the Hu- conducted in private practice. man Research can begin. • Deferral/Disapproval: If the IRB defers or Is it research? A first step in determining the disapproves the Human Research, the IRB need for IRB review is to decide if in fact the will provide a statement of the reasons proposed project is research and then if it is for this decision. Deferral or Disapproval research involving humans. The US Office for means that the Human Research, as pro- Human Research Protection (OHRP) provides a posed in the submission, cannot be ap- series of decision trees to assist investigators proved and the IRB was unable to articulate in understanding human subject regulations specific modifications that, if made, would (http://www.hhs.gov/ohrp/policy/checklists/ allow the Human Research to be approved. index.html). These decision trees list the cat- In most cases, if the IRB’s reasons for the egories under which a research project may deferral or disapproval are addressed in a be exempt from IRB review and are a good re- modification, the Human Research can be source for the investigator in planning for IRB approved. In all cases, the Principal In- review. Exempt categories for research can vestigator has the right to address his/ include research involving educational tests, her concerns to the IRB directly at an IRB survey procedures or observation of public be- meeting and/or in writing. havior, and research involving the collection or study of existing data, documents, records or One of the major areas assessed by the IRB pathological or diagnostic specimens. A prima- when reviewing a research protocol is the ry reason for the exemption is that the subjects potential risk to the subjects from their par- involved in the research cannot be identified, ticipation. As mentioned previously, when dis- meaning there are no personal identifiers that cussing the ethical principle of Beneficence, it can link the data back to the research subject. is incumbent on the investigator to minimize IRB submission is still required and final deter- potential risk. Some research will by its na- mination of exemption is decided by the IRB, ture involve more that minimal risk. In this or in some institutions this determination is instance, a risk/benefit analysis is presented made by the Scientific Review Officer. to the IRB to assist the review process. A second focus of IRB review is the informed con- It is the responsibility of the IRB to review sent document. This document is assessed to non-exempt research proposals prior to the ensure it contains the elements for consent start of any human involvement in the re- as determined by the regulations and ethical search. An IRB has the authority to approve, guidelines: purpose of the study, risks and require modifications or disapprove all re- benefits associated with participation, -alter search activities. (§45 CFR 46.109) natives to participation, confidentiality, com- pensation, a statement of the right to refuse • Approval: If the IRB has approved the re- participation at any time without penalty and a search involving human subjects, the re- person to contact if they have questions about search may commence once all other or- their participation or the research. In addition, ganizational and/or local approvals have the consent should be written in such a man- been secured. IRB approval is granted for ner that it is understandable by a person that a limited period of time, not exceeding one can read at the 8th grade level in their native year, which is noted in the approval notifi- language. cation letter. • Requires Modification(s): If the IRB- re Human Subject Protection Training serves as quires modifications to secure approval, the initial guidance for new investigators con- the notification letter will outline specific ducting research involving human subjects.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 55 Institutions provide this training and there are research with protected populations, and re- online courses available as well. Documen- search with vulnerable subjects, unanticipated tation of Human Subject Protection Training problems and reporting, and students in re- by the investigator and those involved in the search. Web-based training can be found from project is needed for submission to the IRB. the NIH (https://phrp.nihtraining.com) and This training provides the investigator with private educational sites such as the Collab- a basic understanding of the current regula- orative Institutional Training Initiative at the tory and ethical information. Topics include: University of Miami (CITI)(www.citiprogram. basics of IRB regulations and the review pro- org). cess, assessing risk to participants, avoiding group harms, conflicts of interest, and cultural Often considered daunting, obtaining review competence. Also included is information on from an IRB for research involving human sub- FDA-regulated research, genetic research, jects can be a collaborative effort. The IRB can HIPAA-regulated research, informed consent, provide guidance and direction to the inves- international research, Internet research, re- tigator to conduct valuable research with the cords-based research, research in schools, subject’s welfare and wellbeing at the fore- front.

References

1. The Nuremberg Code. JAMA. 1996; 276:1691. 4. Council for International Organizations of Medical Sciences. International Ethical Guide- 2. World Medical Association. Declaration of Hel- lines for Biomedical Research Involving Hu- sinki. JAMA. 1997; 277:925-926. man Subjects. Geneva, Switzerland: CIOMS; 1993. 3. National Commission for the Protection of Hu- man Subjects of Biomedical and Behavioral 5. Emanuel E, Wendler D, Grady C. What Research. The Belmont Report. Washington, makes clinical research ethical? JAMA 2000; DC: US Government Printing Office; 1979. 283(20):2701-11.

56 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Research Data Management 101: How to Construct and Maintain a Usable Dataset

R. Curtis Bay, PhD

Introduction

We advance our understanding of the hu- formation that comes in the form of numbers. man condition by asking questions. In dentist- Statistical software programs are designed to ry, these questions are best answered through analyze numbers. Methods to codify information formulation of hypotheses that allow us to test were shared to make datasets more amenable the validity (truthiness) of one possible answer to statistical analysis. Examples included Male against others. Most simply, “This new treat- as “1”; Female as “2”; Amalgam as “1”; Com- ment is better than what we have always used,” posite as “2”; Glass Ionomer as “3.” or it is not. Very importantly, the discussion included Clinical questions arise naturally in the practice strategies about how best to communicate with of clinical dentistry. Frequently, they are based the project statistician. Researchers should initi- on the desire to use the best available practices ate communication with a statistician before and and procedures to optimize care for patients. after data collection forms are designed; before Answers to clinical questions are readily avail- these forms are used; after data entry has start- able in the numerous dental journals and online ed and before it is completed; during the statis- content that have proliferated over the past few tical analysis, and after it is finished. An open decades using an evidence-based approach to line of communication with the statistician will dentistry. Much of the evidence is trustworthy. help to ease frustration and avoid headaches for Much of it is not. The best and most trustworthy all parties involved in the process. evidence is investigator-initiated, that is, arising from clinical practice and initiated by those who Along with the data, the researcher should seek a truthful answer, untainted by financial present the statistician with a “data map,” or interest. Of course, trustworthy research is the “dictionary” indicating explicitly what each vari- product of sound scientific methodology. Funda- able is, the scale on which it was collected, and mental to sound methodology is the construc- what the data elements mean. Specifically, what tion of a consistent and replicable plan for data does a “1” mean in an Excel column labeled acquisition, recordation and analysis. “Gender”? A “3” which is intended to represent an ordered category (3 out of 5 on a prefer- This session focused on the basic require- ence scale) will be treated very differently from ments for designing, constructing and maintain- a “3” reflecting a nominal category (eg. Glass ing a dataset collected in the course of conduct- Ionomer). The researcher should formally docu- ing a research study. The nature of data was ment the meaning associated with each number also discussed, and how it serves the purpose of in a written form: Word and Excel work well. It research, including the various types or “quali- is poor form to hand a statistician handwritten ties” of data that may be collected. Some types notes with multiple deletions and corrections, or of data (interval and ratio-level) are more infor- to convey this information orally. Doing so may mative than others (ordinal and nominal data). result in forgotten or lost communication, and It is almost always best to collect the most in- the potential downgrade in priority of the proj- formative type of data that can practicably be ect. collected. Data can always be “dumbed down” by recoding, but it is very hard to “smarten-up” Find out early on if the analysis planned for data once it has been collected. the dataset requires a “wide” or “long” format. These are very different, and converting one to Statisticians tend to like numbers and in- the other may be tedious. Simple, one-obser-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 57 vation-per-subject datasets are straightforward: ancillary health sciences university, I issue this One line per subject, column headings in the first plea: CHECK AND CLEAN YOUR DATA BEFORE row. If the analyst is planning a mixed-effects GIVING IT TO YOUR ANALYST! treatment of the data, repeated measures on each subject are typically best treated in a one- I have re-run hundreds of analyses because observation-per-row format, with a unique iden- the researcher failed to check his data before tifier for each subject repeated across rows (a giving it to me. The analysis is completed; the “long” format). However, some analyses (e.g., output is sent to the researcher; we meet to go repeated measures ANOVA) require that all in- over the results. “Whoops! Those should be “7’s,” formation, across all observations for a single not “6’s”. Or, “Those values aren’t possible for subject, be entered in one row: a “wide” format. that variable.” “Sorry, I should have checked my data more carefully. Would you mind re-running In a “long” dataset, one or more variables all of these analyses after fixing my mistakes?” must be included indicating how the multiple Ask your analyst to run a set of descriptive sta- rows for one subject differ from one another. If tistics on the dataset, including means, standard row 1 is for a baseline visit, row 2 is the first fol- deviations, frequencies, minima and maxima so low-up, row 3, end-of-trial, then a column must that the numbers can be reviewed before the be created to convey this information. It might actual analysis begins. be labeled “Visit.” This information, of course, must be included in the data map. And, as an aside, in spite of the fact that the popular press insists upon making “data” sin- Each cell in a spreadsheet can include only gular, as in “The data shows that ...” the word one piece of information. If the subject indicates “data” is not singular, but plural. The singular that he is White, African American and Hispan- form is “datum.” When communicating with a ic, this requires three columns in the spread- statistician, nothing will mark you as unsophisti- sheet. The statistical software, on import of the cated as readily as asking him or her “what the spreadsheet, will interpret a cell entry of “1 2 data shows.” Asking what the data “show” will 5” as text, rather than a series of numbers. If immediately convey that you are “adept” with a subject is asked to list the years in which he numbers, which will gain the statistician’s re- has had restorative dental work performed, and spect and admiration. he lists five years, this requires five columns in the spreadsheet. Worst are the “check all that In addition to a discussion about the fun- apply” formatted questions. A separate column damentals of data preparation such as those must be included for every possible response. above, advantages and disadvantages of using An endorsement of a category equals “1”; a databases rather than spreadsheets to capture non-endorsement should be coded as “0”. research data were explored. Database software offers the potential for more security than soft- Missing data should be explicitly coded as ware conventionally used for spreadsheets, and such; not with the word “missing,” but with a is highly customizable. It also requires consider- numeric value that could not possibly be valid ably more skill to navigate, especially during the for a given variable. As an example, “99” en- setup phase. In the case of complex datasets, tered as a value for a Likert-type variable scored with one to many relationships and/or highly 1 to 7 is an invalid entry, and must be flagged sensitive content, databases may be worth the as “missing” by the analyst. Once “99” is defined extra effort. as “missing,” the statistical software will ignore that particular observation in subsequent analy- The session included a discussion of internet- ses. Missing values should appear in the data based data collection systems, such as Survey- map so that the analyst can define them as such Monkey®, Qualtrics and REDCap™ (Research before beginning the analysis. Again, do not Electronic Data Capture), including the high- type “missing” into a column which is defined lights and lowlights of each. Finally, a quick as a numeric field. The data will be imported as overview of Microsoft® Excel (spreadsheet) text, rather than numeric, and will require con- SPSS (statistical software) and Microsoft® Ac- version before the analysis proceeds. cess (database) was provided, with a demonstration of how each may be used for research Having analyzed data for over 2000 projects data collection and analysis. during 12 years at an academic medical center, and another 10 years at a dental, medical and

58 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Abstracts: Poster Presentations Education Conclusions: Based on student comments daily grading makes them reluctant to ask questions which is a necessary part of learning. Find- Formative and Summative Clinical ing a balance between creating a safe environ- Assessment: The Student Perspective ment where students can learn and assessing competence to ensure graduates can provide Linda D. Boyd, RDH, RD, EdD; Kristeen R. quality care is challenging, but this small study Perry, RDH, MSDH suggests formative and summative assessment system may facilitate student learning. Problem Statement: Identifying clinical assessment models that ensure successful application of knowledge and competency is a challenge A Pilot Study to Determine Impact of for clinical educators. Current literature suggests Germ Simulation on Standard Precaution that clinical teaching methods place stress on Compliance in Dental Hygiene Students students which may impact student learning. Susan L. Tolle, BSDH, MS; Joyce M. Flores, Purpose: The purpose of this study was to RDH, MS; Leslie A. Mallory, BSDH, MS; explore dental hygiene students’ perspectives on Vivienne A. Parodi, RN, DSN the method of daily clinical grading versus formative feedback and summative (comprehensive Problem statement: Compliance with recom- patient case competency) assessment. mended infection control practices is essential to the safe practice of dentistry and often rooted in Methods: Based on the literature a BSDH the educational setting. program developed a method of formative and summative assessment for clinical curriculum. Purpose: The purpose of this pilot study was to A survey was developed to gather student per- determine if participation in a germ simulation ac- spectives on the change from daily clinical grad- tivity had an impact on standard precaution com- ing to formative/summative assessment. A con- pliance in first year dental hygiene students. venience sample of 48 dental hygiene students were surveyed through an online survey tool at Methods: This two-group, pretest-posttest de- the end of fall and spring semesters. sign study used a convenience sample of 29 dental hygiene students as subjects. After informed Results: The response rate was 100%. Re- consent was obtained, participants were random- sponses were as follows: I felt like formative ly divided into control (n=15) and experimental feedback allowed for more collaboration with (n=14) groups. A 10 item pretest/posttest ques- clinical faculty than the daily grading format, tionnaire was given to both groups to determine 98% agreed/strongly agreed. Formative feed- level of compliance with standard precautions pri- back encourages me to ask questions to en- or to the experimental intervention, immediately hance my learning, 98% agreed/strongly agreed. afterwards and 8 weeks later. Subjects only in the When asked about summative assessment, 98% experimental group provided dental hygiene ser- agreed/strongly agreed; Summative assessment vices in a treatment environment where simulated was an appropriate method to evaluate my abili- pathogens were placed in the oral cavity of a man- ties to provide evidence-based dental hygiene ikin. Following the activity, under black light condi- care. The main advantage cited: I feel like for- tions participants immediately viewed the spread mative feedback opened more doors for ques- of simulated pathogens. Before and after treat- tions, there was less pressure so it was easier ment photographs were also used for participants to ask faculty questions regarding patient care to further visualize changes in the treatment unit and to know what’s expected of you before be- due to pathogen contamination as simulated by ing graded. Overall 83% preferred the formative/ the polyethylene microspheres. summative assessment to daily grading.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 59 Results: Statistical analysis (ANOVA) of the 8 skill exams (83%) was perceived most effective week pre/posttest questionnaire scores revealed in assessing competency followed by daily clini- no significant differences (p=0.8207) in standard cal grading (63%). Thematic analysis of quali- precautions compliance in subjects who were ex- tative data revealed formative assessment with posed to the polyethylene microspheres simula- the inclusion of summative assessment rated the tion activity compared to subjects who were not highest (44%) as an effective method of evalua- exposed to the simulation activity. tion followed by summative assessment (16%). Thematic analysis noted respondents may have a Conclusions: Based on the results of this pi- preferred assessment method but feel a blended lot study exposure to a simulated germ activity approach of teaching should be utilized due to did not affect standard precaution practices in first student diversity and learning styles. year dental hygiene students. More research is needed involving a larger sample size over a lon- Conclusions: Findings from this exploratory ger period of time to determine the long term im- study show respondents are satisfied with - as pact of germ simulation with polyethylene micro- sessments that they are currently practicing but sphere on compliance with standard precautions. report a variety of methods are needed to evaluate competency. Further research is recommended with a larger sample and more detail on how An Analysis of Faculty Perceptions on programs define assessment methods used to Assessment Methods Utilized To assess competency and outcomes to determine Evaluate Student Competency in Dental what methods are more effective in the evalua- Hygiene tion of student competency.

Kristeen R. Perry, RDH, MSDH; Linda D. Boyd, RDH, RD, EdD; Debra November- A Survey of Clinical Faculty Calibration Rider, RDH, MSDH; Heather Brown, in Dental Hygiene Programs RDH, MPH Nichole L. Dicke, RDH, MS; Kathleen O. Problem Statement: Competency based Hodges, RDH, MS; Ellen J. Rogo, RDH, PhD; education (CBE) has become an integral part of Beverly J. Hewett, RN, PhD dental hygiene education with the adoption of the Commission on Dental Accreditation (CODA) Problem Statement: Clinical educators with standards in 1997. CODA standards are not varying backgrounds unite to develop competent meant to be prescriptive to aallow for flexibil- graduates. While the goal is unified, the teaching ity with methods of assessment. However, this methods might be conflicted. Calibration exer- makes it difficult to determine if methods used cises that are inadequate could contribute to fac- are effective in measuring student competency. ulty variance and interfere with student learning, performance, and satisfaction. There was a lack of Purpose: The purpose of this study was to research studying clinical dental hygiene faculty’s evaluate clinical dental hygiene faculty percep- perception of calibration. tions regarding assessment methods utilized in determining clinical competency. Purpose: This study investigated the calibration efforts of entry-level dental hygiene programs Methods: This study was a descriptive, cross in the United States. Four aspects were explored: sectional survey design. Survey instrument was faculty attitudes, satisfaction, and characteristics developed based on the literature and contained as well as quality. 31 questions related to the following areas: demographic characteristics, level of knowledge re- Methods: A descriptive comparative survey de- garding assessment methods and perceptions of sign was used. Directors of accredited dental hy- assessment methods. An email to all entry-level giene programs (n=345) were asked to forward an dental hygiene programs was sent to request dis- electronic survey invitation to clinical faculty. Eighty- semination and participation by program faculty. five directors invited 847 faculty, 45.3% (n=384) Data was gathered from a convenience sample of of who participated. The 17-item survey contained dental hygiene clinical faculty (n=181). multiple-choice and Likert scale questions and was open for three weeks. Descriptive statistics were Results: Results revealed use of OSCE (ob- used to analyze demographic data and research jective structured clinical evaluation)/practical questions. The Kruskal-Wallis, Spearman Correla-

60 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 tion Coefficient, and Mann-Whitney U tests were Community of Inquiry framework provided the employed to analyze hypotheses (p=0.05). basis for the self-designed, valid, and reliable Dis- tance Education Best Practices Survey instrument Results: The demographic profile for partici- that assessed participants’ practices and percep- pants revealed that most worked for institutions tions. Instrument validity was established by five awarding associate entry-level degrees, had 1–10 experts in the field of distance education. Seven years’ experience, taught clinically and didactical- online faculty members established test-retest ly, and held a master’s degree. Clinical educators reliability of the survey instrument within plus or value calibration, believe it reduces variation, want minus 1 of 97%. more calibration, and are not offered quality calibration. There was a difference between the entry- Results: Frequency of use ratings ranged from level degree awarded and the program’s evalua- 4.0 (regularly) to 5.0 (always) on a response tion of clinical skill faculty reliability, as analyzed scale ranging from 1.0 to 5.0. Results suggested using the Kruskal-Wallis test (p=0.008). Addition- a change in participants’ perception of the impor- ally, full-time versus part-time employees report- tance of some factors associated with three es- ed more observed student frustration with faculty sential educational constructs: (a) teaching pres- variance, as evaluated using the Mann-Whitney U ence, activities promoting lifelong learning (p = test (p=0.001, bfp=0.004). 0.03); (b) social presence, faculty communication fostering a SOC (p = 0.04), encouraging students’ Conclusions: Faculty members value calibra- self-introduction (p = 0.04); and (c) cognitive tion’s benefits and want enhanced calibration- ef presence, encouraging productive dialogue and forts. Calibration needs to be improved to include respecting diverse opinions (p = 0.04). standards for measuring intra- and inter-rater reliability and plans for resolving inconsistencies. More Conclusions: Findings indicate a potential im- research is needed to determine effective calibra- pact of faculty development programs designed to tion methods and their impact on student learning. enhance online teaching, community, and satisfaction, even for faculty with high self-ratings regarding best practices. Evaluation of future faculty A Faculty Development Program to development programs on the implementation Enhance Dental Hygiene Distance and impact of best practices is recommended. Education: A Pilot Study

