journal of dental hygiene - american dental hygienists...

Vol. 90 • No. 3 • JuNe 2016 The JourNal of DeNTal hygieNe 143

•CollaborativeDentalHygienePracticeinNewMexicoandMinnesota

•AssessingDentalHygienists’CommunicationTechniquesforUsewithLowOralHealthLiteracyPatients

•ViewsofDentalProvidersonPrimaryCareCoordinationatChairside:APilotStudy

•AnEvaluationofPermitLLocalAnesthesiawithinDentalHygienePracticeinMassachusetts

•AssessingCulturalCompetenceamongFlorida’sAlliedDentalFaculty

•UtilizingaDiabetesRiskTestandA1cPoint-of-CareInstrumenttoIdentifyIncreasedRiskforDiabetesInanEducationalDentalHygieneSetting

•DoWaitingTimesinDentalOfficesAffectPatientSatisfactionandEvaluationsofPatient-ProviderRelationships?AQuasi-experimentalStudy

Journal ofDentalHygiene

The americaN DeNTal hygieNisTs’ associaTioN

June 2016 • Volume 90 • number 3

144 The JourNal of DeNTal hygieNe Vol. 90 • No. 3 • JuNe 2016

Journal of Dental Hygiene

CelesteM.Abraham,DDS,MSSumithaAhmed,RDH,BDS,MSCynthiaC.Amyot,MSDH,EdDJoannaAsadoorian,AAS,BScD,MSc,PhDCarenM.Barnes,RDH,MSKathrynBell,RDH,MSStephanieBossenberger,RDH,MSLindaD.Boyd,RDH,RD,EdDJennieBrame,RDH,MSKimberlyS.Bray,RDH,MSColleenBrickle,RDH,RF,EdDLorraineBrockmann,RDH,MSPatriciaRegenerCampbell,RDH,MSMichelePCarr,RDH,MALorindaLCoan,RDH,MSMarieCollins,EdD,RDHSharonCompton,PhD,RDHMaryAnnCugini,RDH,MHPSusanJ.Daniel,BS,MSJaniceDeWald,BSDH,DDS,MSMelissaGEfurd,EdD,RDHKathyEklund,RDH,MHPDeborahE.Fleming,RDH,MSPriscillaFlynn,RDH,MPH,DrPHJaneL.Forrest,BSDH,MS,EdDJacquelynL.Fried,RDH,MS

DanielleFurgeson,RDH,MSMaryGeorge,RDH,BSDH,MedJoanGluch,RDH,PhDMariaPernoGoldie,MS,RDHEllenB.Grimes,RDH,MA,MPA,EdDTamiGrzesikowski,RDH,MEdJoAnnR.Gurenlian,RDH,PhDAnneGwozdek,RDH,BA,MALindaL.Hanlon,RDH,PhD,BS,MedHaroldA.Henson,RDH,MEDJessicaHolloman,RDH,MSAliceM.Horowitz,PhDLynneCarolHunt,RDH,MSOlgaA.C.Ibsen,RDH,MSHeatherJared,RDH,MS,BSRachelKearney,RDH,MSJanetKinney,RDH,MSSalmeLavigne,RDH,BA,MSDHJessicaY.Lee,DDS,MPH,PhDDeborahLyle,RDH,BS,MSLisaF.HarperMallonee,BSDH,MPH,RD/LDDeborahS.Manne,RDH,RN,MSN,OCNOliviaMarchisio,PhDAnnL.McCann,RDH,MS,PhDGayleMcCombs,RDH,MSFrancesMcConaughy,RDH,MS

ShannonMitchell,RDH,MSTanyaVillalpandoMitchell,RDH,MSTriciaMoore,EdDChristineNathe,RDH,MSJohannaOdrich,RDH,MS,PhD,MPHJodiOlmsted,RDH,BS,MS,EdS,PhDPamelaOverman,BS,MS,EdDVickieOverman,RDH,MEdCeibPhillips,MPH,PhDKathiR.Shepherd,RDH,MSMelanieSimmer-Beck,RDH,PhDDeanneShuman,BSDH,MSPhDJudithSkeleton,RDH,MEd,PhD,BSDHAnnEshenaurSpolarich,RDH,PhDRebeccaStolberg,RDH,BS,MSDHJulieSutton,RDH,MSSherylL.ErnestSyme,RDH,MSTerriTilliss,RDH,PhDLynnTolle,BSDH,MSBethanyValachi,PT,MS,CEASMarshaA.Voelker,CDA,RDH,MSPatWalters,RDH,BSDH,BSOBDonnaWarren-Morris,RDH,MeDCherylWestphal,RDH,MSKarenB.Williams,RDH,MS,PhDPamelaZarkowski,BSDH,MPH,JD

eDitorial review BoarD

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

Statement of PurPoSe

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

SuBmiSSionS

The Journal of Dental Hygiene is published bi-monthlyonlineby theAmericanDentalHygienists’Association, 444 N. Michigan Avenue, Chicago, IL60611. Copyright 2016 by the American DentalHygienists’Association.Reproductioninwholeorpartwithoutwrittenpermissionisprohibited.Subscriptionratesfornonmembersareoneyear,$60.

SuBScriPtionS

Chief Executive OfficerAnnBattrell,[email protected]

Chief Operating OfficerBobMoore,MA,[email protected]

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

Editor EmeritusMaryAliceGaston,RDH,MS

Director of [email protected]

Staff [email protected]

PresidentJillRethman,RDH,BA

President ElectBettyKabel,RDH,BS

Vice PresidentTammyFilipiak,RDH,MS

TreasurerDonnellaMiller,RDH,BS,MPS

Immediate Past PresidentKelliSwansonJaecks,MA,RDH

2015 to 2016 aDHa officerS

Volume 90 • number 3 • June 2016

aDHA/JDH Staff


inSiDeJourNal of DeNTal hygieNe

Vol. 90 • no. 3 • June 2016

featureS

eDitorial

reSearcH

146 The Impact of Leadership and Research on Decision Making: Doctoral Degrees in Dental Hygiene – A True Transformation for Dental Hygiene Education JoAnnR.Gurenlian,RDH,MS,PhD

148 Collaborative Dental Hygiene Practice in New Mexico and Minnesota KathleenO.Hodges,RDH,MS;EllenJ.Rogo,RDH,PhD;AllisonC. Cahoon,RDH,MS;KarenNeill,RN,PhD,SANE-A

162 Assessing Dental Hygienists’ Communication Techniques for Use with Low Oral Health Literacy Patients PriscillaFlynn,RDH,MPH,DrPH;KelseySchwei,PhD;JeffreyVanWormer, PhD;KaitlynSkrzypcak,BS;AmitAcharya,BDS,MS,PhD

170 Views of Dental Providers on Primary Care Coordination at Chairside: A Pilot Study MaryE.Northridge,PhD,MPH;ShirleyBirenz,RDH,MS;DanniM.Gomes, RDH;CynthiaA.Golembeski,MPH;ArielPortGreenblatt,DMD,MPH; DonnaShelley,MD,MPH;StefanieL.Russell,DDS,MPH,PhD

181 An Evaluation of Permit L Local Anesthesia within Dental Hygiene Practice in Massachusetts KatherineA.Soal,CDA,RDH,MSDH;LindaBoyd,RDH,RD,EdD;Susan Jenkins,RDH,MS,CAGS;DebraNovember-Rider,RDH,MSDH;Andrew Rothman,MS,EIT

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

197 Utilizing a Diabetes Risk Test and A1c Point-of-Care Instrument to Identify Increased Risk for Diabetes In an Educational Dental Hygiene Setting LoriJ.Giblin,RDH,MS;LoriRainchusoRDH,MS;AndrewRothman,MS, EIT

203 Do Waiting Times in Dental Offices Affect Patient Satisfaction and Evaluations of Patient-Provider Relationships? A Quasi- experimental Study MaritaRohrInglehart,Dr.phil.habil;AlexanderH.Lee,BS;KristinG. Koltuniak,BS,RDH;TaylorA.Morton,RDH,BS;JennaM.Wheaton,RDA, RDH,BSDH


TheImpactofLeadershipandResearchonDecisionMaking:DoctoralDegreesinDentalHygiene–ATrueTransformationforDentalHygieneEducation

eDiTorial

JoAnnR.Gurenlian,RDH,MS,PhD

Thisnextdecadeisgoingtobeanexcitingtimefordentalhygieneeducation.Whiletherehasbeenanem-phasison transformingdentalhygieneeducation, theprofessionisabouttowitnesschangethelikesofwhichhasneveroccurredbefore.DoctoraldegreeprogramsindentalhygienewillbedevelopedforthefirsttimeinprogramhistoryintheU.S.

In2005,theAmericanDentalHygienists’Association(ADHA)publishedadocumententitledDental Hygiene: Focus on Advancing the Profession.1Withinthispaper,theprofessionrecognizedthatdentalhygienescholarswere needed to lead the development of theory andknowledge unique to the discipline of dental hygieneandthattherewasashortageofdentalhygienefacultythatwasexpectedtocontinueintothefuture.Thelead-ersnotedthatdoctoralpreparationofdentalhygienistsisessentialforbuildingthedentalhygieneknowledgebaseforadvancingtheprofessionalizationprocess.Fur-ther,anaimrecommendedwithin thisdocumentwastocreateadoctoraldegreeprogramindentalhygiene.Recommendationswereto:1

• Develop curricular models for both professional(doctorofscience indentalhygienepractice)andacademic (doctor of philosophy or PhD) doctoralprogramsindentalhygiene

• Conduct educators’ workshops at professionalmeetingstopromotethedevelopmentofdoctoralprogramsindentalhygiene

• Publishcurricularmodelsfordoctorateprograms

Overthenextdecade,discussionsoccurredfurthersup-porting theneed for doctoral education in dental hy-giene,2-5workshopswere offered establishing interestincreatingdoctoralprogramsfordentalhygiene,6andresearchhasbeenconductedaboutthistopic.7Specifi-cally,Tumathetal surveyedgraduatedentalhygienestudents to assess perceptions of importance in es-tablishingdentalhygienedoctoralprogramsandinter-estinapplyingtothem.7Ofthe159graduatelearnersrespondingtothesurvey,themajorityofrespondents(77%) indicatedthatdoctoraleducation indentalhy-gieneisneededandtheestablishmentofadentalhy-giene doctoral degree is important to the profession(89%).Althoughmost respondents supportedbotha

PhDindentalhygieneandtheDoctorofDentalHygienePractice(DDHP),38%preferredthePhDprogramwhile62%preferredaDDHPprogramfor themselves.Fur-ther,43%expressedinterestinenrollinginadoctoralprograminthenextonetofiveyears.7

CurriculummodelsforbothaPhDProgramandentryleveldoctorateindentalhygienehavebeenproposed.8ThePhDprogramisdesignedtoprepareacademiciansandresearcherstoexpandthescientificbodyofknowl-edge in the dental hygiene discipline, and develop acadreof leaderscapableof impactinghealthpolicytoimproveaccesstodentalhygienecare.Theentryleveldoctorateconceptisdesignedtopreparegraduatestofunctionindependentlyandworkcollaborativelyonin-ter-professionalhealthcareteams.Studentswillentertheprogramwithabaccalaureatedegreeandcompletea4-yearcurriculumwithpracticumexperiences inall6rolesofthedentalhygienistsotheyarepreparedtofunctioninavarietyofhealthcaresettingstocompli-mentclinicalpractice.8Withmodification,theentryleveldoctoratemodelcouldserveasthebasis foraDDHPprogramforcurrentdentalhygienistsseekingadoctoraldegree.

Inthenearfuture,thereare3viableoptionsfordoc-toraleducationfordentalhygiene.ThePhDprogramisalreadyundergoing institutional approval processandcouldstartasearlyasFall2017pendingstateboardofeducationapproval.Onceoneprogrambegins,others,includingtheDDHPandentrylevelconcepts,willfollow.Asthistransformationofdentalhygieneeducationoc-curs, theprofessionwill change.Theorydevelopmentwilladvance,researchwillbroaden,newacademicianswillbepreparedandahigherlevelofclinicianswillbecontributingtoimprovingtheoralhealthchallengesofthenation.Equallyexciting,thesegraduateswillpos-sessfouryearsofeducationatthegraduatelevelequiv-alenttootherhealthcareprofessionals.Thus,therenolongerwillbeaneedforclinicianstobeheldtounneces-sarysupervisoryrestrictionsbyanotherdiscipline.Thatistrulyalongoverduetransformation!