Vicki J. Dodge, RDH, EP, MS; Denise M. Using Multiple Mini Interviews to Bowen, RDH, MS; Kristin H. Calley, RDH, Identify Noncongnitive Attributes MS; Teri Peterson, EdD For Dental Hygiene Admissions

Problem Statement: Increased use of DE Jacqueline J. Freudenthal, RDH, MHE in dental hygiene curricula necessitates faculty members’ awareness of pedagogy and methodol- Problem Statement: Traditional admissions ogies promoting dynamic communication, devel- interviews and selection criteria do not reliably oping learning communities, and increasing social identify non-cognitive attributes desirable for presence in online courses. health professionals. The Multiple Mini Interview (MMI) demonstrates the ability to identify non- Purpose: This pilot study was designed to as- cognitive characteristics in admissions process but sess current practices and perceptions of distance has not been assessed in dental hygiene. education (DE) dental hygiene faculty and evaluate the impact of a faculty development program Purpose: To determine if using MMI: 1) identi- to enhance best practices for teaching online den- fies desired non-cognitive attributes, 2) differenti- tal hygiene courses. ates between domains identified as important for professionals and 3) yields admissions informa- Methods: Following IRB exemption, a purpo- tion that cannot be obtained by traditional means. sive sample of distance education (DE) faculty (N=7) who taught online courses in DE bachelor’s Methods: From 2011-2014, after IRB exemp- degree completion and master’s degree programs tion, applicants (n=146) to a baccalaureate dental listed by the American Dental Hygienists’ Associa- hygiene program participated in MMI including 5 tion participated in a pretest, distance education individualized interviews with faculty. Every seven faculty development workshop, and posttest. The minutes, applicants moved between stations to

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 61 discuss short standardized scenarios, each de- per surveys. Data were entered into an electronic signed to address an individual domain identified database. Descriptive statistics were used to ana- as important: communication, critical thinking, lyze the data. Since students were surveyed, IRB ethics, honesty, and professionalism. The inter- approval was required and obtained through expe- viewers used a standardized scoring form with six dited review from the University of Bridgeport. items (clear perception or understanding of the problem, effective communication, critical think- Results: A 100% (N=41) response rate was ing skills, disambiguation in point of view, clear achieved. Prior to the workshop, many students and focused responses, and overall performance (27%) reported low confidence in identifying “read- described by a list of traits defined as profession- ily detectable” calculus, whereas post-workshop, alism) using a 5-point Likert scale to rate candi- those “very confident” increased by 10%. The con- dates. Points were averaged for each station and fidence level in completing the required paperwork summed by attribute across the stations. Inter- doubled post-workshop with most (80%) stating viewers had training and written instructions on they were moderately or very confident about pa- desired attributes and scoring. perwork requirements. The majority of students (70%) were not confident in patient choice but this Results: A nested model of generalizability number decreased by 12% post-workshop. In ad- was used to estimate variance component and in- dition, about 10% of student respondents reported teraction using a minimum norm quadratic unbi- that exam anxiety dropped post-workshop. The ased estimation (MINQUE). A G coefficient of 0.74 majority of the students (66%) thought the work- compared favorably with the reported range for shop helped them realize exam time limits; 63% MMI’s of 0.65-0.81. A Cronbach’s alpha of 0.58 did thought it helped them identify calculus; and 59% not measure desired attributes across all five do- thought it helped them improve calculus removal mains. No correlations were found between MMI skills. and traditional cognitive measures. Conclusions: Most students (80%) stated that Conclusions: Interviewers evaluated the can- they felt more confident in paperwork procedures didates on their responses to domain scenarios post-workshop. In addition, the workshop partici- rather than evaluating the desired attributes. At- pants perceived significant benefits in the areas of tention to all processes in the assessment of the time efficiency, deposit identification, and calculus attributes might improve reliability of the MMI in removal skills. Overall, 95% of students considered dental hygiene admissions. the workshop helpful.

Relevance of a Workshop to Prepare For A Comparison of Associate and Bachelor Dental Hygiene Clinical Boards Degree-Seeking Students on Self-Perceptions of Senior Dental Marie R. Paulis, RDH, MSDH Hygiene Students as Health Educators

Problem Statement: Inadequate preparation Deborah L. Dotson, RDH, PhD for clinical board exams may prevent dental hygiene students from becoming licensed. Problem Statement: Although all dental hygiene programs include a patient education compo- Purpose: The purpose of this study is to dem- nent, it is still unknown whether 4-year programs onstrate the success of a workshop day to prepare are more or less demanding as 2-year programs in dental hygiene students for their clinical board the development of skills relevant to patient educa- exam. tion beyond simple brushing and flossing instruction. Methods: This pre and post survey study utilized a convenience sample of 41 dental hygiene Purpose: The purpose of this cross-sectional students. The 8-hour workshop consisted of stu- study was to determine if dental hygiene students dents serving as the voice of a mock board patient attending a 4-year program of study are more like- and typodonts serving as teeth. The self-designed ly to perceive themselves as health educators than instruments used were a pre-workshop survey, with are students in a 2-year program. 13 closed-ended questions and a post-workshop survey, with 11 closed-ended questions. Anony- Methods: Attempts were made to electronically mous survey responses were collected through pa- contact all US accredited schools of dental hygiene.

62 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Two hundred eighty-six program directors were instrumentation of light deposits and biofilm successfully contacted and asked to fill out a ques- disruption, but it is unknown if dental hygiene tionnaire regarding health education in their cur- curriculum has kept pace and reflects current ricula, and to invite their students to participate in applications. the electronic student survey. Purpose: The aim of this ethically approved Results: Sixty-five programs (which was a re- study was to assess new dental hygiene gradu- sponse rate of 22.7%) and 307 students partici- ates’ perceptions of preparedness and use of pated (211 in associate programs and 96 bachelor ultrasonic instrumentation. degree students). This was an average student response rate of about 5 students per participating Methods: All recent Canadian dental hy- program. Eighty-four percent of each group said giene graduates were electronically surveyed their educational experiences have resulted in a about perceptions of preparedness and use positive shift in their views of the patient education with ultrasonic instruments. Descriptive and role of dental hygienists. However, only 45% of the inferential statistics including frequencies, pro- participating schools report requiring students to portions, means and cross-tabulations were show competence in patient education specific to calculated to examine relationships between tobacco users or diabetics. T-tests for independent curricular characteristics and perceived percep- samples (α=.05) showed no significant differences tion of preparedness and use of ultrasonic in- between the 2 and 4-year students on the variables strumentation. of self-perception, behavioral intentions toward patient education, volunteerism, and career expan- Results: Of the 1895 invited dental hygien- sion. There was a significant difference in the vari- ists, 485 agreed to participate, reflecting a able of behavioral intentions toward professional 26% response rate. Participants reported using leadership with 4-year students more likely to take ultrasonics about half of instrumentation time an active role in the professional organization (p= predominantly with magnetostrictive technol- 0.02). ogy (75%). Of these, approximately 75% of respondents report primarily using straight Conclusion: The vast majority of students par- inserts, demonstrating a lack of curve instru- ticipating in this study show positivity toward their ment use. Use focused on heavy deposits with role as patient educators. The expected difference straight, slim inserts, which indicated an in- in 2 and 4 year programs with regard to student correct use of the technology. Subjects were perceptions of their role as patient educators was generally satisfied with ultrasonic education not found. The only area where 2 and 4 year stu- feeling reasonably well prepared in using ul- dents differed significantly was in their intentions trasonics. Although not statistically significant, toward professional leadership. Results of this higher levels of perceived preparedness were study should encourage schools to require stu- associated with graduates from the 3-year di- dents to show competency in patient health edu- ploma program (p=0.69), whereas graduates cation skills for smokers and diabetics. These are from 18-month programs were associated with two of the most common issues affecting both oral greater levels of confidence (p=0.27). Confi- and systemic health and less than half of the par- dence with ultrasonics did not have an effect on ticipating schools report requiring students to show subsequent use—a large proportion (70%) of competence in these areas of patient education. In participants increased use once in practice. An order for dental hygienists to impact these two sig- earlier introduction (p=0.93) and more practice nificant areas of need, they must be better trained. time (p=0.93) in school were both associated with increased feelings of preparation and confidence. Dental Hygienists’ Perception of Preparation and Use for Ultrasonic Conclusions: New dental hygiene graduates Instrumentation perceive greater preparedness, confidence and use of ultrasonic instrumentation within a more Joanna Asadoorian, RDH, PhD; Dani Botbyl, traditional paradigm. In addition, the results in- RDH; Marilyn J. Goulding, RDH, MOS dicate potentially incorrect and/or inappropri- ate application of current technology. Problem Statement: Ultrasonic scaling technology has evolved dramatically providing Funding for this project was provided by greater clinical utility subgingivally including Dentsply Canada Ltd.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 63 Teaching Dental Hygiene Students to The Effects of a Legislative Advocacy Utilize the Logic Model for Community Project on Dental Hygiene Students’ Outreach Programs Knowledge, Values, and Actions

Karen M. Portillo, RDH, MS; Ellen Rogo, Leciel K. Bono, RDH-ER, BS; Ellen J. Rogo, RDH, PhD RDH, PhD; Kathleen Hodges, RDH, MS; Teri Peterson, EdD Purpose/Goals: A new program was implemented during the 2011-2012 academic year Problem Statement: Advocacy is vital to popu- for the purpose of educating dental hygiene stu- lation oral health and professional growth. Linking dents to plan, implement, and evaluate commu- leadership theory to practice as students participate nity oral health programs using a Logic Model. in the legislative process is important in extending their knowledge of being change agents and becom- Significance: An essential role of the dental ing oral health advocates. hygienist is to address community oral health needs to improve population health. Purpose: The intent of this investigation was to assess the self-reported levels of knowledge, val- Approach/Key Features: In the fall semes- ues, and actions of undergraduate and graduate ter, students selected groups of 2-4 and then students who participated in a legislative advocacy identified an organization benefitting from an educational unit (LAEU). oral health program. Next, the group conducted a needs assessment to determine the type Methods: A pretest/posttest design was em- of program the target population required. A ployed with a convenience sample of 27 undergrad- literature review on the target population was uate and 13 graduate students. A questionnaire was completed by each group to ensure students un- administered before and after the completion of the derstood the dynamics of the population. After- LAEU – IRB approval #3594 and was administered ward, the students began planning the program using an online survey tool. Validity and reliability using a Logic Model outlining the inputs, outputs, of the questionnaire was previously established. The outcomes which included goals and objectives data collection instrument assessed three subscales aligned with Healthy People 2020, assumptions (knowledge, values, and actions) and barriers to fu- and external factors. In the spring semester, the ture advocacy actions using a 7-point Likert scale. groups implemented the community outreach Assumptions of normality and homoscedasticity programs, evaluated the outcomes to determine were tested before employing the RM-ANOVA to if the goals and objectives were met, and wrote compare average scale responses. the analysis/evaluation using the Logic Model in a final report. Results: Both undergraduate and graduate students demonstrated a significant increase in knowl- Evaluation: On the Logic Model assignments edge, values, and actions (p<0.001) from the pre- during the fall semester, students earned an av- test to the posttest. Bonferroni corrected p-values erage of 92.9% (n=26) in 2011; 93.9% (n=26) verified knowledge, values and undergraduate- ac in 2012; and 92.9% (n=27) in 2013. On the tions were statistically significant; however, actions Logic Model final report assignment during the at the graduate level were not significant. Actions spring semester, students earned an average of were rated lower than the other two subscales. 89.1% (n=26) in 2012; 95.0% (n=26) in 2013; Cronbach’s alphas revealed internal consistency of and 87.6% (n=27) in 2014. From a community the subscales ≥ 0.80. The top four barriers for both impact perspective, students’ programs pro- MS and BS students were lack of time to be involved, vided outreach to 245 children and 43 adults in lack of comfort speaking to legislators or staff, lack 2012; 246 children and 60 adults in 2013, and of comfort testifying before legislators, and lack of 254 children and 138 adults in 2014. For three priority to be involved in legislative advocacy. years, students were successful in learning to utilize the Logic Model to address community Conclusions: Implementation of a LAEU with BS oral health needs. The Logic Model was a useful and MS students can positively influence the devel- framework for program planning, implementa- opment of knowledge, values, and actions; however, tion, and evaluation. mentorship in the professional association is needed after graduation to continue the development of future leaders.

64 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Dental Hygiene Undergraduate Student Local Anesthesia Training Model Improves Specialty Practicum Clinic: Medical and Confidence and Reduces Anxiety in Students Dental Complexity of Clients Anjum Shah, BSDH, RDH, MS; Tammy K. Lindsay Marshall, RDH; Rachel Haberstock; Swecker, BSDH, RDH, Med; Joan M. Sharon Compton; Minn Yoon Pellegrini, RDH, MS, PhD; Al M. Best, PhD

Problem statement: As the population ages Problem Statement: Administering the first and many older adults retain their teeth, there local anesthesia injection is difficult and induces is an increasing need to better incorporate their anxiety in dental hygiene students. There is no re- complex medical and dental conditions into the search on the benefit of using a preclinical model dental hygiene care plan. (eg. Frasaco AG-3 IB), to enhance the transition from learning to practice of local anesthesia deliv- Purpose: The aim of this project was to de- ery. termine the complexity of the medical and dental status of clients that attended a rehabilitation Purpose: The aim of this study was to evalu- hospital based dental clinic as part of an under- ate whether practicing on a local anesthesia train- graduate dental hygiene program. ing model prior to the students’ initial injection on humans reduces anxiety and increases their confi- Methods: The retrospective medical and den- dence. tal histories of clients that attended a hospital- based dental clinic between September 2011 and Methods: Following IRB approval, 29 senior April 2013 were reviewed by two independent dental hygiene students were randomly assigned research assistants. Information about demo- to a control (n=14) and experimental (n=15) graphics, existing medical conditions, medica- group. Both groups received the same didactic and tions and oral health conditions were recorded. cognitive concepts and technical skills necessary to Ten files were randomly chosen and audited to administer local anesthesia. A pre-questionnaire ensure calibrated data entry. was completed by all students. Participants in the control group took only classroom knowledge to Results: Data from 164 client charts were en- the clinic. Students in the experimental group prac- tered into an electronic database. Clients had an ticed on the training model for four one-hour ses- average age of 66.5 years, with 61% (95/164) sions. Both groups administered local anesthesia over the age of 65. Of these clients, 45% had during one 1½ hour clinical session to anesthetize experienced a major medical event while 12% the greater palatine, inferior alveolar and mental suffered from dementia. 16% of clients required nerves of a student partner. All students completed ambulatory support and close to 100% took a post-questionnaire. multiple medications. Dental chart examination showed that 20% of clients had all twelve ante- Results: Univariate and multiple regression rior teeth while 7% had at least sixteen posterior analysis revealed statistically significant differenc- teeth and 22% of clients were edentulous. Re- es in operator confidence and anxiety levels be- view of the dental charts showed that 32% of cli- tween experimental and control groups. Students ents seen had moderate to severe gingivitis while in experimental group reported more confidence 22 % had moderate to severe periodontitis. (p<0.001) and significantly less anxiety (p<0.001) when compared to the control group. Experimental Conclusions: Review of the records of these group also reported fewer visible signs of anxiety clients illustrates that this population has exten- (heart pounding, sweating, hands trembling) and sive medical and dental issues that can greatly needed less faculty guidance (p<0.001). influence dental hygiene treatment. A more thorough understanding of the complexity of these Conclusions: In this study, practice on local an- issues will allow the dental hygienist to better esthesia training model prior to students’ live pa- incorporate client conditions into the dental hy- tient experience reduces anxiety, increases confi- giene care plan, resulting in more comprehensive dence levels and makes students less dependent care. on faculty assistance. This study suggests that preclinical models may have an important role to play Research funding for the project provided by in training dental hygiene students. A larger study School of Dentistry, University of Alberta. is required to validate the results.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 65 An Integrated Approach in Teaching Enhanced Learning during the Dental Microbiology to Dental Hygiene Students Hygiene Process of Care

Laura Mueller-Joseph, RDH, EdD; Robert Cynthia Howard, RDH, MS; Andrea Beal, Elgart, PhD RDH, MS; Shirley Birenz, RDH, MS; Cheryl Westphal Theile, RDH, EdD; Robert Davidson, DDS, PhD Purpose: The purpose of this program was to evaluate the effectiveness of a redesigned microbiology laboratory course targeted for dental Purpose/Goals: To revise a dental hygiene hygiene students with laboratory exercises fo- care plan form for dental hygiene students cused on clinical applications. whose clinical program is integrated into the curriculum of a large dental school. In this set- Significance: Student centered learning in ting, a comprehensive clinical examination is foundational science courses requires innova- completed by a dental student prior to the first tions to connect concepts, engage students and dental hygiene appointment. solidify intellectual understanding. Significance: The new form includes both a Approach: A foundational course in microbi- template and a “guidebook” that: 1) Orients the ology was redesigned to include 28 laboratory dental hygiene student through the sequence exercises utilizing microbes encountered in the of dental hygiene care, and 2) Fosters compe- dental hygiene clinic. The microbes were either tency in clinical assessment without making the confined to the oral cavity or to the clinical en- clinical encounter a passive and repetitive ex- vironment thereby enhancing the relevancy of ercise for the patient. the exercises to the discipline of dental hygiene. Each exercise was divided into six units, with a Approach/Key Features: The revised form report due at the conclusion of each exercise. was fully implemented in 2013. Multiple evi- The key feature of the program was to utilize dence-based thinking skills are fostered by its discipline related concepts to enhance the stu- design. Knowledge schema organization and dents understanding and appreciation of the slot features organize the process of care, cou- subject matter. All of the basic laboratory prin- pled with watermarked cues that refer directly ciples of microbiology were covered in the rede- to evidence-based resources. signed course. Evaluation: We compared the new form to Evaluation: Evaluation of the program includ- that used in academic year 2011-2012. The ed a student opinion survey that addressed their most significant finding was its effect -on stu level of engagement and appreciation of micro- dents’ analytical, i.e., predictive, skills regard- biology to the profession of dental hygiene. Stu- ing patient care. Using the new form, the me- dents from previous microbiology lab sections dian number of “Expected [Clinical] Outcomes” taught by the same instructor were also sur- increased from a single outcome to three ex- veyed. Results revealed that (80%) of students pected results of therapy (Mann-Whitney U in the redesigned course felt very engaged/ Test; N=50; W=1599; p < 0.001). Our results engaged as compared to (50%) of students in show that the revised dental hygiene care plan other course sections. Additionally, 90% of the form represents an improved instrument for students in the redesigned course felt their lab dental hygiene students to gain competency in skills greatly improved/improved as compared clinical assessment. Dental hygiene students to 30% of students in the other course sections. were able to incorporate the completed dental Of the students in the redesigned course who student’s treatment plan into one from a dental conducted a critique of the lab exercises, 74.3% hygiene perspective, and identify an increased found the laboratory exercises related well to number of meaningful clinical outcomes. the discipline of dental hygiene. Average end of course grades revealed (85%) for students in the redesigned course as compared to 83% for students in other course sections.

Funding was provided by Title III Student First Grant.