Sincerely,

JoAnnR.Gurenlian,RDH,MS,PhD


1. DentalHygiene.FocusonAdvancingtheProfes-sion.AmericanDentalHygienists’Association[In-ternet].2004[cited2016June8].Availablefrom:https://www.adha.org/resources-docs/7263_Fo-cus_on_Advancing_Profession.pdf

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

3. Boyd LD, Henson HA, Gurenlian JR. Vision forthe dental hygiene doctoral curriculum. Access.2008;22(6):16-19.

4. Ortega E, Walsh MM. Doctoral dental hygieneeducation:Insights fromareviewofnursing lit-erature and program websights. J Dent Hyg.2014;88(1):5-12.

referenceS

5. Gurenlian JR, Spolarich AE. Advancing the pro-fession throughdoctoral education. J Dent Hyg.2013;87(Suppl1):29-32.

6. GurenlianJR,SpolarichAE.Creatingthedoctoraldegreeindentalhygiene.Tampa,Florida:Ameri-canDentalEducationAssociationAnnualSession;2012.

7. TumathUG,WalshM.Perceptionsofdentalhygienemaster’s degree learners about dental hygienedoctoraleducation.J Dent Hyg.2015;89(4):210-218.

8. Gurenlian JR, Rogo EJ, Spolarich AE. The doc-toraldegreeindentalhygiene:Creatingneworalhealthcare paradigms. J Evid Base Dent Pract.2016S1:1-6.


Alandmarkreportin2000identifiedoraldiseaseasa “silentepidemic”affectingmillionsofAmer-icans.1 This epidemic is enhanced by oral healthdisparitiesfoundinminoritygroups,2,3low-incomefamilies including Medicaid-enrolled children,4,5olderadultpopulations,6institutionalizedindividu-als3andinpopulationgroupsinoralhealthprofes-sionalshortageareas.5Thesefactorsinfluenceoralhealthoutcomesinapopulation.

In2003,theNationalCalltoActiontoPromoteOralHealthestablishedthenecessityforpublicandprivate entities towork together to enhanceoralandgeneralhealth.3Inresponse,manystatesde-velopedstrategies toexpandoralhealth servicesprovidedbydentalhygienists.7Somestatesliftedpracticerestrictionsandpermittedprovisionofdi-rectaccessserviceswheredentalhygieniststreatpatientsaccording to their assessmentofpatientneeds,work independentlyofadentist’ssupervi-

CollaborativeDentalHygienePracticeinNewMexicoandMinnesotaKathleenO.Hodges,RDH,MS;EllenJ.Rogo,RDH,PhD;AllisonC.Cahoon,RDH,MS;KarenNeill,RN,PhD,SANE-A

AbstractPurpose:Thisdescriptive,comparativestudywasconductedtoexaminecharacteristics,services,mod-elsandopinionsamongcollaborativedentalhygienepractitionersinNewMexicoandMinnesota.Methods:Aself-designedonlinequestionnaire,distributedviaSurveyMonkey®,wasutilizedtocollectdatafrom73subjectswhomettheinclusioncriteria.Amulti-phaseadministrationprocesswasfollowed.Contentvalidityandreliabilitywasestablished.Descriptivestatisticswereusedforanalysisof6researchquestions.TheMann-WhitneyU,PearsonChi-SquareandFisher’sExacttestswereemployedtoanalyze4nullhypotheses(p=0.05).Results: Mostparticipants(n=36)wereexperiencedclinicianswhochosetoworkinanalternativeset-tingafter28yearsormoreinthefieldandreportedincreasedaccesstocareasthereasonforpracticingcollaboratively.AvarietyofserviceswereofferedandprivateinsuranceandMedicaidwereaccepted,althoughmanypractitionersdidnotreceivedirectreimbursement.ThemajorityofNewMexicopartici-pantsworkedinprivatedentalhygienepractices,earnedadvanceddegreesandservicedHealthProviderShortageAreas.ThemajorityofMinnesotarespondentsworkedinvariousfacilities,earnedassociate’sdegreesandwereuncertainifHealthProviderShortageAreaswereserved.Therewerenosignificantdifferencesinthevariablesbetweenpractitionersinbothstates.Conclusion:NewMexicoandMinnesotacollaborativedentalhygienepractitionersaresimilarincharac-teristics,services,andopinionsalthoughmodelsofpracticevary.Collaborativedentalhygienepracticeisaviableanswertoincreasingaccesstocareandisanoptionforpatientswhomightotherwisegowithoutcare,includingtheunserved,underserved,uninsuredandunderinsured.Keywords:oralhealth,healthcaredisparities,healthservices,healthservicesaccessibility,dentalhy-gienist,independentpractice,accesstohealthcareThisstudysupportstheNDHRApriorityarea,Health Services Research: Investigatehowalternativemodelsofdentalhygienecaredeliverycanreducehealthcareinequities.

research

introDuction

sion,andmaintainaprovider-patientrelationship.8

In2014,46statesallowedsomeformofdirectaccess dental hygiene care such as independentpractice, collaborative practice dental hygiene(CPDH), access permits and other deliverymod-els.8Thereisagrowingnumberofdentalhygien-ists with special permits to provide care beyondwhatwasestablishedintheoriginalstate’slaws.9In 2007, 47.3% of all dental hygienists reportedhaving a certification or permit to practice underspecialprovisions,suchasunsupervisedpractice.9

CPDH is the science of prevention and treat-ment of oral disease by providing education, as-sessment,prevention,clinicalandtherapeuticser-vicesinacooperativeworkingrelationshipwithaconsulting dentist without supervision.10 Alaska,Colorado,Maine,NewMexicoandNewYorkhavefurther increased the scope of practice by allow-


ing direct access services to be provided in anysetting, including privately owneddental hygienepractices.8

In1999,NewMexicobecamethesecondstateto allow dental hygienists to practice in any set-tingwithout the supervision of, but in collabora-tionwithdentists. In2001,Minnesota legislationpermitted dental hygienists to be employed by ahealthcarefacility,programornon-profitorganiza-tiontoprovideauthorizedservices.8Treatmentcanbe initiatedwithout thepatientfirstbeingexam-inedbyadentist.Therequiredwrittenagreementforbothstatescontainsmandatorywrittendocu-mentation, suggested written records and proto-cols for care.10,11 The U.S. Department of Healthand Human Services emphasized the importanceofresearchinginnovativeways,suchastheCPDHmodel, to increase theoral healthworkforceandimproveaccesstocaretoreduceoralhealthineq-uities.3

Historically, research conducted in Californiaand Colorado revealed that direct access dentalhygienepracticeprovidedhighqualityoralhealthcare,offeredaviablesolutiontoaddressaccesstooralhealthcareproblemsandreferredpatientstosurroundingdentistsonayearlybasis.12-15Unmetoral health needs have placed a huge burden ontheAmericanpopulation.