66 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Online Course Evaluations: Program Conclusions: As institutions of higher educa- Directors’ and Students’ Knowledge, tion continue to develop online distance educa- Beliefs, and Practices of Online Course tion in dental hygiene, it is important to deter- Evaluations From 100% Online Dental mine what factors motivate students to respond Hygiene Education to online course evaluations and for faculty to educate students about the purpose of course JoAnn M. Marshall, CDA, RDH, MSDH evaluations in order for them to fully understand the importance of their participation in the course evaluation process. Problem Statement: Dental hygiene students from 100% online dental hygiene pro- Basic Science grams have the convenience of completing course evaluations online, but most do not. It was the intent of this study to investigate reasons/methods to initiate change in student re- Comparative Anti-Gingivitis Efficacy of sponse rates to online course evaluations. Oscillation-Rotation Electric Toothbrush versus A Manual Toothbrush Purpose: This study sought to determine: If a relationship between program directors’ Andrea Johnson, RDH, BS; Malgorzata A. knowledge and beliefs and students’ knowledge, Klukowska, DDS, PhD; Neresh C. Sharma, beliefs, and practices of online course evalua- DDS, MS; Julie M. Grender, PhD; Erin Conde, tions influence students’ response rates. BS; Pam Cunningham, BA; Jimmy G. Qaqish, BA Methods: Two confidential electronic -sur veys with open and close-ended questions were Problem Statement: Plaque control is essen- sent to thirty-four program directors from 100% tial for preventing gingivitis. A new brushhead de- online BSDH degree completion programs and sign was developed to increase the potential for 100% online MSDH degree programs via e-mail. better plaque control and ultimately decreasing The survey instrument developed for the pro- the risk of developing gingivitis. gram directors contained 25 items and the student survey instrument contained 24 items. The Purpose: To evaluate an oscillating-rotating instruments were pilot-tested with online stu- (OR) power brush with a novel brushhead utiliz- dents and faculty to establish content validity. ing angled bristle tufts to a manual brush for the The survey information was obtained through reduction of gingivitis. the use of an online survey website. Participa- tion was voluntary and confidential. Descriptive Methods: This study was a 4-week, random- statistics were used to analyze the data. IRB ized, examiner-blind, 2-treatment, parallel group approval was obtained from the University of study design. One hundred subjects with mild to Bridgeport. moderate gingivitis were enrolled and instructed to brush twice daily at home for 4 weeks with Results: The data revealed that the major- their assigned toothbrush and marketed denti- ity of program directors (78%) believe that stu- frice. Gingivitis measurements were evaluated at dents do not know how the course evaluations Baseline and 4 Weeks using the Modified Gingival are used by the institution. The program direc- Index (MGI) and Gingival Bleeding Index (GBI). tors suggested impressing upon the students the Data was analyzed using the Analysis of Covari- importance of the course evaluation process, a ance with Baseline as the covariate. mid-term evaluation, and making the course evaluations mandatory. The data collected from Results: The average baseline whole mouth the students revealed that few students (17%) MGI score was 2.060 for the OR and 2.048 for the believe their feedback is used to improve course manual group (p=0.303). The average BL number content. The student respondents expressed of bleeding sites was 14.6 for the OR and 14.8 that the course evaluation instrument is not al- for the manual group (p=0.676). At Week 4 the ways applicable to the particular class. Student OR power brush group showed a 15.2% reduc- respondents suggested that incentives would tion in gingivitis, and 70.7% in number of bleeding not increase their response rate. Additionally, sites, differing significantly (p<0.001) from base- students are concerned with anonymity. line. The manual group had a 6.8% reduction in gingivitis and 46.3% in number of bleeding sites,

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 67 differing significantly (p<0.001) from baseline. Results: AI users had significantly deeper PD Between-group comparisons showed that the OR and CAL as compared to those not on AIs at brush with novel brushhead was significantly bet- the18 month study visit. A linear mixed model ter for reduction of gingivitis (123.7%, p<0.001) was constructed to investigate bone height as and reduction of bleeding sites (51.5%, p<0.001) a function of time, AI, calcium, vitamin D and at week 4 vs the manual toothbrush. bisphosphonate status, along with an interaction between AI and calcium status. A significant ef- Conclusions: The oscillation-rotation power fect of time was found along with a significant brush with the novel brushhead provided signifi- AI status by calcium use interaction. Those on cant improvements in gingivitis as compared to a AI and calcium had a significantly lower bone manual toothbrush. height value (Mean=2.509, SE=.137) than those not on calcium (Mean=3.325, SE=.231) Funding for this project was provided by Procter (p=0.005). & Gamble. Conclusions: AI therapy has an impact on the oral health of postmenopausal women. Data Effects of Aromatase Inhibitors on suggests a positive relationship between alveo- Alveolar Bone Loss among lar bone loss and the use of calcium supplemen- Postmenopausal Women with Breast tation among postmenopausal women. Cancer Funding for this project was provided by the Iwonka T. Eagle, RDH, BSDH; Erika Michigan Institute for Clinical Health Research/ Benavides, DDS, MS; Robert M. Eber, DDS, CTSA pilot grant UL1RR024986, and the Nation- MS; Marita R. Inglehart, PhD; Catherine H. al Institute of Dental & Craniofacial Research Van Poznak, MD; L. Susan Taichman, RDH, (NIDCR) grant 1K23DEO21779. MPH, PhD

Gingival Abrasion and Recession in Problem Statement: Aromatase inhibitors Manual and Power Brush Users (AIs) are the standard of treatment for women with estrogen receptor positive breast cancer B. Jordan, RDH, MS, NAM; Rosema, J. due to their ability to lower the risk of tumor Grender, PhD; E. Van Der Sluijs; S.C. recurrence. AI use results in estrogen depletion Supranoto, G.A.; Van Der Weijden increasing the risk of osteoporosis and low skel- etal BMD and may impact the alveolar bone. Problem Statement: An investigation to Purpose: The purpose of this investigation evaluate if the use of manual and power brushes was to determine the impact of AI use on alveo- result in gingival recession and/or abrasion. lar bone loss through the use of clinical parameters, salivary bone biomarkers, and the supple- Purpose: To assess the presence of gingival mental use of bisphosphonates, vitamin D, and recession in manual and power toothbrush us- calcium in postmenopausal women on AIs. ers and to evaluate the relationship between the incidence of gingival abrasion and gingival re- Methods: An 18 month prospective exami- cession. Secondary outcomes were the level of nation of periodontal health in postmenopausal gingival inflammation, plaque scores and brush- women (29 receiving AI therapy; 29 controls) ing duration. was conducted between August 2009 and Sep- tember 2013 at University of Michigan. Peri- Methods: This was a single center, examiner- odontal examinations including clinical attach- blind, cross-sectional study consisting of a single ment loss (CAL), periodontal probing depths visit including 181 subjects, 90 manual (MTB) (PD), and bleeding on probing were conducted. and 91 power brush (PTB) users. Baseline as- Linear measurements between the CEJ/restora- sessments included gingival recession (GR) and tion margin, and the alveolar crest of first mo- abrasion (GAS) as primary parameters and lev- lars were taken on baseline, 12, and 18 month el of gingivitis (BOMP) and pocket depth (PPD) radiographs. Bisphosphonate, vitamin D and were evaluated as periodontal parameters. Sub- calcium supplementation was collected via chart jects brushed with their own toothbrush as they review. The UM IRB approved this study. would at home. Plaque (TMQHPI) and brushing

68 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 time were assessed. A non-parametric ANCOVA were required to use the dentifrice daily under was used for analysis of post-brushing group routine conditions at home. In each study, safety changes in GAS and an ANCOVA was used to was assessed via clinical examination or volun- compare brushes for TMQHPI reductions with tary subject report. Data from the 2,664 subjects baseline as the covariate. Two-sample t-test was was then analyzed and adverse events (AE) were used to analyze BOMP, PPD and GR. summarized both by subject and event occurrence and assessed for severity and causality. Results: Whole mouth mean scores for GR were 0.10mm in the MTB and 0.08mm in the Results: The population exhibited consider- PTB group. Full mouth pre-brushing mean GAS able diversity in demographics, behaviors and scores were 11.5 for the MTB group and 10.6 oral health. Of the 2664 subjects assigned the for the PTB group (p=0.389). There was no cor- SnF2 SHMP dentifrice, 50 subjects (1.9% of the relation between GR and GAS for MTB and PTB. population) experienced an AE, with a 95% con- Overall GAS for PTB showed less incremental fidence interval of (1.4%, 2.5%). Desquamation change following a single brushing exercise than was the most frequent AE identified in 17 - sub PTB (p=0.004). The PTB group removed signifi- jects (0.6% of the population), with a 95% con- cantly more plaque (p<0.001) and brushed sig- fidence interval of (0.4%, 1.0%). Desquamation nificantly longer (p=0.008) than MTB users. was mild in severity, and contributed minimally to dropout (0.08% of the population). Other find- Conclusions: In this adult population little ings were less common, and overall, only 8 subgingival recession was observed in either the jects discontinued use due to a treatment related manual or power toothbrush user group. Both AE. groups had comparable levels of GR and GAS. GAS scores were not explanatory for the ob- Conclusions: This inclusive meta-analysis served recession. demonstrated that a 0.454% stannous fluoride dentifrice with sodium hexametaphosphate was generally well-tolerated over periods of up to 2 Meta-Analysis of Oral Safety Data For years daily use, with mild transient desquamation 0.454% Stannous Fluoride Sodium (<1%) representing the most common finding. Hexametaphosphate Dentifrice Funding for this project was provided by Proct- Rebecca VanHorn, RDH, BA; Tao He, DMD, er & Gamble. PhD; Matthew L. Barker, PhD; Melanie C. Miner, BS; Ghebre Tzeghai, PhD; Robert W. Access to Care Gerlach, DDS, MPH

Dental Hygienist Attitudes Concerning Problem Statement: Anedoctal reports of Willingness to Volunteer Care for the desquamation after using a 0.454% stannous Underserved Population fluoride (SnF2) dentifrice with sodium hexametaphosphate (SHMP) have been documented. Con- Lynn A. Marsh, RDH, EdD sequently, steps were taken to objectively review the safety data collected from clinical trials in- vestigating the dentifrice where normal, healthy Problem Statement: In pursuit of healthi- subjects brushed daily with the dentifrice to de- er communities, disparities in oral health care termine the prevalence of this condition. should be recognized and local resources for oral health services should be more readily available Purpose: To evaluate the safety of a 0.454% for the underserved population. SnF2 SHMP dentifrice by conducting a meta-analysis of data from clinical trials. Purpose: The purpose of this study was to investigate registered dental hygienist attitudes Methods: Forty-one randomized clinical stud- concerning community service, sensitivity to pa- ies involving 2664 subjects assigned to the tient needs, job satisfaction and their frequency 0.454% stabilized SnF2 SHMP dentifrice leg of to volunteer care for the underserved popula- each study were included in the meta-analysis. tion. The studies ranged from 2 weeks to 2 years in length depending on the study design. Subjects Methods: The survey instrument was cre-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 69 ated to measure the registered dental hygienist sional initiative with a goal of addressing the attitudes related to community service, spiritu- National HIV/AIDS Strategy by normalizing and ality, volunteerism, job satisfaction, sensitivity integrating HIV into health professionals’ future to patient needs and social responsibility and clinical practices. Dental Hygiene students par- their willingness to volunteer care for the under- ticipate in this program with peers through a served population. There were 306 surveys dis- multidisciplinary didactic and hands-on curricu- tributed to registered dental hygienists on Long lum. In this hands on and didactic curriculum, Island for completion. All items on the survey in- students from these disciplines are introduced strument were subjected to a factor analysis in to the HIV epidemic and their role in address- SPSS version 19.0 to acquire distinct variables ing this issue collaboratively and interprofes- which were reduced to three variables, includ- sionally. ing job satisfaction, attitude toward community service and sensitivity to patient needs. This re- Approach/Key Features: The curriculum search study was conducted with IRB approval. emphasizes the dental hygienist’s role as a primary care provider. Students were didactically Results: This research study indicated that and practically trained how to conduct rapid registered dental hygienists tend to be satis- oral HIV testing. Through case scenarios pre- fied with their job position, held slightly posi- sented by the PTF mentor, students developed tive attitudes toward community service and skills in communicating and educating patients had a strong positive sense of sensitivity to pa- based on their test results. During the fall se- tient needs. Registered dental hygienists who mester 2013, dental hygiene students tested are members of the American Dental Hygien- 142 patients in the screening and urgent care ists’ Association were more likely to hold posi- clinics of the School of Dentistry. Testing pro- tive attitudes toward community service activi- vided awareness to individuals of their HIV ties than non-members. In addition, registered status. Patients testing positive were linked to dental hygienists with higher levels of education care via the PTF mentor. had more positive attitudes toward community service. They did not differ in their level of job Evaluation: Dental hygiene students com- satisfaction. pleted a pre and posttest assessing their knowledge and attitudes toward HIV. Overall scores Conclusions: Understanding what influences increased in both categories. The students’ rat- registered dental hygienists to volunteer care ing of 1) ability to have an informed conversa- for the underserved population provides valu- tion with my patients about HIV; 2) ability to able information to dental hygiene programs discuss HIV in a culturally competent manner and the importance of attitudes toward commu- with patients; 3) comfort offering HIV testing to nity service, sensitivity to patient needs and job all patient rose by 75%, 48% and 25% respec- satisfaction. It is vitally important that dental tively. All students (100%) issued high ratings hygienists volunteer preventive and emergent for their experience in the PTF program as very care to the underserved population. good (63.6%) and good (36.4%) respectively. Interprofessional education creates an environment conducive to collaborative practice. Dental Hygiene Students and Students also learn and value how members of Interprofessional Education in HIV, other disciplines contribute to creating a stron- Involvement in the Institute of Humary ger team when care is provided. Other health Virology’s Jacques Initiative (JI) care providers gain insight into oral health care concerns which may not have been discussed Marion C. Manski, RDH, MS; Sheryl E. in their curriculums prior to this innovative ex- Syme, RDH, MS; Jacquelyn L. Fried, RDH, perience. This integrated learning experience MS; Alexandra Reitz, BS; Valli Meeks, DDS, provides student certification in salivary -test MS, RDH; Sharon L. Varlotta, RDH, MS ing. Students are able to address HIV across the continuity of care spectrum. Purpose/Goals: One in 40 persons thirteen and older living in Baltimore City has been di- Funding provided thru the JACQUES Initia- agnosed with HIV. tive for testing kits and the University of Mary- land School of Dentistry. Significance: Preparing the Future (PTF) though the Jacques Initiative is an interprofes-

70 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 The Association between Early Childhood sionals from underrepresented backgrounds are Caries (ECC), Feeding Practices, and an also more likely to provide care to underserved Established Dental Home communities and to conduct health disparities research. Unfortunately, there is a lack of racial and Erin A. Kierce, RDH BA; Linda Boyd, RDH, RD, ethnic diversity in the oral health workforce. EdD; Lori Rainchuso, RDH MS; Carole A. Palmer, EdD, RD, LDN; Andrew Rothman, MS, EIT Purpose: The purpose of this poster is to compare ethnic backgrounds of the current U.S. popu- Problem Statement: ECC is a significant pub- lation to dental hygiene students in the U.S and lic health concern disproportionately affecting low- those specifically at New York University College income children. Consistent preventive dental ser- of Dentistry (NYUCD). vices are critical for Medicaid-enrolled children to reduce their risk of developing caries. Methods: Distribution of population by ethnicity was compared using the 2010 U.S Census and Purpose: The purpose of this study was to de- the 2010-2011 ADA Allied Dental Education Sur- termine the association between the prevalence vey results. of ECC and the nutritional intake of a low-income child, with an established dental home. This study Results: According to the survey, there was also compared ECC among two groups of children, obvious disparity in the representation of minori- one without an established dental home and one ties in the future of the dental hygiene profession with an established dental home. compared to the U.S population (over 75% of enrolled students in all dental hygiene programs Methods: A cross-sectional survey was con- were White). However, the NYUCD dental hygiene ducted among 132 Medicaid-enrolled children be- program demonstrated a more accurate reflec- tween 2 and 5 years of age with and without a tion in all groups. Minorities comprised almost half dental home to compare feeding practices, paren- (46%) of this program’s dental hygiene student tal knowledge of caries risk factors, and oral health population and Hispanic students (14.8%) and status. were almost a mirror image to the U.S. census. Black/African American students were still some- Results: Children with a dental home had lower what underrepresented in the program (7.4% rates of plaque (P<0.05), gingivitis (P<0.05), and compared to the U.S. population (12%) where- mean dmft score (P<0.05). Children without a den- as Native Hawaiian and other Pacific Islanders tal home consumed more soda (P<0.05) and juice (14.8%) were almost fifty times the Nation’s dis- (P<0.05) daily, and ate more sticky fruit snacks tribution (0.2%). (P<0.05) than children with a dental home. Conclusions: Efforts to enroll more minority Conclusions: The results suggest that the es- dental hygiene students across the country may tablishment of a dental home, especially among result in a more equitable geographic distribution high-risk, low-income populations, decreases the of dental hygiene health care providers and ulti- prevalence of ECC and reduces the practice of car- mately address one aspect of the access to care iogenic feeding behaviors. problem.