The National Institute of Dental and Craniofa-cialResearchsuggestedthemostcommonhealthproblemsamonglow-income,disadvantaged,dis-abled and institutionalized individuals were oraldiseases.16Specifically, low-incomeandMedicaid-enrolledchildrenwereatanincreasedriskforpoororalhealth.17

The older adult population is another high-riskpopulationgroup.Periodontaldiseaseispresentin75%ofadultsovertheageof65andisthemostcommoncauseoftoothlossinolderadults.18Manyelderlyindividualshavelostdentalinsuranceuponretirementwhichhasinfluenceddecisionstoseekcare.1Coupletheriskofperiodontaldisease,toothlossandotherdiseasessuchascaries,xerostomiaandheartdiseasewiththelossofdentalinsuranceandtheriskfororaldiseaseisintensified.

Unfortunately, institutionalizedandhomeboundindividuals have suffered a disproportionate bur-den of accessing dental care, regardless of theirability to pay for services.19 In the recent past,approximately 1.8 million people were living innursinghomes, and this number is increasing asthepopulationages.20With limitedaccess tooralhealthcare,affordableornot,optimumoralhealthisdifficulttoachieve.

Lastly,disparitiesinoralhealtharealsothere-sult of an unevenly distributed oral healthwork-force.TheU.S.DepartmentofHealthandHumanServicesestimated thatanadditional 7,208den-tistswereneededintheU.S.tomeettheadequatepopulationtopractitionerratioof4,000:1forhighneedcommunities.21Unlesschangesaremade inoralhealthworkforceinitiatives,accesstocareis-sueswillmostlikelyfurtherdeteriorate.

Theinitialdirectaccessresearchwasconductedwith dental hygienists participating in the HealthManpower Pilot Project #139 (HMPP #139) from1987to1990 inCalifornia.13-15Kushmanetal re-portedthatHMPP#139practicesshowedasteadyincreaseofnewpatients,lowfeesforservicesandreferralsbeingmadetosurroundingdentists.14Theauthors concluded that theHMPP#139 practicesoffereddentalhygienistsaviableandflexibleal-ternativetotraditionalsettings.14Ayearlater,an-other study determined that patientswere satis-fiedwithtreatment,followedthedentalhygienists’advice and visited a dentist within 12 months.15TheHMPP#139wasaprecursortotheRegisteredDentalHygienistinAlternativePractice,whichwasinitiatedin1998allowingdentalhygienistsinCali-forniatoperformdirectaccessservices.8

A study of 6 independent practice Coloradodental hygienists assessed productivity, services,office structure and patient process of care, andmadeacomparison to theHMPP#139.12Conclu-sions suggested that care and services providedby independentdentalhygienepractitionersweresafeandposednoharmtothepublic.Thisstudyand theHMPP#139studiesconcluded that inde-pendentdentalhygienepracticeanddirectaccessdentalhygienenotonlyofferedaviablesolutiontoaddress access to care problems, but provided areferralsourceforsurroundingdentistsandasafealternativeforthepatient.12-15

Limited Access Permits (LAPs) in Oregon wereanotherformofdirectaccess.In2007,apositiveworkingrelationshipwasfoundbetweenLAPden-talhygienistsand theaffiliateddentists,and thispractice model offered patients high quality oralhealth care.22 As of 2011, the LAP was replacedbytheExpandedPracticeDentalHygienist(EPDH)furtherexpandingthescopeofpractice.8

Depending on state law, dental hygienists areabletoprovidecertainserviceswithoutthepres-enceofadentistand,thus,cancontributetoim-provingaccesstooralhealthcare.8Currently,Col-orado istheonlystate inwhichdentalhygienistscanpracticeinallsettingswithoutcollaborationorsupervisionofadentist.Fourdirectaccessstatesallowpracticeinanysettingwithawrittenagree-ment and/or availability of a dentist for referral


or consultation.8 Many other direct access statespermitpracticeinlimitedsettingsandrequireanyorallofthefollowing:writtenagreement,referralplanand/orpriordentistauthorization.8

Direct access dental hygiene plays an impor-tant role in the accessibility and affordability oforalhealthcare;therefore,asearlyas2001,theAmerican Dental Hygienists’ Association (ADHA)recognizedthatdirectreimbursementfromMedic-aidandprivateinsurancecompanieswascritical.23Only 16 of 46 direct access states had statutoryor regulatory language allowing a dental hygien-isttobedirectlyreimbursedbythestateMedicaiddepartment.23

Ofthemanydirectaccessstates,7(Alaska,Ar-kansas, Massachusetts, Minnesota, New Mexico,NewYorkandSouthDakota)hadpracticeactsthatincluded collaborative practice terminology.8 NewMexicoandMinnesotawerestudiedbecausetheywere similar in regards to the services provided,the year CPDH was established and the lack ofresearch on collaborative practice; although, theCPDHsettingsweredifferent.

ThestateofNewMexicoisrichincultureanddi-versitywiththemajorityofitspopulationbeingofethnicoriginand20.4%ofpersonslivebelowpov-ertylevel.24In2013,aNewMexicoStrategicPlanwas devised, including an objective to increaseaccess to preventive and dental services.25 It in-cludes5strategiessuchasdevelopingaculturallyappropriateandbilingualpreventioncampaignfororalhealth,increasingaccesstocareforthoseinlongtermandnursinghomefacilities,anddevel-opinganoralhealthstrategicplan.25

Since 1999, CDHPs in New Mexico have beenpracticing with fewer restrictions than other li-censeddentalhygienists inthestate.Therehavebeenconflictingreviews,however,onthefeasibilityandcomplexityofestablishingthistypeofpractice.Some restrictions still apply that limit the CPDHfromperformingefficientlyandeffectively includ-ing,butnot limitedto,difficultybuildingpartner-shipswithdentistsandcomplications inreceivingreimbursementfromthird-partypayers.26In2011,12 out of 17CDHPs did not have aMedicaid re-imbursementnumberbecausethepaperworkwaschallengingandconfusing.26ThegreatestbarrierstoCPDHwerefindingawillingdentistandreceiv-ing reimbursement.26 Currently, efforts are beingmadetodevelopadentaltherapistinNewMexico.