Snapshot of Dental Hygiene Diversity Geographic Comparisons of Washington Trends State Non-Traumatic Dental Complaint Emergency Department Patients Andrea L. Beall, RDH, MA; Rosemary D. Hays, RDH,MS; Lisa B. Stefanou, RDH, Jacqueline A. Juhl, RDH, MSDH Candidate; MPH; Cheryl M.Westphal Theile, RDH, EdD Ellen J. Rogo, PhD; JoAnn Gurenlian, RDH, PhD

Problem Statement: As the U.S. becomes Problem Statement: The treatment costs more ethnically diverse, there is need for health- for Non-Traumatic-Dental-Complaint [NTDC] pa- care providers that can reflect and respond to an tients to Emergency Departments [EDs] has been increasingly heterogeneous population. Workforce reported as skyrocketing and ineffective. Local, diversity has been associated with greater patient state, and federal agencies struggle seeking cost- satisfaction with care and improved patient-pro- effective options while providing clinically effec- vider communication. In addition, health profes- tive quality of care for NTDC treatment.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 71 Purpose: This study investigated rural-to- in males and females are of interest to dental urban and an urban Washington State hospital hygienists. Emergency Department [EDs] utilization from March, 2012 to March, 2013 to determine the Purpose: To identify gender differences in demographic profiles, institutional administrative masticatory difficulty in elderly Koreans. experiences, and clinical experiences of 1380 Non-Traumatic Dental Complaint [NTDC] pa- Methods: This study used data obtained dur- tients. ing the 2011 Community Health Survey (CHS) of Korea. Data from 56,624 subjects aged over Methods: After receiving IRB approval, (HSC 65 years old who participated in the CHS were #4005), data were electronically extracted from included in this study. Power analysis suggested de-identified patient records and analyzed using that this was representative of 5,639,218 per- a one-way t-test, Mann-Whitney U test, Pearson sons. Of those persons, 2,368,200 (42.0%) Chi-square analysis, and Fisher’s Exact test with were males and 3,271,018 (58.0%) were fe- a 0.05 alpha level. males. Masticatory dysfunction was the dependent variable and independent variables were Results: Results indicated males (RTU=52.8%, divided into regional factors (regional urban- URB=63.1%) utilized EDs more than female ization), demographic factors (age, education, (RTU=47.2%, URB=36.9%) in both sample pop- monthly household income, qualification of basic ulations. Significant differences were found in livelihood recipient, private insurance, economic demographic patient profiles (p<0.001). In the activity, living together), chronic disease factors rural sample population, more patients were <10 (medical history of hypertension, diabetes), and years of age (RTU=8.1%, URB=0.7%), and >70 oral health factors (number of teeth, denture years of age (RTU=3.0%, URB=1.0%) presented status, subjective gingival health). The SPSS to the ED than in the urban sample population. 20.0 program was used for statistical analysis, Differences between geographic site provid- and T-test, ANOVA and multiple logistic regres- ers were found in utilization of ICD-9 diagnostic sion were performed. To identify the factors that codes (p<0.001). Differences were observed in affected masticatory dysfunction, multiple logis- the kinds of ICD-9 codes used between both in- tic regression analysis was performed with de- stitutions and between provider types at the URB mographic factors set as control factors. site. No significant differences were found for the institutional administrative experiences due to Results: Prevalence of masticatory dysfunc- provided data inconsistencies. tion was higher in elderly females than in elderly males (50.2% and 42.6%, respectively (p<0.05). Conclusions: Variances existed between The number of teeth (males: aOR=2.01, fe- URB and RTU institutions in several aspects of males: aOR=1.68) and subjective gingival health NTDC ED patient experiences which could impact (males: aOR=7.60, females: aOR=7.31) had a policy development, federal funding, and future higher influence on masticatory dysfunction in research. This investigation identified provider males than in females (p<0.05). Hypertension variance of ICD-9 codes in diagnoses of NTDC (females: aOR=0.97, males: aOR=0.96), dia- patients between URB and RTU providers and betes (females: aOR=1.07, males: aOR=1.05), between provider types within EDs which might and type of denture (females: aOR=1.75, adversely affect patient outcomes. males: aOR=1.57) exerted higher influence on masticatory dysfunction in females than males (p<0.05). Gender Differences in Masticatory Difficulty in Elderly Koreans Conclusions: Masticatory dysfunction in the elderly is mainly influenced by gender, custom- Yeun-Ju Kim, RDH, BA; Won-Gyun Chung, ized management and education. Considering DDS, PhD; Yang- Hee An, RN, HCNS, PhD; each influencing factor is required when- plan Chun-Bae Kim, MD, MPH, PhD; Nam-Hee ning dental hygiene interventions. Kim, RDH, MPH, PhD This study was performed with financial sup- Problem Statement: Masticatory difficulty is port of the 2013 Community Health Survey Re- a common oral problem in aging people, affect- search Fund of Korea Centers for Disease Con- ing 50% of elderly Koreans. Thus, factors influ- trol and Prevention. encing the occurrence of masticatory difficulty

72 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Attitudes, Behaviors, and Needs of Conclusions: The majority of team dentists do Team Dentists perform oral screenings; however, lack of awareness about oral health supports the need for edu- Lesley A. McGovern, RDH, BS, MS(c); Ann cational strategies for athletes, coaches, owners, E. Spolarich, RDH, PhD schools and leagues. Clinical Dental Hygiene Practice Problem Statement: Elite athletes strive to attain superior levels of health and fitness; however, many have high levels of oral disease. Oral Views of Dental Providers on Primary health may not directly affect physical ability to Care Coordination perform athletically; however, dental pain and dysfunction could alter level of performance dur- Shirley Birenz, RDH, MS; Mary E. Northridge, ing practice and competition. Oral screenings de- PhD, MPH; Danni Gomes, RDH, BS; Cynthia tect disease and need for treatment, and identify Golembeski, MPH; Ariel Port, DMD; Janet opportunities for preventive interventions. Many Mark, MA; Donna Shelley, MD, MPH; Stefanie dentists volunteer their time with sports organiza- L. Russell, DDS, MPH tions, but knowledge about their scope of practice and needs are unknown. Problem Statement: Dental hygienists are Purpose: The purpose of this study was two- well-positioned to screen for diabetes and hyper- fold. First, to gather baseline data to learn about tension and provide tobacco cessation and nutri- practice behaviors, attitudes, and needs of team tion counseling at the dental hygiene treatment dentists. Second, to identify if/ how often oral visit, notwithstanding such challenges as limited screenings are conducted on athletes, differences time and access to evidence-based resources. in screening practices across leagues, and barriers to implementing regular oral screening programs. Purpose: To assess dental hygienists’ and dentists’ perspectives and experiences regarding Methods: An online survey using 37 supplied current scope of practice and the integration of response questions was developed and pilot-test- primary care activities with routine dental care; ed for face and content validity. All dentist mem- and to assess the needs of hygienists and the of- bers of the Academy for Sports Dentistry were in- fice environment around primary care screening vited to participate (n=491), and 150 responded, using a clinical decision support system (CDSS) yielding a 30.5% response rate. Data collected at chairside. included level of athletes, league affiliation, scope of services provided, and type of oral screenings Methods: In this exploratory study, we uti- performed. Dentists’ attitudes regarding athletes’ lized maximum variation sampling to recruit 10 treatment and preventive needs, practice behav- hygienists and 6 dentists from 10 urban dental iors, and self-identified needs were assessed. De- offices with diverse patient mixes and volumes. scriptive statistics were used to analyze the data. A faculty dental hygienist conducted semi-struc- IRB approval was obtained (USC UPIRB #UP-14- tured, in-depth interviews, which were digitally 00326). recorded and transcribed verbatim. Data analysis consisted of multilevel coding based on consis- Results: Preliminary results revealed that tent and systematic review, resulting in emer- 79.5% (n=116) of team dentists have a league af- gent themes with accompanying categories and filiation. The most frequently provided services to identified hierarchy and predominance patterns. athletes were emergency treatment and mouth- guards (95.5%), restorative treatment (78.5%), Results: The majority of dentists and hygien- oral hygiene instruction (63%), and prophylaxis ists interviewed identify screening for hyperten- (61%). Most team dentists (80%; n=90) perform sion and diabetes and discussing tobacco use and oral screenings, with the most commonly reported nutrition as relevant to their dental practices, screening being for all athletes prior to the sea- particularly for vulnerable patients. Respondents son with individualized follow-up examinations suggested that such activities are important (41%; n=36). The most commonly cited barrier for many of their colleagues, although further to screenings reported was lack of awareness of analysis suggests certain challenges, including the importance of oral health. lack of continuity, accountability, resources, and systems-level support, with opportunities for im-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 73 provement regarding timeliness, efficiency, and determine the presence of plaque and gingival effectiveness. Dental providers’ perspectives of bleeding on the 6 Ramfjord teeth. vWD type and patients’ reactions to discussing the aforemen- severity was determined through a chart review. tioned health matters underscore salient barriers IRB approval was obtained from the University of to care and support increased care integration. Michigan and Michigan State University prior to Overwhelmingly, hygienists reported using elec- data collection. tronic devices at chairside to obtain web-based health information, with variation in terms of ac- Results: Data collection is ongoing. Current curacy, quality, and reliability. data shows that 50% of sites contained plaque, yet did not bleed upon flossing. Only 4.5% of Conclusions: Dental hygienists occupy a sites without plaque bled upon flossing. A chi- unique and vital role in providing trusted pa- square test will determine if bleeding is depen- tient-centered primary care, and may be well- dent on plaque presence. Each test will provide positioned to help facilitate greater integration of an odds-ratio and 95% confidence interval. - Lo oral and general health care, including screening, gistic regression will be used to control for con- monitoring, and care coordination. founding variables.

Funding for this project is supported in part by Conclusions: Current data suggests that vWD grant UL1 TR000038 from the National Center for has minimal effect on the amount of gingival Advancing Translational Sciences, National Insti- bleeding that occurs. tutes of Health. Funding for this study was through the Rack- ham Graduate School-University of Michigan-Ann Gingival Bleeding and Oral Hygiene of Arbor. Women with Von Willebrand Disease

Stefanie Marx, RDH, BSDH; Jill Bashutski, Diabetes Detection: A New Intraoral DDS, MS; Karen Ridley, RDH, MS; Mark Screening Approach in the Dental Setting Snyder, DDS; L. Susan Taichman, RDH, MS, MPH, PhD Lindsey Cohen Vine; Joanna Pitynski; Rosemary Hays, RDH, MS; Dianne Sefo, Problem Statement: Von Willebrand Dis- RDH, BA; Mary T. Rosedale, PhD, PMHNP- ease (vWD) is the most common hereditary BC; Shiela M. Strauss, PhD, MA, BS coagulation abnormality, presenting in roughly 1% of the population. Individuals with vWD ex- Problem Statement: According to the Ameri- perience increased gingival bleeding. Some evi- can Diabetes Association, approximately 25.8 mil- dence suggests gingival bleeding is due to poor lion Americans have diabetes. Of this population, oral hygiene. However, no studies have shown a 7 million remain undiagnosed and unaware of correlation between vWD and gingival bleeding their condition. when adjusting for possible confounding factors such as plaque, dental care utilization, and oral Purpose: The research study, “Novel Interdis- hygiene habits. ciplinary Intra-Oral Diabetes Screening in Dental Patients,” is examining whether oral blood (i.e., Purpose: The purpose of this pilot study gingival crevicular blood (GCB)) collected from was to examine the relationship between vWD, persons whose gingiva bleed on probing may be plaque score, and gingival bleeding and to deter- an efficient screening method for diabetes identifi- mine oral hygiene habits, oral health quality of cation. A key component in this examination is the life, and dental care utilization in those with vWD. extent to which an optimal GCB sample can be obtained for analysis of hemoglobin A1c (HbA1c) in Methods: This multi-site study included 40 the laboratory. HbA1c, also referred to as glycated adult women with vWD who completed a ques- hemoglobin, is currently viewed by the American tionnaire to evaluate demographics, oral hygiene Diabetes Association (ADA) as an acceptable test habits, and dental care utilization. The reliabil- for diabetes as it identifies the average plasma ity and validity of the survey have been estab- glucose concentration over a 2-3 month period. lished, as the questions were derived from a previously conducted study on women’s oral health. Methods: Dental and dental hygiene students Clinical dental examinations were conducted to have been charged with collecting a debris free,

74 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 steady stream of GCB into a micro-pipette which tle. The study examined the frequency with which is then released onto a sample card. Simultane- dietary advice provision was recorded by students ously, nursing graduates collected finger stick over a 12-month period. The study also investi- blood (FSB) from the patient for HbA1c compari- gated the age and gender of patients, as well as son. Armamentarium, site selection and control of other treatment provided during the appointment, contamination factors assist the clinician in obtain- to determine whether these factors influenced the ing a sample viable for analysis. Several factors, frequency that dietary advice was provided. including the patient’s medical and social history, may affect the quality of GCB samples. Despite Results: The results indicated that dietary ad- the factors outside of operator control, proper in- vice was provided infrequently by dental hygiene strumentation, periodontal knowledge of the clini- students, with only 6.48 percent of all patients cian, and the utilization of a laboratory adhering seen during the 12-month period receiving dietary to ADA protocols can increase the likelihood of ob- advice. Logistic regression analysis revealed a sta- taining an accurate HbA1c result. tistically significant correlation between dietary advice and age, with children 2.5 times more like- Results: In view of the large number of Ameri- ly than adults to receive dietary advice (p<0.012). cans who remain unaware that they have diabe- Additionally, patients who received oral hygiene tes, it is imperative that we identify innovative, instruction were 2.5 times as likely to receive di- evidence-based tests and alternate sites for dia- etary advice (p<0.003). Strong correlations were betes screening. Utilizing this novel approach to also observed between fluoride applications and diabetes screening would increase opportunities to dietary advice. screen for this life-threatening condition. In fact, collection of GCB has been proven to be a promis- Conclusions: The findings from the present ing method to enable HbA1c testing in the dental study indicate that dietary advice is provided in- setting with preliminary findings indicating a cor- frequently by dental hygiene students. Further re- relation of GCB HbA1c and FSB HbA1c of 0.99. search is required to investigate barriers to dietary advice provision, including whether education and training in this skill is sufficient for future clinical The Frequency of Dietary Advice practice. Provision in a Student Dental Hygiene Clinic: A Retrospective Cross-Sectional Occupational Health Study

Johanna Franki, BOH, BHSc(Hons); Melanie J. Radiographic Imaging for Disaster Victim Hayes, BOH, BHSc(Hons), PhD; Jane A. Taylor, Identification (DVI) In Dental Hygiene BDS, BScDent (Hons), MScDent, PhD Ann M. Bruhn, BSDH, MS; Tara L. Newcomb, Problem Statement: While the majority of BSDH, MS dental hygienists agree that they should have a role in providing dietary advice, research indicates it is implemented infrequently in practice. The per- Problem Statement: The ABFO recom- ceived extent of training appears to affect dental mends dental hygienists (DH) on disaster vic- hygienists’ confidence in providing dietary advice; tim identification (DVI) teams; however, no cur- it would be therefore valuable to review whether riculum exists on infection control in mortuary students are adequately experienced in dietary settings or radiation safety and technique when counseling during their education and training. imaging human dental remains.

Purpose: The aim of this retrospective, cross- Purpose: The purpose of this study was to sectional study was to assess the frequency of di- compare two groups (high media/low media) etary advice provision by dental hygiene students on DVI and errors made with radiographic tech- and to investigate factors that influence the fre- niques (paralleling and bisecting) for the expo- quency that dietary advice is provided. sure of images on simulated victim remains.

Methods: IRB approval was gained (Approval Methods: Participants were divided into two no H-2013-0116) and data were obtained from groups to compare knowledge and interest: clinical records (n=1189) of third-year Bachelor of the experimental group (n=20) received a high Oral Health students at the University of Newcas- media lecture with topics on safety and radio-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 75 graphic technique; the control group (n=18) threefold: to determine if self-reported operator received a low media lecture on the same top- positioning was correlated with development of ics. All participants took a pre-test measuring MSDs; to assess whether use of ergonomic de- baseline knowledge and interest, participated vices helped reduce risk for occupational injury; in a radiology lab including 11 intraoral expo- and to measure the impact of MSDs on dental sures with both techniques on simulated victim hygiene workforce issues in Mississippi. remains, and a post-test. A handheld x-ray device, (Nomad Pro®), direct digital sensor, lead Methods: A 47 item questionnaire was devel- barriers and modified image receptor holder oped and pilot-tested for face and content valid- were used. ity. The online survey was sent to all licensed Mississippi dental hygienists (n=1,553), obtain- Results: Interest was high from baseline ing a 22% response rate. This IRB-approved (99.9%) to post-test (94.8%) on the role of study utilized a correlational design examin- the DH’s for DVI teams. While no overall differing relationships between operator positioning ence between groups was found for knowledge and development and time to onset of MSDs, scores (p=0.6455). All participants improved and impact of MSDs on practice behaviors and from baseline to post-test in radiation safety workforce retention. Data analysis consisted of (+58.9%) and infection control in a mortuary Pearson chi-square correlation and Kaplan Meier setting (+61.5%); scores were decreased from survival analysis. baseline to post-test in dental radiation technique (-17.9%) and forensics (-17.9%). The bi- Results: There was no significant difference secting technique had significantly higher errors in prevalence of MSDs between those sitting in than the paralleling technique at the .05 level front of or behind the patient (χ² (1) = 1.67, (p<0.001); errors in angulation occurred more p=0.196), although those who sat behind the frequently (mean=8.4). patient developed MSDs sooner (χ² (1) = 3.92, p=0.048). Regardless of operator position, by Conclusions: DVI training is applicable for 16+ years in practice, 80% (n=271/338) of den- DH’s with interest in safety protocols and radio- tal hygienists developed MSDs. Having MSDs did graphic technique when working in a mortuary not impact ability to work, need to take time setting. Knowledge increased similarly between off from work, reduce work hours or reduce pa- the high and low media groups. The parallel- tient load. Ergonomic devices were used by only ing technique yielded better quality images with 21.6% (n=73/338) of study participants. fewer errors on simulated victim remains. Conclusions: The majority of practicing den- Funded by Old Dominion University’s Faculty tal hygienists develop MSDs regardless of oper- Innovator Grant. ator position. Sitting behind the patient resulted in earlier development of MSDs. Few practitioners use ergonomic devices. Dental hygiene Musculoskeletal Disorders – Does workforce issues were not negatively impacted Operator Positioning or Use of Ergonomic by MSDs. Devices Matter?

Beckie M. Barry MEd, RDH; Ann E. Spolarich, Dental Radiographic Prescribing RDH, PhD Practices: Survey of Illinois Dental Hygienists

Problem Statement: Results of worldwide Kathleen B. Muzzin, RDH, MS; Diane J. studies indicate that musculoskeletal disorders Flint, DDS, MS; Emet Schneiderman, PhD; (MSDs) are highly prevalent and remain a po- Frieda A. Pickett, RDH, MS tential occupational health hazard to practicing dental hygienists. It is unknown how current Problem Statement: Potential harm from recommendations for operator positioning and ionizing radiation has led to the development of use of ergonomic devices impact development guidelines to protect patients and practitioners of MSDs and workforce issues among dental hy- from unnecessary radiation exposure, which may giene practitioners. or may not be followed in practice.

Purpose: The purpose of this study was Purpose: The purpose of this pilot study was

76 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 to survey Illinois Dental Hygienists regarding ra- clinical efficacy of Colgate Total Mouthwash - diology policies in the workplace. 0.075% CPC (fluoride and alcohol free) and Crest Pro-Health Mouthwash - 0.075% CPC Methods: The survey was based on the 2004 (fluoride and alcohol free) vs. a negative con- American Dental Association (ADA) and Food trol mouthwash in controlling established den- and Drug Administration (FDA) “Guidelines for tal plaque and gingivitis after six weeks of the Selection of Patients for Dental Examina- product use. tions” and consisted of 46 knowledge and practice items regarding use of dental x-rays. Study Methods: Subjects were randomly assigned granted exempt status by TAMU, BCD, IRB. All to one of three treatment groups according to 823 dental hygienists, who were members of the their baseline gingival and plaque scores. The Illinois State Dental Society, were sent an email three treatment groups were: (1) Colgate® To- that contained the survey link. tal® Mouthwash containing 0.075% CPC - fluoride and alcohol free (Test Group), (2) Crest Results: Descriptive statistics were used to Pro-Health Mouthwash containing 0.075% CPC identify trends in decisions for taking radiographs - fluoride and alcohol free (Positive Control within Illinois dental practices. One hundred Group) and (3) Placebo Mouthwash - fluoride twenty-two dental hygienists completed the sur- and alcohol free (Negative Control Group). Af- vey for a 16% response rate. Approximately 48% ter brushing, subjects were instructed to rinse of the respondents reported the dentist deter- their mouth with 20ml of their assigned mouth- mined the need for radiographs and 47% report- wash twice daily for thirty seconds. ed the decision was made by the dental hygienist. The majority of respondents (81%) reported Results: After 6 weeks of product use, the that a clinical examination was not performed be- Test Group exhibited statistically significant fore radiographs were taken. However, 91% stat- (p<0.05) reductions of whole mouth gingival ed they “sometimes or always” took radiographs (24.4%), gingival interproximal (25.0%), gin- based on the patient’s clinical symptoms. A ma- gival severity (46.4%), whole mouth plaque jority (92%) reported radiographs were ordered (21.5%), plaque interproximal (20.1%) and based on a set time interval and/or were taken plaque severity (25.4%) index scores as com- when no clinical disease was evident (91%). Ap- pared to the Negative Control Group. After proximately 54% took radiographs based on in- six weeks of product use, the Positive Control surance reimbursement. Roughly 62% had not Group exhibited similar statistically significant taken a dental radiology course within the past (p<0.05) reductions vs. the Negative Control 8 years. Group. After six weeks of product use, no statistically significant (p>0.05) difference was Conclusions: This study suggests that dental observed between the Test Group and the Posi- practices were not following the ADA/FDA radio- tive Control Group. graphic guidelines. However, due to the low response rate, the results cannot be generalized to Conclusions: The results of this double- all dental practices. A national study will be con- blind clinical study support the conclusions that ducted to determine whether the radiology prac- (i) both mouthwashes containing 0.075% CPC - tice trends observed in this pilot study is wide- fluoride and alcohol free - provide a significant spread throughout the U.S. reduction in dental plaque and gingivitis after six weeks of product use and (ii) no statistically Technology significant (p>0.05) difference was observed between the two CPC-containing mouthwashes in controlling established dental plaque and Efficacy of Total Mouthwash Compared gingivitis after six weeks of product use. To Pro-Health and Placebo Mouthwash Funding provided by Colgate-Palmolive Com- B. Stewart; M. Morrison; J. Miller; J. Chung, pany. DMD, MPH; S. Pilch; A. R. Elias-Boneta; R. Ahmed