Incontrast toNewMexico, themajorityof theMinnesotapopulation(86.2%)waswhiteandonly11.5%was below poverty level.27 In early 2008,efforts were made in Minnesota to establish 2new“mid-level”oralhealthproviders; theDental

Therapist(DT)andtheAdvancedDentalTherapist(ADT).28DTsgraduatewithabachelor’sormaster’sdegreeandprovidebasicpreventiveserviceswith-outadentistonsite,however,allbasicrestorativeservicesandextractionsrequirethepresenceofadentist.TheADTisamaster’slevelpreparedden-tal hygienemodel permitting evaluation, assess-ment,treatmentplanning,nonsurgicalextractions,preventiveservicesandbasicrestorativeserviceswithoutthepresenceof,butincollaborationwith,a consulting dentist.28 Also, the AdvancedDentalHygienePractitioner(ADHP)model,developedbytheADHA,describesadentalhygiene“mid-level”practitionerwhoprovidesprimaryoralhealthcaredirectlytopatientsthroughassessment,diagnosis,treatmentandreferrals.29

Although these states differ demographically,they are similar in regards to CDHP. Therefore,6 research questions were studied about CDHPscharacteristics, services provided, models, opin-ions,benefitsorobstaclesofoperatingorworkinginacollaborativepracticeinNewMexicoandMin-nesota.Inaddition,4nullhypothesesweretestedtoassessanydifferences inCDHP inNewMexicoand Minnesota in regards to characteristics, ser-vicesprovided,modelsandopinionsaboutCPDH.

metHoDS anD materialS

A descriptive, comparative survey design wasusedandnon-probabilitysamplingemployedtoob-tainapurposivesample.Thepopulationconsistedof156CDHPs inNewMexicoandMinnesotawithactivecollaborativelicensesprovidingservicesfora minimum of 1 year. A 43-question instrumentwasdevelopedincludingclosed-ended,open-end-ed, and 6-point Likert scale questions, the latterwithresponsesfrom“stronglyagree”to“stronglydisagree.”Sixprofessionalexpertsuseda4-pointContentValidityIndexScaletorateeachquestionfor relevance to establish content validity. Ques-tionsscoringlessthan0.80wererewrittentoim-proveclarity,ordiscarded.30Apilottest,conductedtoestablishtest-retestreliability,employed3NewMexicoand7MinnesotaCDHPswhocompletedthesurveyontwoseparateoccasions.A0.83levelofagreementwasestablishedindicatingreliability.

ThelicensingagencyineachstatewascontactedforlistsofCDHPscontainingnames,addressesandtelephone numbers. First, each qualifying CDHPwascontactedbylettertoobtainanemailaddress.Twoweekslater,telephonecallsweremadetocol-lectemailaddressesofthosewhodidnotrespondto the mailed letter request. Next, a pre-noticeemail letterwassent topotentialparticipants in-vitingthemtoparticipate.Oneweeklater,acoverletteremailandquestionnairewassentusingSur-


reSultS

veyMonkey®.Informedconsentnotifiedpotentialrespondents that participationwas voluntary andtherewerenoconsequences fordecliningtopar-ticipateorwithdrawing.Participantsindicatedcon-sentandprovidedanemailaddressifinterestedinentering the incentivedrawing.A follow-upemailwasdeliveredtoallpotentialparticipants1weeklater.Lastly,anemailwassenttothosewhofailedto respond to the follow-up email within 7 days.Datawerecollectedoveraperiodof3weeks.

Data were downloaded, confidentiality of re-sponses was maintained and anonymity of par-ticipation was protected. Descriptive statistics(means, percentages) were used to summarizedataandinferentialstatisticstestedfordifferencesbetween the New Mexico and Minnesota CDHPs.Nonparametric tests, including theMann-WhitneyU,PearsonChi-SquareandFishersExact,wereem-ployedtoanalyzethe4nullhypotheses(p=0.05).Theresponses to theopen-endedquestionswereanalyzed by first assigning codes to small seg-ments of data representing a significant piece ofdatathatpotentiallycouldbeusedtoanswertheresearchquestion.31Oncetheentiredatasetwasdeconstructedintoinitialcodes,thesecodeswerereviewedtodeterminecommondescriptivethemesin which to group numerous initial codes.31 ThethemesrelatedtobenefitsandobstaclesofCDHPbycategorizingresponsesbystateandorganizingresponsesintocommonthemes.

Of 156 potential CDHPs, 73 email addresseswereobtained;25fromNewMexicoand48fromMinnesota. The remaining 83 email addresseswereunattainableduetodisconnectedtelephonenumbers (n=38)andnotansweringor returningtelephone calls (n=26). Fourteen potential par-ticipantswere no longer aCDHP and 5 declinedtoparticipate.Of the73 surveysdistributed,36responses were obtained (49.3%, 6 from NewMexicoand30fromMinnesota;23%and64%re-sponseraterespectively).FourrespondentsfromMinnesotadidnotanswerquestionsabout“prac-ticemodels”and“opinions.”

Mostrespondents(n=32)were40yearsorold-erandhad28yearsormoredentalhygieneexpe-rience(n=14).Eighty-threepercentofNewMexi-coCDHPsand33%ofMinnesotaCDHPsearnedabachelor’sdegreeorhigher.TheprimaryreasonsforbecomingaCDHPwere“greatercontrolofpa-tientcare”and“increaseaccesstocare”(TableI).

Table II presents the services providedby re-spondents practicing in a CDHP model. Thirty-three percent (n=2) of NewMexico CDHPs pro-vided20to29adultprophylaxesperweek.Eight

MinnesotaCDHPs(26.7%)provided30to39perweek. Most CDHPs provided child prophylaxes,nonsurgical periodontal therapy, and periodontalmaintenancetherapyonaweeklybasis.Mostre-spondents cared for patients with private insur-ance coverage (100% New Mexico and 76.6%Minnesota).Themajorityofrespondents(88.9%,n=32) cared for those with Medicaid coverage,and96.7%(n=29)oftheMinnesotapractitionersprovided care for patients with Medicaid cover-age.Onlyabout30%oftheparticipantsreceiveddirectreimbursementfromMedicaidorprivatein-surancecompanies.

HalfofNewMexicorespondingCDHPs(n=3)re-ferredpatientstootheroralhealthcareprovidersandhalf(n=3)preferredthecollaboratingdentisttomakereferrals.Approximately66.7%(n=4)ofNew Mexico CDHPs referred patients to generalphysicians for medical consultations. In Minne-sota,about70%ofCDHPspreferredthatthecol-laboratingdentistmakebothtypesofreferrals.

TableIIIreportstheCDHPmodels.Thesedatashowthatmostrespondentsprovidedservicesinhealth provider shortage areas. Themajority ofmodelshad3ormoredentistsproviding servic-es within the collaborative practice model (NewMexico 50%, Minnesota 69.3%). Half of NewMexicocollaborativepracticemodels(n=3,50%)employed 1 or 2 additional part-time dental hy-gienists,whereasinMinnesota,themajorityem-ployed2ormoreadditionalpart-timeorfull-timedentalhygienists(n=18,69.1%).Employmentofadditionaldentalassistantsandreceptionistswascommon, however, only half of the New Mexicorespondentsemployedadditionalstaffmembers.Mostcollaborativepracticeswereinoperationforatleast5to6yearsandlonger(78.1%).Regard-ingthestructureofthecollaborativepractice, inNewMexico halfwere office-based (n=3, 50%),2 were institutional-based, and 1 was mobile-based. In Minnesota, half of the collaborativemodelswere institutional-based (n=13,50%),9wereoffice-basedand4weremobile-based.