Purpose: The objective of the double-blind, randomized clinical study was to evaluate the

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 77 Clinical Investigation of Whitening Efficacy of Total Mouthwash Compared Efficacy on Colgate Optic White To Listerine and Placebo Mouthwash Dentifrice P. Chaknis; J. Miller; M. Morrison, PhD; S. A.R. Elias-Boneta; L.R. Mateo; E. Delgado, Pilch; B. Stewart; A.R. Elias-Boneta; R. DDS, MSc; Y. P. Zhang; S. Miller Ahmed

Purpose: The aim of this two-cell, double- Purpose: This double-blind, randomized blind clinical study was to assess the intrinsic clinical study evaluated the clinical efficacy of tooth whitening efficacy for (1) Colgate Optic two commercial mouthwashes against a nega- White Toothpaste (1% H2O2 and 0.76% so- tive control mouthwash in controlling estab- dium monofluorophosphate), and (2) matching lished dental plaque and gingivitis after six placebo (0% H2O2 and 0.76% sodium mono- weeks of product use. fluorophosphate). Methods: Subjects were randomly assigned Methods: Baseline Mean shade guide scores to one of three treatment groups according to (Vitapan Classical) among maxillary anterior their baseline gingival and plaque scores. The teeth were calculated for each of the consent- three treatment groups were: Colgate Total ing participants 7 days after a professional den- Mouthwash containing 0.075% CPC - fluoride tal prophylaxis procedure. Participants were and alcohol free (Test Group), Listerine Mouth- then randomly assigned to brush twice daily wash containing essential oils with 21.6 alco- (morning and evening) for 1 minute each time hol - fluoride free (Positive Control Group) and with either the test or placebo dentifrice. Mean Placebo Mouthwash - fluoride and alcohol free tooth shade guide and soft tissue examinations (Negative Control Group). After brushing, sub- were repeated after 1 and 4 weeks of assigned jects were instructed to rinse their mouth with product use. All examinations were performed 20ml of their assigned mouthwash twice daily under the same lighting condition and by the for thirty seconds. Gingivitis and plaque as- same examiner. sessments were conducted after six weeks of product use. Results: Eighty voluntary participants entered the study, complied with the protocol Results: After six weeks, the Test Group and completed the four-week clinical trial. Both exhibited statistically significant (p<0.05) re- study groups (test and placebo) were balanced ductions of whole mouth gingival (27.0%), for Vita shade guide scores and all participants gingival interproximal (27.9%), gingival se- had an A3 or darker mean shade score at the verity (48.5%), whole mouth plaque (27.4%), baseline examination. The mean tooth shade plaque interproximal (24.5%) and plaque se- improvements after 1 and 4 weeks of product verity (30.6%) index scores as compared to the use were respectively 1.05 and 2.38 for the Negative Control Group. After six weeks, the test group and, 0.09 and 0.23, for the placebo Positive Control Group exhibited similar statis- group. The test group demonstrated statistical- tically significant (p<0.05) reductions vs. the ly significant (p<0.05) whitening improvements Negative Control Group. After six weeks, no of 0.96 in mean tooth shade as compared to statistically significant (p>0.05) difference was the placebo group after 1 week of product use observed between the Test Group and the Posi- and 2.15 after 4 weeks of product use. tive Control Group.

Conclusion: The clinical results demon- Conclusion: The results support the conclu- strate that the 1% H2O2 and 0.76% sodium sions that (i) Colgate Total Mouthwash contain- monofluorophosphate dentifrice provides - sta ing 0.075% CPC - fluoride and alcohol free and tistically significant intrinsic tooth whitening Listerine Mouthwash containing essential oils improvements in mean shade scores as com- with 21.6 alcohol - fluoride free provide a sig- pared to a matching placebo dentifrice after 1 nificant reduction in dental plaque and gingi- and 4 weeks use. vitis after six weeks vs. the negative control mouthwash and (ii) no statistically significant Funding provided by Colgate-Palmolive Com- (p>0.05) difference was observed between pany. Colgate Total Mouthwash containing 0.075% CPC - fluoride and alcohol free and Listerine

78 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Mouthwash containing essential oils with 21.6 Conclusions: In vitro testing demonstrated alcohol - fluoride free in controlling established that Colgate® Optic White Whiten and Protect, a dental plaque and gingivitis after six weeks. dentifrice containing a combination of 1% peroxide and pyrophosphates, provides superior stain Funding provided by Colgate-Palmolive Com- prevention effects to other commercially avail- pany. able products.

Funding provided by Colgate-Palmolive Com- In Vitro Stain Prevention Efficacy of pany. Commercially Available Whitening Dentifrices Health Literacy/Cultural H. Strotman, MS; V.P. Maloney; S. Chopra Competency

Avatar-Mediated Practice Scenarios to Purpose: To evaluate the stain prevention ef- Evaluate Cross-Cultural Knowledge and fects of four commercially available whitening Understanding dentifrices. Tara Newcomb, RDH, MS; Joyce Flores, Methods: HAP discs were cycled through treat- RDH, MS; Amy Adcock, PhD; Brett Cook, ments to model daily exposure to toothpaste and MS; Laurie Craigen, LPC, PhD stain components. HAP discs were treated with a 1:2 (w/w) dentifrice slurries made with Colgate® Optic White Whiten and Protect, a toothpaste Problem Statement: Identified as a critical is- containing 1% peroxide and a pyrophosphate sue in dental hygiene education, to date there is system, Crest 3D White Luxe Glamorous White, a no standardized assessment tool for cultural com- toothpaste containing disodium pyrophosphate, petence. Rembrandt Deeply White + Peroxide, a toothpaste containing peroxide, and Colgate® Cavity Purpose: The purpose of this study was to eval- Protection Paste, a toothpaste that does not con- uate cross-cultural knowledge and understanding tain peroxide or pyrophosphates. The discs were using avatar-mediated practice scenarios. rinsed and baseline CieLAB values measured with a spectrophotometer. Discs were cycled through Methods: With IRB approval, 71 students from three alternating exposures of a staining broth various mid-Atlantic community colleges, colleg- composed of coffee, tea, and wine (15 minutes), es and universities participated in this study. All and saliva (20 minutes). CieLAB measurements materials and data collection instruments were were recorded after the completion of each cy- embedded into an online computer-based instruc- cle. The HAP discs were treated with a 1:2 (w/w) tional unit, which integrated instructional content, toothpaste slurries and CieLAB values measured. assessment items, and interview simulations into The change in whiteness before and after cycling a seamless, dental hygiene environment. Partici- is reported as ΔW*. Analysis of variance was used pants were randomly assigned to one of the two to compare the mean ΔW* values with p<0.05 groups: the experimental group received a pre- indicating significant differences. instructional unit, evaluation survey, knowledge posttest and culminating role play simulation and Results: The dentifrice containing perox- the control group did not receive the pre-instruc- ide and pyrophosphate after cycle comple- tional unit but completed the same other materi- tion achieved a ΔW* of 9.358+0.330, which is als. Patient agent response was designed to be statistically significantly lower than the other indicative of their culture. tested dentifrices. The dentifrice containing pyrophosphate and the dentifrice containing perox- Results: Using a One-way Analysis of Vari- ide produced ΔW* values of 21.260+0.681 and ance (ANOVA), results yielded an unexpected sig- 21.738+0.966, respectively, and were not statis- nificant difference (p < .01) for the experimental tically different from each other. The toothpaste group receiving both the pre-instructional and cul- without peroxide or pyrophosphate gave a ΔW* minating role-play simulations. Formative evalua- value of 32.172+0.282. This value represented tion on instructional content and simulation pack- statistically significantly more staining than the age were favorable. Participants were asked to other three dentifrices. rate the quality of instructional content, quality of

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 79 visual content, quality of audio content, and ease databases used contained 819 articles to which of use. A composite score for all categories yielded 41 articles met inclusion criteria. an average rating of 3.9 with a median of 4 and a mode of 5. Conclusions: Medical providers’ age, time of education, exposure to oral health training and Conclusions: Instructional simulations mim- the environment of medical practice influence icking real-world scenarios may be an effective the knowledge and attitude towards oral health means of instruction for complex and ill-structured screenings. Curricular modifications and -con diagnosis-solution problem types when partici- tinuing medical education (CME) courses per- pants are repeatedly exposed to the instructional taining to oral health education have been made simulation. in medical field to increase competency among providers. Health Behaviors Statistical Methods: Meta-analysis was not performed due to variations in methodology, re- Systematic Review of Medical search design and inferential statistics among Providers’ Knowledge and Attitude studies. towards Oral Health Screenings for Children Motivational Interviewing: Assessment Denise M. Claiborne, BSDH, MS, PhD of Dental Hygiene Students’ Perceptions Student; Deanne Shuman, BSDH, MS, PhD of Importance in Using and Confidence in Applying

Objective: The incidence of Early Childhood Angela J. Mills, RDH, BSDH; Wendy E. Caries (ECC) remains a global concern; and af- Kerschbaum, RDH, MA, MPH; Philip S. fects a child’s growth, development, cognitive Richards, DDS, MS; Gail A. Czarnecki, DDS; and speech abilities. Unlike dental providers, Anne E. Gwozdek, RDH, BA, MA medical providers such as pediatricians, nurses and physician assistants have more encounters with the mother and child during the first 12 Problem Statement: Motivational Interview- months of life. Therefore, assessing the risk for ing (MI) is an evidence-based, patient-centered ECC and educating mothers on establishing a counseling approach for eliciting behavior change. dental home for the child should be encouraged In 2012, the University of Michigan (U-M) Den- among medical providers. tal Hygiene Program significantly enhanced their Motivational Interviewing curriculum. Search Strategy/Selection Criteria: Sys- tematically review the literature of medical pro- Purpose: The purpose of this study was to ex- viders’ knowledge and attitude towards oral amine students exposed to the enhanced MI cur- health screenings for children. riculum and assess both their perceptions of the importance of MI and their confidence in using it. Data Collection and Analysis: The literature was searched for articles published from Methods: A convenience sample of 22 dental 2000-2014 in the following databases: Pubmed, hygiene students receiving the enhanced curricu- Medline, CINAL Plus Full Text, Cochrane Library. lum from the U-M Class of 2015 participated in Inclusion criteria were: peer-reviewed journal this study utilizing a retrospective pre-test/post- articles of medical providers’ knowledge and at- test design. A comparison group of dental hy- titude towards oral health screenings for chil- giene students from the Classes of 2014 (28) and dren, dental caries prevention, or caries risk 2013 (25), who did not experience the enhanced assessments to children <6 years. The two re- MI curriculum, completed one of the post-tests. searchers independently assessed quality and The U-M IRB approved this study as exempt. results of studies. Studies were organized according to specialty of the medical provider, type Results: A t-test compared the Class of 2015 of study, sample characteristics, methodology means and standard deviations reported for the and results. importance and confidence questions. Students’ perceptions of importance increased with statis- Main Results: Preliminary results from the tical significance in five out of eight MI - strate

80 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 gies. Perceptions in confidence increased in sev- Purpose: The aim of the study is to verify en out of eight strategies. Comparisons between the applicability of the HAPA model in studying a the Class of 2015 and the Classes of 2013 and sample of patients with gingivitis and the role of 2014 were analyzed using one-way ANOVAs. Sig- different types of technologies used in a dental nificant cohort differences were found for impor- hygiene appointment. tance with three MI strategies and for confidence with two MI strategies. Assessment of qualitative Methods: We are in the process of launching data provided additional insight on student expe- a four-wave longitudinal study for participants, riences. patients with gingivitis, who will answer an online self-reported questionnaire, which will analyze Conclusions: Class of 2015 student percep- their oral health behavior and the determinants tions of importance of using and confidence in of behavior proposed by the HAPA model (risk applying MI increased in a majority of the strat- perception, outcome expectancies, self-efficacy, egy categories. Successes with patient health planning, and action control). Since the literature behavior change and challenges with time to in- on dental hygiene behavior and on dental floss tegrate this in practice were noted. Minor modifi- in particular has been criticized for being solely cations in the curriculum have resulted. Research based on self-reported data collection, concrete on longitudinal impact, utilization of individual clinical measures will be considered. Clinical data strategies and faculty feedback calibration is rec- to evaluate the state of gingival health will be col- ommended. lected since, for instance, the fact that a person uses dental floss does not mean that its use is Funding for this project was provided by the clinically effective. Thus, the data of Bleeding on U-M Center for Research on Teaching and Learn- Marginal Probing (BOMP) will enable the assessing Faculty Development Grant. ment of gingival health. The strategy for data collection, according to a quasi-experimental design, will be based on the use of qualitative and The Role of Technologies in Promoting quantitative measures that will facilitate under- Periodontal Health standing the role of technologies in oral health behavior change. Mário R. Araújo, RDH, M. Psych; Cristina A. Godinho, MA; Maria-João Alvarez, PhD Results: A multiple regression analysis will be performed to ascertain whether the use of technologies is among the best predictors of oral Problem Statement: In order to improve our health behaviors. knowledge on the role of technologies (intra-oral camera, SMS and Gum Chucks) in dental hygiene Conclusions: We expect the study to help appointments, we propose to investigate their Dental Hygienists to decide when and what type predictive power in the Health Action Process Ap- of technologies to use in appointments on the ba- proach (HAPA), a self-regulation model of health sis of their role in health behavior change. behavior change.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 81 Abstracts: Oral Free Papers Education Conclusions: Currently there are no defined variables associated with clinical and national licensure pass rates. Further research is needed Linking Dental Hygiene Admissions to identify variables that are associated with Criteria to Licensure Examination clinical and national licensure pass rates. Pass Rates

Tammy R. Sanderson, RDH, MSDH; Marcia An Evaluation of the Effects of Blended H. Lorentzen, RDH, MSEd, EdD Learning Pedagogy on Student Learning Outcomes Problem Statement: Research specific to dental hygiene is needed to discover admissions Luisa Nappo-Dattoma, RDH, RD, EdD variables currently implemented by programs, and to validate these variables as predictors of student success as evidenced by successful Problem Statement: The paradigm shift in completion of the National Board Dental Hy- healthcare reform has altered healthcare deliv- giene Examination (NBDHE) and regional clinic ery and subsequently the role of the dental hy- licensure exams. gienist. It is imperative for dental hygiene education to incorporate engaging student-centered Purpose: Dental hygiene research can pro- pedagogy to promote the critical-thinking and vide programs guidance to implement the best problem-solving skills required for the profes- admissions practices for the profession. This sion of dental hygiene. study sought to first identify the many admissions variables currently being utilized by dental Purpose: The purpose of this study was to hygiene programs. Secondly, this study looked evaluate the effectiveness of blended learning for associations between these variables and (BL) pedagogy on successful learning outcomes program pass rates on national and regional of sophomore dental hygiene students as com- clinical board examinations. pared to the learning outcomes of traditional face-to-face (F2F) teaching and learning. Methods: An online survey was sent via email to 309 dental hygiene chairs/program di- Methods: Forty-one dental hygiene students rectors. The survey was comprised of eighteen in an Associate Degree program were enrolled questions to collect program demographic infor- in an IRB approved redesigned blended learn- mation, program admissions requirements, and ing nutrition course required within the dental program pass rates on both the NBDHE and re- hygiene curriculum. Successful student achieve- gional clinical board examinations. ment was evaluated by comparison of percent distribution of student final course grades be- Results: One hundred thirty-nine respon- tween the redesigned BL course and the F2F dents participated in the survey for a response traditional course from the previous academic rate of 45%. Twenty-nine admissions variables year. Student scores on unit exams, final exams, were analyzed and correlated to program pass in-class audience response system (ARS) clicker rates on regional clinical board examinations assessments, and pre-class online quizzes and (N=131) and program pass rates on the NBDHE puzzles were examined for student learning out- (N=133). Program demographic information in- comes. Student engagement was determined dicates that the two admissions variables most by evaluating interaction and attendance in all often used by dental hygiene programs are online pre-class activities. To monitor student overall college grade point average (GPA) at perceptions toward the BL pedagogy a mid-se- 67.6% and college science GPA at 61.2%. Mul- mester course evaluation was utilized. tiple regression analysis detected no statistically significant variables as positive indicators for Results: Blended learning was as effective neither the NBDHE nor regional clinical licensure as face-to-face learning in achieving success- examination pass rates. ful student learning outcomes as evidenced by no significant difference between percent dis-

82 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 tribution of final course grades of A through C. available to students. The majority of respon- Mean scores of exams illustrated similar results dents (67.8%) reported identifying students as compared to the previous year’s F2F scores. with clinical deficiencies in the pre-clinical se- Mean scores of in-class clicker assessments and mester, and 15.5% of respondents identified pre-class online quizzes and puzzles demon- students in the second year, second clinical se- strated successful student learning outcomes. mester. Instrumentation technique was identified as the area in greatest need of remediation Conclusions: Value added benefits of blend- (81%), followed by critical thinking skills (12%). ed learning include increased pre-class pre- Coordination of faculty and student schedules to paredness, better attendance, enhanced stu- conduct remediation was identified as one of the dent engagement, and active peer teaching and greatest challenges by one-fourth of the respon- learning. dents (25.2%).

Funding for this project was provided by Title Conclusions: These findings indicate that III- Students First Grant. respondents are well aware of the need for remediation policies in dental hygiene programs. The point in time varies when students in need Factors Associated With Clinical Skill of remediation are identified. Therefore, further Remediation in Dental Hygiene research needs to be conducted to determine Education Programs the reasons for this difference.

Donna F. Wood, RDH, MS; Tanya V. Mitchell, RDH, MS; Lorie A. Holt, RDH, MS; Current Issues of Community Dental Bonnie G. Branson, RDH, PhD Hygiene Practice Education in Korea

Nam-Hee Kim, RDH, MPH, PhD; Yang-Keum Problem statement: Evaluation of students Han, RDH, MD; Young-Kyung Kim, RDH, in a clinical environment can be difficult for a MPH; Hyun-Ju Lim, RDH, MPH, PhD; variety of reasons, including faculty calibration, Yang-Ok Kown, RDH, MPH, PhD; Han-Mi patient conditions and institutional guidelines. Kim, RDH, BA; Yeun-Ju Kim, RDH, BA; Early identification of skill deficits is critical in Jeong-Ran Park, RDH, PhD order for remediation to begin early in the educational process before deficiencies become complex. Problem Statement: It has been 50 years since dental hygiene education started in Korea. Purpose: The purpose of this study was to Today, many dental hygienists are working in the examine the challenges related to formal clinical clinical field; but more students wish to enter in remediation in dental hygiene programs, which the community field. On this context, we explore include timing of student identification, policy the practical training practice and issues regard- development and the issues of methodology and ing it in the current education program for com- scheduling. munity dental hygiene in Korea. We consider it is important to share the information with the Methods: A 23 item investigator-designed dental hygienists around the world. survey was electronically distributed to 303 United States entry-level dental hygiene pro- Purpose: We aim to find out the current is- gram directors. This questionnaire included 23 sues of community dental hygiene practice edu- forced-choice questions with the options to add cation in Korea. comments to eight of the questions. One hundred eleven surveys were returned yielding a Methods: Cross-sectional study directed to- response rate of 36%. Descriptive statistics and ward the 82 dental hygiene education institu- Chi-square analyses were utilized to analyze re- tions across the nation was conducted to ex- lationships between responses and the degree plore this topic. We requested the cooperation of earned from the dental hygiene program. a faculty member of community dental hygiene for each institution. The data were collected via Results: All schools reported having a reme- online with Survey Monkey, a web survey devel- diation policy; however, 13.6% of the respon- opment program. Among the recipients, those dents revealed this information was not readily who rejected to answer and who answered do

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 83 not participate in practical training for com- Methods: Approval was granted by the IRB munity dental hygiene was excluded from the (HSC #3618) before implementation of the final analysis. 46 faculty members (response qualitative case study. A cross-sectional ap- rate: 60%) from 79 institutions were included proach was used to recruit participants. The in- in the analysis. Statistical analysis includes the terviewer was a recent graduate of the program descriptive and frequency analysis using SPSS and was responsible for completing informed 20.0 program. consent procedures. A semi-structured interview was employed to gain deeper responses Results: The 60% of the dental hygiene edu- related to the phenomenon. Interviews were cation programs in Korea are currently conduct- audio recorded, transcribed and then verified to ing the community health center practical train- assure accuracy. Data analysis was completed ing, which is mainly operated during the junior by a three step process involving open coding, or senior of the students. The main curriculum focused coding and theoretical coding. of the practical training allows students to experience government-leading dental hygiene proj- Results: Seventeen participants completed ects, including fluoride and scaling. Through the interviews. The data revealed that learning com- community health center training, the students munities followed four stages throughout the are able to experience their institution’s dental graduate program (1) building a foundation for hygiene field, meet members of the community the learning community; (2) building a support- to examine their oral health need and design ive network within the learning community; (3) the promotion plans for them. Since the curricu- investing in the community to enhance learning; lum mainly consists of exposure to the field and and (4) disconnecting from the learning commu- hands-on experience of the everyday practice of nity. Three key elements were constructed from the field, the program is helpful in building up the analysis to create the e-model: experience field experiences. with strengthening online relationships through fellowship, collective and synergy; metamor- Conclusions: Showing actual practice and phosis through the affective domain from the having students to have hands-on experience awareness level to the highest level where val- help students to accumulate the field experi- ues guide actions in the online learning commu- ence. However, the program needs to be en- nity; and metamorphosis through the cognitive hanced in terms of basic planning capability of domain from the remembering level to the high- the students, where they can capture the needs est level of creating knowledge. of the community, decide priorities, set goals, conduct the projects to achieve those goals and Conclusions: The interrelationship between assess the results, all under the continuously the experience with strengthening online rela- changing needs of the community dental hy- tionships, affective development and cognitive giene project. advancement are the essential factors needed for maximizing the potential of learning commu- Funding for this project was provided by the nities in an online program. Dental hygiene stu- Korean Association of Dental Hygiene Profes- dents and educators need to be mindful of these sors. factors when participating in and designing an online curriculum.

E-Model of Online Learning Communities Funding for this project through American Dental Hygienists’ Association. Ellen J. Rogo, RDH, PhD; Karen M. Portillo, RDH, MS Assessing The Cultural Competence/ Problem Statement: The literature is limit- Faculty Development Needs among ed on the phenomenon of learning communities Florida’s Allied Dental Faculty in an online program. Linda S. Behar-Horenstein, PhD; Frank A. Catalanotto, DMD; Cyndi W. Garvan, PhD; Purpose: The intent of this inquiry was to ex- Yu Su, MEd candidate; Xiaoying Feng plore graduate students’ experiences with learning communities as they progressed through an online dental hygiene curriculum. Problem Statement: The Council of Dental Accreditation (CODA) requires that prospective

84 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 dental health care providers become culturally The Impact of Clinicians’ Interpersonal competent, socially responsible practitioners. Skills: Differences between Dentally However little is known about the skills of the Anxious and Non-Anxious Patients State of Florida allied dental faculty who train the state’s workforce. Laura J. Dempster, RDH, MSc, PhD Purpose: The purpose of this study was to assess the cultural competence and faculty de- Problem Statement: The clinician/patient velopment needs among Florida’s allied dental relationship has important implications for pa- faculty. tient care. Evidence supports the importance of this relationship based primarily on clinicians’ Methods: Participants were asked to take interpersonal skills, less on technical skills. In- the Knowledge, Efficacy and Practices Instru- terest lies in the impact of this relationship for ment (KEPI), (RR= 117/193 or 61%) and the patients in general and dentally anxious pa- faculty development assessment survey (RR = tients in particular. 115/204 or 74%). The KEPI, a validated measure, provides mean scores for three subscales: Purpose: To investigate patients’ percep- efficacy of assessment, knowledge of diversity, tions of clinicians’ interpersonal skills related to and culture-centered practice. The faculty de- communication, trust, control and ethical be- velopment assessment measures knowledge of havior. and priorities in teaching, scholarship, and career advancement. IRB approval was obtained Methods: Third year dental students ran- from the University of Florida. domly selected patients at the University of Toronto, Faculty of Dentistry to complete a Results: Mean scores for KEPI subscales are paper questionnaire regarding their thoughts 3.30 (α=.88), 3.58 (α=.88) and 2.85 (α=.74), and feelings about dental treatment. Dental (4 is highest) respectively. Participants indicat- anxiety was assessed (Modified Dental Anxiety ed low knowledge and high priority needs in Scale (MDAS), Dental Fear and Avoidance Scale 18 of 25 faculty development assessment mea- (DFAS)), plus patients’ perceptions of clinician sures. behavior based on the Revised Dental Belief Survey (R-DBS) scored 1 (never)- 5 (almost al- Conclusions: Professional schools are typi- ways). Data was confidential with all personal cally diligent in ensuring students’ technical identifiers removed when reported. Ethics ap- and procedural skills. However, rarely do they proval was received from the University of To- assess if faculty meet the needs of ever-chang- ronto. ing, diversified student body. This problem is further exacerbated by a lack of training in Results: 281 patients participated (60.2% pedagogy and assessment methods. Given the female; mean age 55.3 years; range 14-86 CODA mandates, it is crucial to assess facul- years). Patients reported the following issues: ty needs and priorities. Previous studies have communication (17.7%; mean(sd) 2.0 (0.6)); shown that there is an inverse relationship be- ethics (20.3%, mean(sd) 1.8(0.50)); trust tween knowledge areas and priorities. Similar (17.3%, mean(sd) 1.7 (0.6)); and lack of con- findings were observed in this study, though trol (2.1%, mean(sd) 1.8 (0.6)) as occurring participants showed higher mean scores on somewhat/often/nearly always. 39.1% of sub- the KEPI compared to the dental faculty. The jects (n=110) reported dental anxiety based on findings suggest the faculty development- as the MDAS (score >15) and DFAS (scoring >5 sessment needs among allied dental and dental for fear and avoidance) with significantly higher faculty are similar and that allied faculty seem (p<0.05) mean(sd) scores and percentage of inherently more culturally competent than den- communication, trust, control and ethical is- tal faculty. Whether the latter result is due to sues for the majority of questions with the ex- training or socialization into the profession is ception of 3 ethics related questions. unknown. Conclusions: Clinicians’ interpersonal skills Funding for this study was provided by the appear important to patients in general, but Health Resources and Services Administration more so for dental anxious patients. All patients Award # 1 D86HP24477-01-00. reported concern that clinicians do not provide all the information needed to make good de-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 85 cisions for treatment; are reluctant to correct Conclusions: The development of a profes- unsatisfactory work; and do not take the time sional tool to assist students and employers in the to talk to patients. This should be noted by cli- hiring process aligns with the college’s mission to nicians as well as educators to ensure inclusion prepare students for successful employment. of curriculum related to interpersonal skills.

Theory Analysis of the Dental Hygiene Guiding Dental Hygiene Students in Human Needs Model Creating Employment E-Portfolios That Can Help Hygienists Find Jobs Laura L. MacDonald, DipDH, BScD(DH), MEd

Sharon L. Mossman, RDH, EdD Problem Statement: Over 20 years ago, Problem Statement: The assessment portfo- dental hygiene scholars challenged the profes- lio used in the entry-level degree dental hygiene sion to identify dental hygiene concepts and the- curriculum at Delaware Tech Community College ories purporting to be dental hygiene-knowing validates the effectiveness of the students’ train- (epistemology) and dental hygiene-being (on- ing but offers limited use for their employment tology). The Dental Hygiene Human Needs Mod- search. This oral presentation identifies the need el (DH HNCM) offered by Darby & Walsh (1995) to develop student employment e-portfolios for informs curricula and practice of many dental use in job searches from the employers’ perspec- hygiene programs; the model guides student tive. knowing of the profession’s way of being.

Purpose: The goal of this study was to assess Purpose: The purpose of this scholarly ac- the usefulness of student portfolios in the dental tivity was to conduct a theory analysis on the hygienists’ employment search. In order to assist DH HNCM using the Walker and Avant Theory dental hygiene students with this endeavor, it is Analysis (2011) method. This methodology fo- necessary to identify what types of resources stu- cuses on concepts, relations, and propositions dents have available to them. of a profession’s phenomenon of interest; it promotes scholarship and professional accountabil- Methods: A qualitative research approach ity to advancing professional theoretical under- investigated how the current portfolio could be pinnings. modified to meet employment search initiatives. The data collection used a combination of liter- Method: A singe scholar used the Walker ature/document review, surveys with 20 senior and Avant seven step theory analysis to ex- dental hygiene students/7 dentists and face-to- plore the DH HNCM: 1) origins; 2) concept(s) face interviews with thirteen dentists. Interviews relationship(s); 3) logic of structure; 4) useful- were audio-recorded; notes were transcribed and ness to practice; 5) generalizability; 6) parsimo- emailed to the participants for content approval. ny; and 7) testability. The interviews captured information about desirable content, navigation strategies and how the Results: The DH HNCM was deductively de- employment portfolio could be used in the hir- rived from a middle range nursing theory, the ing process. An inductive data analysis was used Yura and Walsh (1983) Human Needs and Nurs- to identify coding frames. A systematic technique ing Process Theory. It was constructed based on was designated to determine subdivisions in the the four dental hygiene concepts (client, health/ transcripts that contain common themes. Two oral health, environment, and actions). Respect- doctoral candidates provided a peer debriefing ing humans have needs and dental hygienists strategy to confirm accuracy of common themes are positioned to facilitate the client in satisfying identified in the analysis of the interview tran- these needs, the DH HNCM provides logic, ease scripts. and generalizability independent of practice setting. It is parsimonious and testable, though it Results: The data analysis supports the use of remains theoretical in nature at this time. electronic portfolios for the students’ job search. Desired content was recommended based on the Conclusion: Conceptual models, schematics interview results. This included education/hon- of a theory, depict relationships between con- ors, professional experience, validation of licen- cepts and constructs of the theory. The Darby sure and references. and Walsh DH HNCM is a depiction of a middle

86 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 range dental hygiene human needs theory. The vironment that exposes students to more medi- Walker and Avant Theory Analysis of the DH cally complex and vulnerable populations can im- HNCM affirmed the model is reasonable and in- pact the level of comfort and confidence of dental sightful, adding greatly to the epistemology and hygiene students’ capacity to treat such clients ontology of the dental hygiene profession. and enhance their understanding of complexities involved in treatment.

Dental Hygiene Student Practicum Funding for this project was provided in kind Experiences In A Hospital-Based by the University of Alberta. Dental Clinic Basic Science Minn N. Yoon, PhD and Sharon M. Compton, RDH, PhD. University of Alberta, Canada Identification and Characterization of Novel Human Papillomaviruses in Oral Problem Statement: To prepare dental hy- Cancers giene students to serve the dental needs of medically complex populations, it is crucial students Juliet Dang PhDc, MS, RDH; Nancy B. have experiences to develop familiarity and com- Kiviat, MD; Qinghua Feng, PhD; Stephen fort with a variety of practice settings such as Hawes, PhD; Greg Bruce, PhD hospital-based clinics, and develop confidence in their skills to treat such populations. Problem Statement: To identify novel human Purpose: The aim of this study was to gain an papillomaviruses (HPVs) using high throughput understanding of the dental hygiene student per- sequencing technology in oral lavage samples spective of experiences in an external practicum (OLS) collected from oral squamous cell carci- at a hospital-based dental clinic. noma (OSCC) and oropharyngeal squamous cell carcinoma (OPSCC) patients. Methods: This study was approved by the University of Alberta Human Research Ethics Purpose: In our previous study, we identified Board. Reflective journals submitted by senior and cloned 3 full-length novel HPVs in OLS col- dental hygiene students were subjected to con- lected from healthy individuals. We hypothesize tent analysis to identify major themes. Question- that novel oncogenic HPVs can be detected in naires were presented using an online tool, which OLS collected from OSCC/OPSCC patients. asked students to self-report their level of comfort and confidence in domains of practice readi- Methods: We collected OLS from 110 healthy ness on a 4-point Likert scale. subjects and 100 from OSCC/OPSCC patients. HPV 16 and 18 were detected using type-specific Results: The presentation will overview the real-time PCR Taqman assays. Multiply-primed practicum and findings from the reflections in rolling circular amplification (MP-RCA) was - per which students expressed initial fear of the ex- formed on 49 OSCC/OPSCC samples to preferen- perience, an enhanced understanding of current tially amplify circular HPV genomes. Four pooled disparities in oral health and oral care for vul- samples were selected to undergo Next Genera- nerable and medically complex clients; a work- tion Sequencing (NGS) using the HiSeq 2500 ing through of physical and emotional reactions platform, and sequence data was analyzed using to the experience; and an appreciation for the VELVET and BLASTN search. learning they have obtained. An overview of the previously validated Readiness for Practice Sur- Results: Only one control sample (1/110) vey will be provided as well as how it was adapt- was positive for HPV 18 and none were positive ed to address the dental hygiene student popula- for HPV 16. Twenty-three OSCC/OPSCC sam- tion. The domains of practice readiness: comfort ples (23/100) were positive for HPV 16 (p-value and confidence with both clinical and relational <0.001), and none were positive for HPV 18. skill performance and the development of profes- We identified five potentially novel HPV types in sional identity of the dental hygiene students will OSCC/OPSCC samples using NGS. be outlined. Conclusions: HPVs can be detected in OLS, Conclusion: Providing a clinical learning en- which could be used for oral cancer detection in

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 87 the future. Novel HPV types are identifiable in both groups significantly improved oral parame- OSCC/OPSCC samples using NGS after MP-RCA ters (p<0.0001). Caregiver compliance was 41% enrichment. Future studies are needed to deter- with no difference between groups. Caregivers mine whether the novel HPV types we identified preferred (69%) the power brush and 78% found are oncogenic. it easier to use.

Funding for this project was provided by the Conclusions: Power toothbrushes may be pre- ITHS TL1 Training Program and the University of ferred options for use in nursing homes but care- Washington Royalty Research Fund. giver compliance remains an issue.

Access to Care Funding was provided by the Canadian Founda- tion for Dental Hygiene Research and Education; power toothbrushes were provided by P&G. Effects of Power Toothbrushing on Caregiver Compliance and Oral and Systemic Inflammation in a Nursing Transforming the Culture of Oral Care Home Population in Long-Term Care

Salme E. Lavigne, RDH, MSDH, PhD(c); Mary F. Bertone, RDH, BScDH Malcolm B. Doupe, PhD; Anthony M. Iacopino, DMD, PhD; Salah Mahmud, MD, PhD; Lawrence Elliott, MD, MSc Purpose: Older adults residing in long-term care are at high risk for compromised oral health due to frailty and dependence on others Problem Statement: Oral care in nursing for oral care. homes is deplorable and caregiver compliance problematic. Power brushes may improve oral hy- Significance: Several studies have cited giene and caregiver compliance. significant barriers to the provision of oral care for older adults including: lack of knowledge Purpose: The purpose of this study was to in- among nursing staff, competing care needs vestigate whether twice-daily use of a rotating– taking greater priority, limited oral care sup- oscillating power toothbrush (Oral-B Professional plies and limited access to oral care services Care 1000™) with nursing home residents will (BC Seniors’ Oral Health Secretariat, 2011; improve caregiver compliance with oral care and Samson, Berven & Strand, 2009). reduce oral and systemic inflammation. Approach: This presentation shares prelimi- Methods: In this repeated measures single- nary findings on a pilot study of a -new mod blinded randomized controlled trial, after receiving el of care that includes a dental hygienist on IRB approval from the University of Manitoba, 59 the interprofessional care team in a 175 bed residents of a nursing home in Winnipeg, Cana- long-term care home. This conceptual model da, were randomized to receive either twice daily is based on oral health promotion strategies brushing with a power toothbrush or standard built on the pillars of standards, commitment, care. Consent was obtained from either residents education and training, assessment and profes- or their proxies. Participants had some natural sional care, and daily mouth care. These pil- teeth; oral inflammation; non-aggressive behav- lars are supported by the principal actions of iour; no communicable diseases; non-smokers assessing strengths and challenges, collabora- and non-comatose. Baseline and 6 weeks outcome tion, engaging personnel effectively and apply- measures included: oral inflammation (Lobene); ing best practices. The outcomes of a dental bleeding (Loesche); plaque (Turesky); systemic hygienist providing oral health education, train- inflammation (hsCRP); caregiver compliance (dai- ing and mentorship on staff knowledge will be ly care chart); and an 11-item caregiver survey. discussed. The pilot, currently in progress, is Oral & systemic data were measured by ANOVA testing a “new” oral health assessment tool and and Wilcoxin and Mann-Whitney tests; compliance daily care plan. The role of the dental hygienist and survey data using descriptive statistics. in improving access to dental treatment will be assessed. Results: No significant differences were found between groups in oral or systemic outcomes; Evaluation: Baseline data, oral health as-

88 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 sessment tools and nursing education and icance was noted for the level of education and mentorship strategies will be shared. This inno- awareness of OC signs and symptoms (r=0.24; vative and collaborative strategy brings togeth- p=0.06). er nursing and dental professionals to advance care approaches and improve the oral care of Conclusion: The levels of OC awareness older adults in long-term care. in the surveyed seniors were low. Additional research is needed to determine how to best Funding for this project was provided by Re- communicate OC awareness, and design and vera Retirement Living. implement programs specifically for this high- risk group.