OpinionsofCDHPsareoutlinedinTableIV.Mostrespondents“stronglyagreed”thatpatientsweresatisfied with the services they received, CPDHofferedautonomyandcollaborativedentistsweresupportive.ThemajorityofCDHPs(n=29,90.6%)“agreed,” “moderately agreed” or “stronglyagreed” that finding a collaborative dentist waseasy,however,2NewMexicoCDHPs“stronglydis-agreed.”Also,themajorityofrespondents(n=24)agreed that patient’s followed-up on dentist re-ferrals,however,8MinnesotaCDHPswereunsureabout this follow through. Unfortunately, directreimbursement from Medicaid or private insur-ance companies was unlikely (n=20, n=19, re-


CharacteristicsNewMexico Minnesota

n Percent n PercentOwnthePractice

YesNo

42

66.70%3.30%

129

3.30%96.70%

OwntheFacilityYesNo

15

16.70%83.30%

030

0.00%100.00%

GenderMaleFemale

06

0.00%100.00%

030

0.00%100.00%

Age<20years21to29years30to39years40to49years50to59years>60years

000222

0.00%0.00%0.00%33.30%33.30%33.30%

01311132

0.00%3.30%10.00%36.70%43.30%6.70%

HighestDegreeAssociatedegreeinDentalHygieneBaccalaureatedegreeinDentalHygieneBaccalaureatedegreeinanotherfieldMaster’sdegreeinDentalHygieneMaster’sdegreeinanotherfieldDoctoraldegree

120120

16.70%33.30%0.00%16.70%33.30%0.00%

2052030

66.70%16.70%6.70%0.00%10.00%0.00%

YearsofClinicalDentalHygieneExperience<6years7to13years14to20years21to27years>28years

00213

0.00%0.00%33.30%16.70%50.00%

047811

0.00%13.30%23.30%26.70%36.70%

HoursperWeekProvidingCollaborativeDentalHygieneServices<10hoursperweek11to19hoursperweek20to29hoursperweek30to39hoursperweek>40hoursperweek

22020

33.30%33.30%0.00%33.30%0.00%

913161

30.00%3.30%10.00%53.30%3.30%

ReasonforBecomingaCollaborativeDentalHygienistAutonomyFinancesCareergrowthopportunityIncreaseaccesstocareforunderservedGreatercontrolofpatientcare

11220

16.70%16.70%33.30%33.30%0.00%

2011215

6.70%0.00%3.30%40.00%0.5

TableI:CharacteristicsofCollaborativeDentalHygienePractitioners(n=36)a

aTotalpercentagesmightnotequal100%duetorounding

spectively).Only12CDHPs(37.5%)receiveddi-rectreimbursementfromMedicaid,8ofwhichfeltitwasaneasyprocess.ThirteenCDHPs(40.6%)receiveddirectreimbursementfromprivateinsur-ance companies, 9 of which felt it was an easyprocess. On the other hand, 4 CDHPs (12.5%)“disagreed” or “strongly disagreed” that receiv-

ingdirectreimbursementfromMedicaidorprivateinsurance companies was easy. Seventy-eightpercent(n=25)ofCDHPswere“nottheownerofthecollaborativepractice,”however,5of7own-ers “agreed,” “moderately agreed” or “stronglyagreed”thattheincomegeneratedexceededex-penses.


ServicesNewMexico Minnesota

n Percent n PercentAdultProphylaxis

NoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

012210

0.00%16.70%33.30%33.30%16.70%0.00%

641685

20.00%13.30%3.30%20.00%26.70%16.70%

ChildProphylaxisNoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

051000

0.00%83.30%16.70%0.00%0.00%0.00%

4205100

13.30%66.70%16.70%3.30%0.00%0.00%

NonsurgicalPeriodontalTherapyNoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

051000

0.00%83.30%16.70%0.00%0.00%0.00%

6231000

20.00%76.70%3.30%0.00%0.00%0.00%

PeriodontalMaintenanceTherapyNoYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

033000

0.00%50.00%50.00%0.00%0.00%0.00%

6148200

20.00%46.70%26.70%6.70%0.00%0.00%

FluorideNoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

031110

0.00%50.00%16.70%16.70%16.70%0.00%

11412300

3.30%46.70%40.00%10.00%0.00%0.00%

RadiographsNoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

111300

16.70%16.70%16.70%50.00%0.00%0.00%

572862

16.70%23.30%6.70%26.70%20.00%6.70%

TableII:CollaborativeDentalHygieneServices(n=36)a


ResultssupportedthenullhypothesesthattherewasnosignificantdifferencebetweenNewMexi-co and Minnesota CDHPs characteristics, servic-es,modelsoropinions(p=0.05).However,therewasasuggestivedifferencebetweenstateswhencomparinghighestdegreesearnedbyCDHPs(as-sociate’sdegreesversusbachelor’sandhigher)asanalyzedwith theFisher’sExact test (p=0.063).Therewas also a suggestive difference betweenstateswhencomparingtheeaseoffindingaden-tistwillingtoparticipatecollaborativelyusingtheMann-WhitneyUtest(p=0.07).

Selected comments about benefits and obsta-cleswereorganizedbythemes(TableV).Improveaccess tocare,autonomy, finances,patientcareand interprofessional practice were identified asbenefits of CPDH.Obstacles included collaborat-ing dentists, direct reimbursement, employeesand facility, financial concerns,patient follow-upcare,andmobileequipment.Ontheotherhand,multiple respondents reported no obstacles toCPDH.