Oral Cancer Awareness among Community-Dwelling Senior Citizens The Integration of Dental Hygienists as in Illinois Part of the Primary Healthcare Team: A Strategic Analysis of the Barriers to Direct Dental Service Delivery by Ewa Posorski, RDH, MS; Linda Boyd, RDH, Federally Qualified Healthcare Facilties RD, EdD; Lori J. Giblin, RDH, MS; Lisa Welch, RDH, BS, MSDH Trisha M. Johnson, RDH, MHA

Problem Statement: Low oral cancer (OC) Problem Statement: The gross necessity for survival rates are disproportionally over repre- oral healthcare providers and the general lack of sented in the low SES population. While the so- dental programming in underserved areas is not cioeconomically disadvantaged individuals are being fulfilled due to current workforce policy in In- at highest risk for OC, they are also typically diana. the population without access to preventive and screening care. Purpose: This study identifies the barriers to dental health access and suggests opportunities to Purpose: The study assessed participant expand access to care. It explores the feasibility of awareness of oral cancer, risk factors, signs dental hygienists working collaboratively in a pri- and symptoms, and history of an OC screen- mary care setting. ing exam and whether a relationship exists between these factors and the participant’s age, Methods: This qualitative, aggregate interview level of education, SES, ethnicity, and gender. process focuses on three of Indiana’s nineteen Fed- erally Qualified Health Centers. Key informant in- Methods: The study was granted a Certifi- terviews were conducted with the Chief Executive cate of Exemption by the MCPHS University In- Officer of each health center, and the results were stitutional Review Board. It was a descriptive developed into a SWOT analysis based on the pre- survey research with a non-randomized sam- dominant themes from each facility, and their ac- ple. Participants were a convenience sample cess to care. of seniors participating in a congregate dining program. Data was collected through a written, Results: Dental professionals in the primary self-administered survey. The survey was vali- care setting are necessary and desired. If practice dated by Dodd et al., the original authors. act changes are implemented, all of these facilities would be willing to implement a dental hygienist Results: Ninety-three individuals were ap- into the primary care setting to achieve more com- proached to participate, and 62 surveys were prehensive care for their patients. Within a Fed- completed. Statistical tests included; frequency erally Qualified Health Center, a model based on distribution, mean, standard deviation, t test, these results would satisfy the necessity for dental and Spearman rank Correlation. A statistically concerns to be addressed and managed more ap- significant relationship was found between the propriately. level of education and awareness of OC risk factors (r=0.26; p=0.04). An inverse relation- Conclusions: This study will aid in a dental pro- ship was found between the level of educa- gram to be designed for Federally Qualified Health tion and the level of OC awareness questions, Centers to implement a dental hygienist into a pri- “have you ever heard about OC?” (r=-0.37; mary care setting and for other outlets, such as p=0.004), and “how much do you know about local dental students, to receive rotation-like ex- OC?” (r=0.35; p=0.008). A trend toward signif- periences in these medically underserved areas.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 89 This study has provided the qualitative data that Conclusions: Eating disorder professionals will be needed to assist in implementing a model may lack understanding of associated oral risk for hospital systems, long-term care facilities, and factors and current oral guidelines. Oral care pro- any health care setting. viders should be considered for inclusion within the eating disorder treatment team.

Oral Health Knowledge of Eating Disorder Treatment Providers A Comparison of Dental Hygienists’ and Dentists’ Clinical and Telehealth Lisa Bennett Johnson, RDH, MSDH; Linda D. Screening for Dental Caries in Urban Boyd, RDH, RD, EdD; Lori Rainchuso, RDH, MS Children

Susan J. Daniel, RDH, PhD Problem Statement: Individuals with eating disorders require significant preventive and/or restorative dental treatment as a result of this Problem Statement: Telehealth has been disorder, and many lack access to appropriate identified as an effective and efficient means of oral care during treatment. increasing access to care for screening, referral, and treatment. Use of telehealth in some states Purpose: The aim of this study was to assess is restricted and dentists must provide a clini- oral health knowledge among professionals who cal examination prior to the delivery of oral care specialize in treating eating disorders, and iden- services. There is no comparison of dentists’ and tify to what extent their education and training dental hygienists’ clinical and telehealth screen- addresses oral health care delivery and recom- ing for caries and restorations in the literature. mendations for individuals with eating disorders. Purpose: The purpose of this study was to de- Methods: A research instrument was devel- termine whether or not there was a difference oped by comparing question agreement between in dental hygienists’ and dentists’ screening for six experts; a question with item agreement av- dental caries with either clinical or telehealth erage of 0.80 was deemed valid and included methods. in the survey, and then piloted by an unrelated group of experts (n=6). A descriptive, explor- Methods: A convenience sample of 82 chil- atory survey of licensed behavioral and medical dren 4–7 years of age was selected for the study. health providers assessed level of oral health re- The clinical dentist’s screenings were required lated education, knowledge, and treatment rec- for an urban mobile preventive program. Two ommendations. An invitation to participate in a clinical examiners, dental hygienist and dentist, web-based survey was sent via electronic news- and two telehealth examiners, dental hygienist letters and/or list-servs to three professional eat- and dentist, screened for dental caries and ex- ing disorder organizations. An inability to track isting restorations. Each professional’s findings the use of electronic media within the study time were recorded on separate charts. Photographs frame precluded an exact number for the study of each child’s teeth were obtained using the population; however the proportion of respon- iPhone 4S, images were stored in an album by dents directly corresponds to the framework of participant number, uploaded to the Cloud© for the eating disorder treatment team. retrieval, checked for quality and uploaded to a course in Blackboard© accessible by the two tele- Results: Of the 107 respondents who com- health examiners. The telehealth examiners re- pleted surveys, a majority (64.4%) reported viewed photographs for caries and restorations, dissatisfaction with their level of oral health ed- and charted findings. Caries and restorations on ucation, and 19.5% reported no oral health edu- the four charts for each child were converted cation. Respondents consider their knowledge of to decayed filled surfaces (DFS) scores used to clients risk for oral disease as average or above compare the professionals’ screening. (84%), and ranked tooth erosion as the greatest reason for oral care (63%) while dry mouth led in Results: Seventy-eight children met inclu- the rankings for least significant (33%). Referral sion criteria. Spearman’s correlation between for oral care was found to be more common after the clinical screening of the dental hygienist and reports of complication (55%). dentist was 0.99; p=0.001. Spearman’s correlations in other group relationships with the clinical

90 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 dentist were 0.75; p=0.001 (telehealth dentist) were demonstrated between predictor variables and 0.81; p=0.001 (telehealth dental hygienist). and outcome measure. Rather, the final statisti- No significant difference was found between the cal model demonstrated individual characteristics telehealth dental hygienist and the clinical dentist and graduating from a 3-year program together (p>0.10) using the Wilcoxon Signed Ranks. significantly predicted decision making capacity. Thematic analysis of key informant data revealed Conclusions: Dental hygienists’ telehealth or 8 broad environmental influences on decision clinical screening for dental caries is not signifi- making capacity. When data were merged, indi- cantly different from screening performed by a vidual characteristics were shown to be a product clinical dentist. of broad environmental factors and educational preparation had a particularly strong influence. Clinical Dental Hygiene Practice Conclusions: Individual characteristics and education are predictive of decision making ca- Exploring Dental Hygiene Clinical pacity but are outcomes of broad structural in- Decision Making: A Mixed Methods fluences. Modifications to these structures are Study of Potential Organizational recommended to support dental hygiene decision Explanations making capacity within expanded practice scopes and/or settings. Joanna Asadoorian, RDH, PhD; Evelyn L. Forget, PhD; Mahmoud Torabi, PhD; Lesley F. Degner, RN, PhD, FCAHS; Joan Grace, PhD Efficacy of Novel Brush on Paste “MI Paste Plus One Step”

Problem Statement: Dental hygienists are Annette Scheive, RDH, MS; Linda Belllisario, targeted for practice expansion to improve pub- RDH, BS; Gina Durkin; Sayako Hotta, DH, lic access to oral health care, but they have not PhC; Takuya Sato; Yoko Ishihara; Tomohiro established their decision making capacity within Kumagai alternative practice models.

Purpose: This mixed methods study aimed to Problem Statement: CPP-ACP (RECALDE- identify and test the impact of influential factors NT™) known for its anti-caries and anti-sensitiv- in dental hygiene decision making capacity. ity effect, contains high level of bioavailable ions. To improve patient compliance with this material, Methods: An ethically approved, mixed meth- we developed CPP-ACP topical cream with “One- ods two-phased study was conducted. PHASE I: Step” brush on concept. A series of focus groups were conducted with a purposive sample of dental hygienists in Mani- Purpose: Purpose of this study was to mea- toba. Using a semi-structured interview guide, sure content of bioavailable ion and to evaluate data was collected until reaching saturation. Data efficacy of this new product against tooth sensi- underwent coding and thematic analysis and a tivity. qualitative decision making model, including key predictor variables and outcome variable (deci- Methods: Three materials examined in this sion making capacity), was developed to guide study were MI Paste Plus One Step (MOS, GC Phase II. PHASE II: Aspects of the qualitative Corp.), MI Paste Plus (MIP, GC Corp.) and Clin- model were tested via an electronic survey ques- pro tooth crème (CTC, 3M ESPE). Slurry (10 wt tionnaire of a census of Manitoban dental hygien- %) was prepared and centrifuged at 12,000g for ists and through key informant interviews. Sta- 15 min. Supernatant (water soluble) was col- tistical and qualitative thematic analyses were lected for analysis. Levels of calcium and phos- conducted respectively and findings merged for phate ion were determined by atomic absorption interpretation. spectrometer (Z-2300, HITACHI High-Technolo- gies) and molybdenum acid colorimetric method Results: Focus group data yielded 75 codes respectively. Level of fluoride ion was measured and 6 themes plus 1 theme from the literature by ion meter (pH / ION METER F-23, HORIBA). comprising the model and guiding the survey. Block specimens (n=4) for evaluation of the ef- The Phase II survey was completed by 161 dental fect against dentin sensitivity were made of bo- hygienists (38%). Moderate to weak correlations vine maxillary incisor root dentin. Blocks were

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 91 embedded in resin and polished with SIC paper. sample 4 mm from the airpolishing nozzle and Each Paste was applied to test samples and im- airpolishing was applied using a constant circular mersed in water for 30 min with gentle shaking. motion. Each sample was analyzed with a pro- Then, test samples were observed with SEM (SU- filometer, gloss meter and scanning electron mi- 70 FE-SEM, HITACHI High technology). The levels croscope. of dentin blockade were measured using image analysis software (ImageJ). Data were statistical- Results: A three-way ANOVA model was used ly analyzed with ANOVA and Turkey test (p<0.05). to determine differences in outcome based on type of powder, material, and time. The model Results: Mean values of each bioavailable ion included interaction terms for powder type and level of MOS and MIP were not statistically differ- material and powder type and time. Based on the ent. Bioavailable calcium and phosphate was not ANOVA model, there were statistically significant detected from CTC containing TCP. Level of dentin interactions between type of powder and materi- blockage of MOS (63% ; SD 8.4) was same as al for difference in gloss, roughness. There was a MIP (49% ; SD 8.3) and significantly higher than statistically significant difference between rough- CTC (3% ; SD 2.1). ness and gloss at 5 seconds of treatment.

Conclusions: MOS has high level of bioavail- Conclusions: Overall analysis of roughness able ion. Effect against dentin sensitivity of MOS revealed order of abrasiveness of airpolishing is expected to be better than CTC. powders to be (least to most abrasive): glycine sodium bicarbonate B, sodium bicarbonate A, Funding for project through GCC. calcium carbonate, aluminum trihydroxide and calcium sodium phosphosilicate.

An In Vitro Comparison of the Effects of Funding for this project is through EMS. Various Airpolishing Powders on Enamel and Selected Esthetic Restorative Materials Utilization of an American Diabetes Caren M. Barnes, RDH, MS; David A. Covey, Association Adopted Diabetes Risk Survey DDS, MS; Hidehiko Watanabe, DDS, MS to Identify Patients at Increased Risk for Type 2 Diabetes Mellitus in Asymptomatic Patients Problem Statement: Specially processed sodium bicarbonate was the only airpolishing Lori J. Giblin, RDH, MS; Lori Rainchuso, RDH, MS powder available until 2004, when aluminum trihydroxide was introduced for sodium intolerant patients. Since 2004, four airpolishing powders Problem Statement: National data indicates have been introduced: glycine, a second type of the incidence and prevalence of Type 2 Diabetes sodium bicarbonate powder, calcium carbonate, Mellitus (T2DM) is on the rise. T2DM is a prevent- and calcium sodium phosphosilicate. able disease with early diagnosis.

Purpose: The purpose of this study was to Purpose: To implement an American Diabetes compare the effects of each airpolishing powder Association (ADA) adopted diabetes risk survey on the surface characterization of enamel (E), to assess patients at increased risk for T2DM and composite resin (CR) and glass ionomer (GI). rate of compliance for A1c screening in a dental setting. This descriptive cross-sectional study Methods: Six airpolishing powders, sodium contributed to the feasibility of implementing a bicarbonate A and B, aluminum trihydroxide, diabetes risk survey and rate of compliance for calcium carbonate, glycine and calcium sodium A1c screenings in dental settings. phosphosilicate were investigated on surfaces of E, CR and GI samples. Samples were uniformly Methods: The Institutional Review Board of polished using 1200 grit abrasive paper. Each MCPHS University ensured the protection of the type of airpolishing powder was applied with the subjects engaged in this study. Participants con- same airpolishing unit. Each type of powder was sisted of a purposive sample of Forsyth School of used for 1, 2 and 5 seconds on 5 samples each of Dental Hygiene patients, 18 years or older not E, CR and GI samples, for a total of 225 samples. diagnosed with prediabetes or diabetes. The ADA Custom equipment was fabricated to hold each diabetes risk survey determined patients at in-

92 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 creased risk for developing T2DM were offered outcome utilizing critical thinking and evidence an opportunity for a point of care A1c screening. based decision-making.

Results: To date: 160 of 422 solicited patients Data Collection and Analysis: A meta-anal- agreed (compliance rate 38%, 95%CI: 33% - ysis was used to calculate the results of each 43%). As per the ADA survey 77 patients were at study, and calculate an average of those results. increased risk for T2DM for an at-risk prevalence We performed meta-analysis for overall asso- of 48% (95%CI: 40% - 56%). The 77 at-risk ciations by head and neck assessment, intraoral patients were asked if they would take an A1c soft and hard tissue assessment, radiographic, test of which 45 agreed (compliance rate 58%, and clinical settings. This meta-regression will 95%CI: 47% - 70%). Results of administered be used to determine the homogeneity between A1c tests are in the process of being aggregated. the studies.

Conclusions: Implementation of the ADA Main Results: Results will reflect the degrees diabetes risk survey determined a 38% rate of of complexity and variability among the studies. compliance and 58% of patients at increased risk agreed to an A1c screening. Conclusions: The dental hygienist appears to be as effective as a dentist in their capability Funding for this project through a MCPHS Uni- to perform a technically competent clinical oral versity faculty development grant. diagnosis in various settings.

Capability of a Dental Hygienist to Soft-Rubber-Interdental-Cleaner Perform a Clinical Oral Diagnosis in Compared To an Interdental Brush on Various Settings: A Multi-Level Analysis Plaque/Gingivitis/Gingival Abrasion

Kelly T. Williams, RDH, MSDH, CDA; Joyce D.E. Slot, RDH, MSc; D. Ekkelboom, RDH, BoH; M. Flores, RDH, MSDH E. Van Der Sluijs, RDH, BoH; S.C. Supranoto, RDH, BoH; G.A. Van Der Weijden, PhD

Objective: The purpose of the systematic review was to identify the capability of a den- Problem Statement: Different interdental tal hygienist to perform a technically competent devices are available for dental professionals to clinical oral diagnosis in various settings. recommend; however, it is not clear as to which is more effective or acceptable to patients. Search Strategy/Selection Criteria: Elec- tronic databases were searched to identify rel- Purpose: To determine the effectiveness of evant articles. Searches were limited to the a rubber bristled interdental cleaner (RIBC) as English language and publication date from compared to an interdental brush (IDB) on gin- the earliest available date for each database to givitis, plaque and gingival abrasion scores, and March 31, 2014. Literature searches were con- to evaluate participants’ attitudes towards these ducted using APA, Alexander Street, EBSCO, two devices. Elsevier, FirstSearch, Gale, ISI, JSTOR, Oxford, OVID, ProQuest, PubMed/ Medline, Thomson Methods: After IRB approval, an examiner- Reuters, and VIVA databases. The search strat- blind, randomized split-mouth design was used. egies included subject headings and subhead- After a dental prophylaxis, 42 subjects refrained ings, combined with keyword searching. Search from brushing their mandibular teeth for 21 focus included such words as dental hygiene days to allow for the development of gingivitis. diagnosis, dental diagnosis, oral diagnosis, and During a subsequent 4-week treatment phase, dental therapist diagnosis. The study identified participants resumed twice daily toothbrushing. 1,576 unique articles with 43 meeting the inclu- Contralateral quadrants were assigned to the sion criteria. Inclusion criteria were quantitative use of either the RICB or the IDB. Plaque, gin- studies that compared technical competency be- givitis and gingival abrasion were assessed at tween groups of dental hygienists and/or dental baseline (Day 0), after 21 days of no oral hy- therapists and dentists and/or dental specialists. giene, and after 1, 2 and 4 weeks of once daily Capability in this study is defined as the - pro product use. cess utilized to achieve a technically competent

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 93 Results: After experimentally-induced gin- selection, the subjects were provided with a tooth- givitis (EIG), use of both interdental devices brush and randomly assigned to the test (n=32) (N=42) resulted in a significant decrease in or the control regimen (n=34). Those in the test bleeding and plaque scores. Mean plaque scores group used the tooth/tongue gel, mouthrinse, and at day 21 reduced from 3.29 to 2.49 for the a tongue cleaner, whereas those in the control IDB, and from 3.32 to 2.44 for the RIBC. Mean group used only fluoride toothpaste. Written life- bleeding scores changed from 1.06 to 0.52 for style instructions regarding food intake and per- the IDB, and from 1.09 to 0.45 for the RIBC. sonal use of cosmetics were provided regarding At the end of the treatment period, there was use prior to the breath analyses being performed. no significant difference between the two inter- Clinical measurements were taken between 7:30 dental cleaning devices. For the intermediate am and 12:00 pm, at baseline, overnight (day 1), assessments at 2-weeks, a significant difference day 7 and day 21. The primary outcome was the in favor of the RIBC was observed for gingivitis mean of duplicate Organoleptic scores (ORG) by (p<0.05). The mean gingival abrasion score at trained examiner. The secondary outcome was the end of treatment was 0.26 for the IDB and Volatile Sulphur Compounds (VSC) measure- 0.22 for the RIBC. Out of the 42 participants, 27 ments assessed using Oral Chroma (H2S, CH3SH preferred the RIBC over the IDB. and (CH3)2S) and Halimeter (HM) readings.