ServicesNewMexico Minnesota

n Percent n PercentPitandfissuresealants

NoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

150000

16.70%83.30%0.00%0.00%0.00%0.00%

7230000

23.00%76.70%0.00%0.00%0.00%0.00%

PatientsperWeekHavingPrivateInsuranceCoverageNoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

023100

0.00%33.3%50.0%16.70%0.00%0.00%

7104810

23.30%33.30%13.30%26.70%3.30%0.00%

PatientsperWeekHavingMedicaidCoverageNoneYes,<10patientsperweekYes,11-19patientsperweekYes,20-29patientsperweekYes,30-39patientsperweekYes,>40patientsperweek

321000

50.00%33.30%16.70%0.00%0.00%0.00%

1169121

3.30%53.30%30.00%3.30%6.70%3.30%

ReceivedDirectReimbursementfromMedicaidYesNoDidnotprovideanswer

150

16.7%83.3%0.00%

10191

33.30%63.30%3.30%

ReceiveDirectReimbursementfromPrivateInsuranceCompaniesYesNoDidnotprovideanswer

150

16.70%83.30%0.00%

9201

30.30%67.30%3.30%

ReferralofPatientstootherOralHealthCareProvidersReferpatientsdirectlyCollaboratingdentist(s)referDidnotprovideanswer

330-

50.00%50.00%0.00%

8211

26.70%70.00%3.30%

ReferralofpatientsformedicalconsultationsReferpatientsdirectlytoaphysicianCollaboratingdentist(s)referDidnotprovideanswer

420

66.70%33.30%0.00%

9201

30.00%66.70%3.30%

TableII:CollaborativeDentalHygieneServices(n=36)a(continued)


DiScuSSion

CDHPs in both states were seasoned, estab-lished, experienced clinicians. Therefore, CDHPsappearconfidentintheirknowledgeandskillsandchosetodiversifytheirmodelofpracticetocollab-orativecare.Onepossible reason for thischangeisthatCDHPswereconcernedaboutincreasingac-cess to oral health care, particularly when com-paredtoconcernsaboutprofessionalautonomyorfinancialrewards.TheseresultsdemonstratethatCPDH isaviablealternativemodeloforalhealthcareintendedtoincreaseaccesstocare.

WhencomparingCDHPsfrombothstates,prac-titionersinNewMexicotendedtoholdanadvanced

degree suchas abaccalaureateormasters.NewMexico CDHPs acquired an advanced degree be-foreorwhileowningandoperatingacollaborativepractice,supportingtheideathatCDHPswerecon-fident in pursuing this type of practice. It wouldbevaluabletoassesswhentheadvanceddegreeswere earned to determine if a relationship existsbetween degree earned and practicing with thecollaborativemodel.ContrarytoNewMexico,Min-nesotaCDHPsdid not have the option of owningacollaborativepractice,therefore,theymightnothavefelttheneedtoobtainanadvanceddegree.ResultsmighthavebeendifferentifMinnesotalawallowed practitioners to own a private practice.


Models NewMexico Minnesotan (Percent) n (Percent)

HealthProviderShortageAreacountiesservednone1234ormoreUnknown

110211

16.70%16.70%0.00%33.30%16.70%16.70%

6110414

23.10%3.80%3.80%0.00%15.40%53.80%

Dentistsprovidingserviceswithinthecollaborativepractice

none1234ormore

12021

16.70%33.30%0.00%33.30%16.70%

125126

3.80%7.70%19.2%46.2%23.10%

EmploymentofadditionaldentalhygienistsNo1hygienistfull-time1hygienistpart-time2hygienistsfull-time2hygienistspart-time>3hygienistsfull-time>3hygienistspart-time

3010200

50.00%0.00%16.70%0.00%33.30%0.00%0.00%

5217353

19.20%7.70%3.80%26.90%11.50%19.20%11.50%

EmploymentofadditionaldentalassistantsNo1dentalassistantfull-time1dentalassistantpart-time2dentalassistantsfull-time2dentalassistantspart-time>3dentalassistantsfull-time>3dentalassistantspart-time

3210000

50.00%33.30%16.70%0.00%0.00%0.00%0.00%

51101162

19.20%3.80%3.80%0.00%3.80%61.50%7.70%

EmploymentofadditionaldentalreceptionistsNo1dentalreceptionistfull-time1dentalreceptionistpart-time2dentalreceptionistsfull-time2dentalreceptionistspart-time>3dentalreceptionistsfull-time>3dentalreceptionistspart-time

3110100

50.00%16.70%16.70%0.00%16.70%0.00%0.00%

41260112

15.40%3.80%

7.7%23.1%0.00%42.30%7.70%

Lengthofoperation1monthto2years3to4years5to6years7to8years>8years

11112

16.70%16.70%16.70%16.70%33.30%

14948

3.80%15.40%34.60%15.40%30.80%

StructureofthecollaborativepracticeOffice-basedInstitutional-basedMobile-based

321

50.00%33.30%16.70%

9134

34.60%50.00%15.40%

TableIII:CollaborativeDentalHygienePracticeModels(n=32)a


ThereappearedtobesimilaritiesbetweenCDHPsandothermid-levelprovidermodels,suchastheADT and the ADHP, including the earning of ad-vanceddegreestoservethepublic.Withnewmid-level provider options becoming available, theremightbeanincreaseinthenumberofCDHPswith

advanced degrees in the near future. The afore-mentionedhighnumberofdentalhygienistswithspecial permits points to a growing demand forADHPs.9Youngdentistsare relyingondentalhy-gienists to perform complex care and dental hy-gienistsdesiretoexpandtheirknowledgebaseas


OpinionsNewMexico Minnesotan (Percent) n (Percent)

PatientsaregenerallysatisfiedwiththeservicesIprovide.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagree

500001

83.30%0.00%0.00%0.00%0.00%16.70%

1932002

73.10%11.50%7.70%0.00%0.00%7.70%

CollaborativeDentalHygienePracticeoffersmemoreautonomy.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagree

330000

50.00%50.00%0.00%0.00%0.00%0.00%

978101

34.60%26.90%30.80%3.80%0.00%3.80%

Dentist(s)Iamincollaborationwitharesupportive.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagree

321000

50.00%33.30%16.70%0.00%0.00%0.00%

1942001

73.10%15.40%7.70%0.00%0.00%3.80%

Findingdentistswhoarewillingtoparticipateincollaborativedentalhygienepracticehasbeeneasy.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagree

121002

16.70%33.00%16.70%0.00%0.00%33.30%

1528100

57.70%7.70%30.80%3.80%0.00%0.00%

Patientsinthecollaborativepracticefollow-upondentistreferralsthatIorotherdentalhygienepractitionersmake.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagreeUnknown

1230000

16.70%33.30%50.00%0.00%0.00%0.00%0.00%

44100008

15.40%15.40%38.40%0.00%0.00%0.00%30.80%


TableIV:OpinionsaboutCollaborativePracticeDentalHygiene(n=32)a

wellasbroadentheircareeroptions.9Furtherre-searchisneededtoexploretheassumptionsaboutrelationships between advanced degrees and di-rectaccessmodels.