Conclusions: When used in combination Results: At baseline, according to ORG, H2S with toothbrushing, there were no statistically and HM, there was no statistical significant differ- significant differences between the 2 interdental ence between the regimens. At day 1, a statisti- devices in reducing plaque and gingival inflam- cal difference (p<0.05) was obtained in favor of mation. Less gingival abrasion occurs with the the test treatment regimen for ORG, H2S and HM RIBC, and participants preferred using this de- measurements. On day 7, this effect according to vice. H2S and HM was still maintained. At day 21, only the HM readings showed a statistical difference Study products were provided by SUNSTAR, (p<0.05) in favor of the test regimen. Japan/Switzerland, and funding support was provided by ACTA Dental Research BV. Conclusions: MBB was significantly reduced overnight with the test treatment regimen for several parameters. At day 21, the prolonged effect Effect of Chemotherapeutic Agents and on VSCs of the test treatment was only detectible Mechanical Tongue Cleaning on Morning with the HM readings. Bad Breath The study was performed with a grant from the Eveline Van Der Sluijs, RDH, BoH; Dagmar ACTA Dental Research BV. GABA, Switzerland ini- E. Slot, RDH, MSc; Sam C. Supranoto, RDH, tiated the study project and provided study prod- BoH; Fridus A. Van Der Weijden, PhD ucts. ACTA Research BV received financial support for their commitment to appoint this study to the ACTA Department of Periodontology. Problem Statement: The specific anti-halito- sis mouthwash containing amine fluoride, stannous fluoride, 0.2% zinc lactate and oral malodour Oral and/or Peri-Oral Piercings Are Not counteractives has not been evaluated in combi- Without Risks! nation with tongue cleaning and tooth brushing using a dentifrice formulated with similar ingredi- Nienke L. Hennequin-Hoenderdos, RDH, ents as the mouthwash. BoH, CRC; Dagmar E. Slot, RDH, MSc; Fridus A. Van Der Weijden, PhD Purpose: To assess the effect of a regimen using this specific mouthwash and a dentifrice with chemotherapeutic agents, and a tongue cleaner Objective: Oral complications of oral and/or on Morning Bad Breath (MBB) in periodontally perioral piercings have been documented, al- healthy subjects. though knowledge of the prevalence of piercings and related complications is lacking. To date, Methods: In total, 66 non-dental University the estimated effect size of this phenomenon is students participated in a 3-week parallel single- not known. blind, randomized, controlled clinical trial. After

94 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 Search Strategy/Selection Criteria: To Occupational Health systemically search the literature to determine the prevalence of oral and perioral piercings in young adults; the incidence of complications as- The Effect of Stainless Steel vs. sociated with lip and/or tongue piercings; and, Silicone Dental Instrument Handles to provide an overview of case reports describ- on Hand Strength and Comfort ing adverse effects. Melanie J Hayes, BOH, BHSc(Hons), PhD Data Collection and Analysis: This systematic review was performed in accordance with Problem Statement: Many dental hygien- PRISMA guidelines. The MEDLINE-PubMed, Co- ists experience musculoskeletal pain during the chrane-CENTRAL and EMBASE databases were course of their careers, often as a result of the comprehensively searched to identify appropri- sustained grips and repetitive movements em- ate studies (case reports, case series, case con- ployed throughout the work day. Current re- trols and cohort studies). Independent screen- search suggests that lighter instruments with ing by 2 reviewers of 1500 unique titles and a larger diameter reduce force and load on the abstracts resulted in 13 publications that provid- hand during scaling tasks; therefore, the texture ed information concerning prevalence; another and weight of silicone handles is designed to de- 13 publications evaluated incidence of compli- crease the strain placed on the hand and fingers. cations; and 67 case reports described complications concerning hard and⁄or soft tissues of Purpose: The purpose of the research is to in- the oral cavity and/or effects concerning general vestigate the effect of silicone instrument handles health. Data extraction regarding the three dif- vs traditional stainless steel instrument handles ferent purposes was performed by 2 reviewers. on hand comfort and strength; it is hypothesized Data was summarized in a meta-analysis, and that the silicone handle design will be more com- quality of the selected studies was graded. fortable to use, and have less impact on hand strength measures than traditional stainless steel Main Results: The mean prevalence of oral instrument handles. and/or peri-oral piercings was 5.2%. Tongue piercing (5.6%) was most common, followed by Methods: IRB approval has been obtained lip piercing (1.5%). Gingival recession was the from the University of Newcastle (Approval no most frequently described complication. The in- H-2014-0024). Using a crossover study design, cidence of gingival recession was 50% of sub- a convenience sample of dental hygiene students jects with lip piercings and 44% of subjects with (n=23) participated in two simulated scaling ses- tongue piercing. Tooth fracture was reported in sions for 30 minutes, one week apart. During 37% of subjects with tongue piercing. Oral and/ the first session, students were required to use or perioral piercings were observed in a rela- traditional stainless steel instruments (10 mm tively small percentage (5.2%) of young adults. diameter and 21-26 g weight), while during the Both lip and tongue piercings were frequently second session students used instruments with associated with risk of gingival recession and silicone handles. Following each session students tooth injuries. Among the case reports, there were required to complete a Hand Health Profile were minor complications, but also more severe and undertake hand strength tests. complications that were potentially life-threatening. Results: Paired t-tests will be used to analyze the data as the same subjects will be tested in Conclusions: Oral and/or perioral piercings this cross-over design. The analysis will look for are not without risks. Dental care profession- significant differences (p<0.05) between the sur- als are in an ideal position to offer information vey and hand strength measures after each ses- regarding safe piercings and to provide advice sion. regarding oral hygiene, aftercare and possible complications. Conclusions: The study has the potential to broaden the current knowledge base on ergo- This project was self-funded by the authors nomic instrument design and prompt the further and their institutions and supported by a seed investigation on the design of periodontal instru- grant from the Dutch organization that promotes ments. Future studies should consider random oral and dental health (Ivory Cross). assignment to the intervention being tested to limit potential confounders.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 95 Technology proven qualitatively to serve the patient, the teledentistry-assisted affiliated practice dental hygienist, and the affiliated practice dentist. Teledentistry-Assisted Affiliated Wilcoxon Signed Rank Tests demonstrate hy- Practice Dental Hygiene gienists’ abilities to obtain diagnostically effica- cious digital data from remote locations. Fred F. Summerfelt, RDH, AP, MEd

Purpose: The 2010 Patient Protection and Plasmadent: Advances in Plasma Affordable Care Act (PPACA) calls for midlevel Medicine Provides Promise for dental healthcare providers to work in under- Applications in Dentistry served areas with underserved populations. In 2004, Arizona passed legislation allowing quali- Gayle B. McCombs, RDH, MS fied dental hygienists to enter into an affiliated practice relationship with a dentist to provide oral healthcare services for underserved pop- Problem Statement: The need for devel- ulations without general or direct supervision oping new therapies to meet the challenges of in public health settings. The Northern Arizo- dentistry opens the door to utilizing plasma as a na University (NAU) Dental Hygiene Depart- medium to inactivate bacteria, enhance adhesion ment developed a teledentistry-assisted affili- and whiten teeth. ated practice dental hygiene model that places a dental hygienist in the role of the midlevel Purpose: Plasma is one of the universal four practitioner as part of a digitally-linked oral states of matter, the others being solid, liquid, and healthcare team. gas. In nature, the sun is a superheated ball of plasma; however, in the laboratory, low tempera- Significance: Utilizing current technologies, ture bio-compatible plasmas can be generated. affiliated practice dental hygienists can digitally Plasma is an ionized gas that has been charged/ acquire and transmit diagnostic data to a dis- energized to excite particles such as electrons tant dentist for triage, diagnosis, and patient and ions, and produce reactive oxygen species referral while providing preventive services (ROS). Plasma-cell interactions are complex, but permitted within the dental hygiene scope of studies show that ROS exhibit strong oxidative practice. properties that bacteria were found unable to survive. PlasmaDent, the utilization of plasma in Approach: NAU has pioneered an innova- dentistry, represents a major paradigm shift from tive teledentistry-assisted affiliated practice mechanical and chemical treatments, to device- dental hygiene model to answer the call of based molecular therapies. Low temperature at- the PPACA to provide comprehensive preven- mospheric pressure plasma (LTAPP) is under in- tive oral healthcare and diagnostic services for vestigation as a medium to inactivate pathogenic the growing population of underserved in both microorganisms associated with biofilms, dental urban and remote areas. NAU’s initial training caries, periodontal diseases and root canal infec- endeavors show that teaching the data acqui- tions. Other applications are in development to sition technologies to dental hygiene students enhance tooth whitening, adhesion, and surface and dental hygienists has been easily and suc- modification. cessfully accomplished. With only six-hours of training, dental hygiene students and dental hy- Methods: An electronic search was conduct- gienists have demonstrated their ability to set ed in PubMed, Medline and Google scholar. Key up and manage remote patient-service facili- search words included: cold plasma, dentistry, ties. While providing preventive oral healthcare and low temperature atmospheric pressure plas- services within the scope of affiliated practice, ma. Literature revealed numerous studies related dental hygiene students and dental hygienists to LTAPP utilization in dentistry. have acquired and forwarded diagnostically ef- ficacious digital data from remote locations us- Results: Increased interest in plasma has ing both store-and-forward and cloud-based brought about considerable research in the field. technologies. Studies have shown that various pathogenic microorganisms can be effectively reduced or ren- Evaluation: NAU’s teledentistry-assisted dered nonculturable after exposure to LTAPP. Lit- affiliated practice dental hygiene model has erature obtained revealed some contradictions

96 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 and/or inconsistencies among studies; however, strated effectiveness based upon self-assess- these may be due in part to the characteristics ment surveys and reflection. They were able to of individual microorganisms and configuration of apply this course material to practice and devel- the plasma equipment. Overall, preliminary data oped culturally relevant case scenarios to inte- supports the use of LTAPP to inactivate bacteria grate the unique ethnic data with the practice of associated with numerous oral conditions. LTAPP dental hygiene. The comparison group is a work has also been shown to enhance tooth whitening in progress. They have had clinical experiences and surface modification related to adhesion. to deliver care to diverse patient population yet not been evaluated to confirm the outcomes. Conclusions: Based on success in plasma medicine, a myriad of plasma applications in den- Funding for this project was through the Den- tistry are plausible. tal Hygiene Programs at New York University.

Health Literacy/Cultural Racial/Ethnic, Cultural, and Linguistic Competency Diversity among the Dental Hygiene Students Cultural Competence Curriculum: Are Anna Matthews, RDH, MS; Susan Davide, We There Yet? RDH, MS, MSEd; Anty Lam, RDH, MPH Cheryl M. Westphal Theile, EdD, RDH Problem Statement: Data collected about Purpose: The goal of this project is to dem- students is usually limited to race/ethnicity and onstrate outcomes which indicate effective cur- doesn’t include students’ cultural and linguistic riculum content for building cultural competence. background.

Significance: There is a need to develop eval- Purpose: to study the racial/ethnic, cultural, uation mechanisms designed to monitor knowl- and linguistic diversity of the dental hygiene stu- edge and performance indicating the graduate is dents; to determine the number of students who competent to communicate with diverse groups. are first-generation Americans, their countries of The U.S. population is growing so diverse that by origin and first/primary languages; and to inves- 2050 ethnic groups will make up 48% of the total tigate whether non-native English speakers ex- U.S. population. In 2010-2011 white dental hy- perience language-related difficulties. giene student population was 75.4% compared to 64% of U.S. population. Methods: This study was approved by CUNY IRB #461429-2. In 2013 we administered a Approach: In order to evaluate the effective- 24-question survey to 149 dental hygiene stu- ness of a curriculum two groups of students are dents. The survey consisted of two main parts: compared in this study. The first group enrolled 1) basic demographics, including race/ethnicity, in a formal online course and participated in all country of birth, cultural and educational back- assignments. Pre and post-tests were assigned ground; and 2) questions for students whose and evaluated by the instructor. Qualitative and first/primary language was other than English quantitative analysis was done to develop trends about their language use, preferences, and spe- in responses and to evaluate each learning mod- cific difficulties/concerns. Data was analyzed by ule. The comparison group is the current stu- descriptive statistics. dents in the program who have received only the experiential curricular content without structured Results: Most students were female (n=133, lecture content. The two groups will be compared 91.7%); average age was 27 years. Responders to determine which cultural content needs to be identified as: White – 52 (35.6%), Asian –37 required for all students. An IRB is submitted (25.3%), Hispanic/Latino – 31 (21.2%), Black/ for second group of students as they are still in African-American – 13 (8.9%), and Mixed Race/ the program. The first group has completed the Other – 13 (8.9%). Eighty-one responders course and the data is historical. (54.3%) were first-generation Americans born in 33 countries. Eighty-three students (56.1%) Evaluation: The first group indicated that all reported one of 26 different languages other aspects of learning were positive. They demon- than English as their primary. Although major-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 97 ity reported using English while communicating by residents to resist staff assistance, partially at work (65.9%), reading (58.9%), watching motivated by residents’ lack of confidence in care TV (57.3%) and using internet (73.0%), 20.7% staffs’ oral hygiene literacy and skills. In turn, by of these responders translated material when honoring resident’s independence, the staff en- studying, 23.5% had difficulty understanding abled excessive autonomy to occur and did not texts, and 42.0% felt they needed more time provide oversight in oral hygiene; creating an en- during tests. Additionally, 33.7% of responders vironment of iatro-compliance. had difficulty expressing their thoughts in writing and 32.5% orally. Conclusions: While it is beneficial to encourage autonomy, oversight and education must re- Conclusions: Our dental hygiene students are main an integral component of oral hygiene care very diverse racially/ethnically, culturally, and lin- in this population. Improved oral hygiene skills guistically. Students who are non-native English can be fostered in LTCF’s by utilizing the current speakers can experience language-related diffi- oral health care workforce. Registered dental hy- culties and barriers to success. gienists (RDHs), under indirect supervision of a dentist, can fulfill the role of an oral health care director (OHCD) in LTCF’s. A director’s presence Iatro-Compliance: An Unintended in a facility can decrease staff caused iatro-com- Consequence of Excessive Autonomy pliance and increase oral hygiene skills and lit- in Long Term Care Facilities eracy of the residents, while enhancing their autonomy through education and support. Melanie V. Taverna, MSDH, RDH; Carol Nguyen, MS, RDH; Rebecca Wright, MS, Health Behaviors RDH; James W. Tysinger, PhD; Helen M. Sorenson, MA, RT Association between Cigarette and Electronic Cigarette Use and Perceptions Problem Statement: Periodontal disease and of Risks in Urban High School Males: A caries remain the most prevalent preventable Pilot Cross-Sectional Study chronic diseases for seniors. Seniors transitioning into long term care facilities (LTCF’s) often pres- Elizabeth T. Couch, RDH, MS; Benjamin W. ent with oral health challenges linked to systemic Chaffee, DDS, MPH, PhD; Stuart A. Gansky, diseases, plaque control, psychomotor skills and DrPH; Gwen Essex, RDH, MS, EdD; Margaret oral health literacy. Many retain a discernible lev- M. Walsh, RDH, MS, MA, EdD el of physical and cognitive ability, establishing considerable autonomy. Problem Statement: Tobacco use, a major Purpose: This study examines the effect of risk factor for oral and systemic diseases, is often autonomy on residents’ ability to perform oral established during adolescence. Although youth hygiene. cigarette use has declined recently, electronic cigarette (e-cigarette) use is rising rapidly. Dif- Methods: Descriptive data were developed ferences in perceived risks associated with ciga- utilizing mixed methodology on a convenience rettes and e-cigarettes may contribute to adoles- sample of 12 residents and 7 care staff of a LTCF. cent use. One-on-one interviews consisted of Likert Scale questions about demographics. Fixed data were Purpose: To explore the association between analyzed using descriptive statistics to supple- perceived social risks (SRs) and health risks ment qualitative findings. Qualitative information (HRs) and use of cigarettes and e-cigarettes was analyzed using NVIVO 9™ in the construc- among high school males. tivist tradition to develop themes about ageism, respect, and time constraints and their influence Methods: A convenience sample of urban high on resident autonomy in oral care practices. school males completed a survey in this cross- sectional pilot study, in preparation for a larger Results: Data suggested shortcomings, such prospective study. After obtaining IRB approval, as a failure of the staff to ensure oral hygiene permission from school officials, and parent/stu- oversight and failure of the resident to ask for dent consent, data were collected on-site via an assistance. Autonomy, while laudable, was used anonymous, web-based survey. For cigarettes

98 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015 and e-cigarettes, the survey assessed ever-use miological data indicates a marked increase in (lifetime) and participants’ perceived probability the prevalence of childhood dental caries over (0 to 100%) that 6 specific SRs and 5 specific the past decade. This trend is very close in prev- HRs would happen to them from using each prod- alence to childhood obesity and shares similar uct. Mean ranked perceived HRs and SRs were influence from behaviors associated with both compared (Krusal-Wallis test) across 4 groups: diseases. Moreover, a lack in behaviors such as (a) never users (b) ever-users of cigarettes only; brushing and exercise also attribute to these (c) ever-users of e-cigarettes only; and (d) ever- disease processes. Interactive gaming should users of both. be recognized as a tool to improve toothbrushing behaviors among children. Results: Among 104 participants, 71% reported never-use, 9% only e-cigarette use, 8% Purpose: The purpose of this study was to only cigarette use, and 13% used both. Across all investigate effects of a collaboratively-designed participants, perceived SRs and HRs were greater interactive game on toothbrushing behaviors for cigarettes than for e-cigarettes. Perceived SRs for 5-6 year old children. and HRs of cigarettes were lowest among those reporting ever-use, but did not significantly differ Methods: This randomized, double-blinded across the 4 groups (p=0.33 for SRs, p=0.12 for study examined a convenience sample of 32 HRs). For e-cigarettes, perceived SRs and HRs children who were asked to play a game with were lowest among self-reported ever-users and a rhythmic toothbrushing song. Game play in- highest among never-users, with statistically sig- cluded animated guidance and feedback from a nificant differences detected across the 4 groups toothbrush sensor in the form of a haptic con- (p<0.001 for SRs and HRs). troller, similar to the popular Wii® game platform. 7 and 14-day dose-effects were measured Conclusions: In this population, cigarettes by calibrated examiners using pre and post- were perceived to have greater SRs and HRs than test data quantifying Time-on-Tooth Surface e-cigarettes. For e-cigarettes, lower perceived (TOTS) and metrics to evaluate toothbrushing SRs and HRs were associated with use. techniques. IRB approval was obtained from Morehouse School of Medicine. Parametric tests Funding for this project provided by NIH/NCI/ were used to analyze the data. FDA P50CA180890. Results: TOTS (p=.003) and sulcular brush position (p=.014) were toothbrushing behav- Brush Off! Promoting Oral Hygiene iors most strongly affected by game play of 14- Behaviors with a Game days.

Joyce M. Flores, RDH, MS; Traci Leong, Conclusions: A game using song, sensors PhD; Stella Lourenco, PhD; Dov Jacobson; and science should be considered as an inter- Jesse Jacobson; Stephanie Chergi; R.L. vention tool aimed at improving toothbrushing Jacobson, DDS behaviors in children.

Funding for this project was provided by Na- Problem Statement: The magnitude and tional Institute of Dental and Craniofacial Re- severity of dental caries exists globally and is a search, NIH R43 DE021334-01A. pending public health crisis. World-wide epide-

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 99 Explore the DHNet! The dhnet serves as the home base for the National Center for Dental Hygiene Research & Practice (NCDHRP or Center) and your connection to research resources that support dental hygiene education, practice and research. Within each of the sections there are several categories and quick links to major resources for your convenience. Also, each section has links to training programs, many of which are online and can be accessed at your convenience. Learn more about the Center and our research projects, educational and faculty development programs, and opportunities for you to volunteer to be part of studies in the About Us section. We also have created the DHNetwork for all those interested in research, from the novice or beginner just getting interested in research through those with extensive research experience. Click on Network to join and later begin to explore commonalities and research interests, learn from each other about new and ongoing research programs, and participate in collaborative efforts to systematically and purposefully advance dental hygiene practice and education through research.

Introducing the Master of Science in Dental Hygiene

Mission: to educate and train leaders to develop and promote advancements in the art and science of Dental Hygiene in today’s transforming health care environment. - Designed for dental hygienists who want to advance on transform their career - Three emphasis options: Education, Geriatric Dentistry & Pediatric Dentistry - Complete your program in just 16 months (30 units) - Classes on the USC University Park campus two days per week

For more information: dentistry.usc.edu/programs/dental-hygiene/master-of-science-in-dental-hygiene 100 The Journal of Dental Hygiene Vol. 89 • Suppl. 1 • February 2015

DHNET.indd 1 1/9/15 7:46 AM YOU CAN’T ALWAYS BE WITH YOUR PATIENTS— BUT YOUR RECOmmENdATION CAN Introducing the Oral-B® PRO 5000 with Bluetooth® Technology Oral-B’s latest power toothbrush connects to the Oral-B App to help patients brush in a gentle, effective, and compliant way. The app tracks their daily brushing routine so you can continue to coach and motivate them between visits. Recommend the Oral-B PRO 5000, and make patient compliance easier than ever.

Vol. 89 • Suppl. 1 • February 2015 The Journal of Dental Hygiene 101