CDHPsprovidedawidevarietyofservicessug-gestingall permissible serviceswerebeingdeliv-ered.CDHPsperformedperiodontaltherapiesonaweeklybasissignifyingthatappropriatecarewasprovided to patients with periodontal diseases.Perhaps the older adult populationwas receivingthesetypesofservicesbecauseofthesubstantialpercentage of older adults who have periodontaldisease.18Agoodunderstandingofcurrenttrendsinperiodontitisisimportantforplanningservices,studying workforce models and updating educa-tional curricula.32 In fact, previous studies haveshown that 5 to 20% of any population has ad-

vancedperiodontitis,andamajorityofadultshaveearlytomoderateperiodontitis.33,34Itis,therefore,paramount that periodontal therapy be deliveredinthispracticemodelaswellasotheralternativemodels.

Also,CDHPsfeltstronglythatpatientsweresat-isfiedwiththeservicesprovided.Therefore,thesefindingsparallelthoseofapreviousstudyindicat-ing patient satisfactionwith direct access servic-es.15 Patient safety was not specifically exploredinthisstudy,however,theNationalGovernorsAs-sociationreportedthat innovativestateprogramsareshowingincreaseduseofdentalhygienistsandevidenceindicatesthesepracticesaresafeandef-fective.35 Therewere no indications in this studythatsafetywasaconcern.


OpinionsNewMexico Minnesotan (Percent) n (Percent)

ReceivingdirectreimbursementfromMedicaidhasbeeneasy.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagreeDonotreceivedirectreimbursementfromMedicaid

0002004

0.00%0.00%0.00%33.30%0.00%0.00%66.70%

20610116

7.70%0.00%23.10%3.80%0.00%3.80%61.50%

Receivingdirectreimbursementfromprivateinsurancecompanieshasbeeneasy.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagreeDonotreceivedirectreimbursementfromprivateinsurance

0100014

0.00%16.70%0.00%0.00%0.00%16.70%66.70%

21500315

7.70%3.80%19.20%0.00%0.00%11.50%57.70%

Becomingacollaborativedentalhygienepractitionerwaseasy.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagree

221010

33.30%33.30%16.70%0.00%16.70%0.00%

1249100

46.20%15.40%34.60%3.80%0.00%0.00%

Asownerofthecollaborativedentalhygienepractice,theincomegeneratedexceedsexpenses.StronglyagreeModeratelyagreeAgreeDisagreeModeratelydisagreeStronglydisagreeNottheownerofthecollaborativepractice

1021002

16.70%0.00%33.30%16.70%0.00%0.00%33.30%

01100123

0.00%3.80%3.80%0.00%0.00%3.80%88.50%


TableIV:OpinionsaboutCollaborativePracticeDentalHygiene(n=32)a(continued)

It is important to note that oral health ser-viceswereutilizedbypatientswhohadMedicaidcoverage. Most CDHPs did not receive direct re-imbursement from Medicaid or private insurancecompanies. These findings imply that receivingreimbursement from thecollaboratingdentistsorfrom a public health facility is less complicatedthanreceiving itdirectly fromthirdpartypayers.Naughtonpointsoutthataprovidernondiscrimina-tionclauseispresentinNewMexicoandColoradoinsurancelaws,however,notallthirdpartypayersareregulatedbystateinsurancelaws.36Thisclausepreventsdiscriminationagainstanyproviderwhoparticipatesinaplanofferingdentalbenefitswhois practicingwithin the legal scope.36 Further re-searchisneededtodetermineandovercomebar-riersinreceivingdirectreimbursement.

In regards to referrals, CDHPs preferred thecollaborating dentist refer patients to other oralhealthcareprovidersperhapsbecauseoftheden-tist’sroleinsupportingthecollaborativepractice.CDHPs“agreed”thatpatientsfollowedthroughwith

referralstocollaborativedentists,however,itwasrecognizedthatpatientsfacedifficultieswithrefer-ralcomplianceduetofinances, languagebarriersand/or lackof transportation.Protocols formain-tainingpatientrecordsareincludedinthewrittencollaborativeagreementforbothstates.10,11There-fore,referralrecordswerekeptandknowledgeofpatientcompliancewasassumedadequate.Thesefindings suggest referral protocols were success-ful, however, future research is needed to studyreferralsfromCDHPstocollaborativedentistsinanefforttoenhancethistransition.

In New Mexico, most CDHPs worked in dentalhealthprovider shortageareas. InMinnesota themajority of CPDHswere uncertain if the servicesprovidedwerewithinashortagearea.NewMexicoCDHPshavetheautonomytoexpandservicesintodentalhealthprovidershortageareasasevidencedbythefindingthathalfofNewMexicoCDHPspro-videdservicesto3ormoredentalhealthprovidershortageareas.Minnesotahasrestrictionsoncol-laborative practice settings and it could be that


BenefitsofCollaborativePracticeDentalHygieneThemes NewMexicoResponses MinnesotaResponses

Improveaccesstocare

Theabilitytoprovideservicestotheunder-served.

Helpingapopulationwhichwouldotherwisefinditverydifficulttoaccessdentalcare.

The“feeling”Iamhelpingdiscoversolu-tionstobarrierstocare.

Goingtoschoolsisthebestwaytoreachthisunderserved,underinsuredornot

insuredpopulation.Itisacaptiveaudienceanditissoeasyforthechildrentoreceive

carebecausetheyarerightthere.

Autonomy

Autonomy.AllowingmetodecideifIshouldtakea

film,applyfluoride,makerecommendationsforreferrals,etc.

Imanagemyowndaysandhours.Autonomy,morecontrolovermyschedule,andabletoseemorepatientsandplanfor

theirneedsmoreeffectively.Imanagemyofficetotally. -

Financial Thepotentialtoearnmoremoneythanwhenemployed.

Usingcollaborativepracticehygienistsallowsthismodelofcaredeliverytobefis-

callyfeasible.

Improvedpatientcare -

Decisionmakingistimeefficient.Itgivesthehygienistresponsibilitiesthatotherwisewouldhavetowaituntiltheden-

tistisavailable.

InterprofessionalPractice -

Ourcollaborativepracticeisinamedicalfacility.Ittookmanyyearstobuilduptrustandbecomeintegratedwiththemedical

staff.

Nobenefits - Havenotseenrealbenefitstocollaborativepractice.

ObstaclestoCollaborativeDentalHygienePractice

- -

Themes NewMexicoResponses MinnesotaResponses

Collaborativedentists Keepingdentistsintheofficeisdifficult.Gettingacollaborativeagreementcan

sometimesbedifficultifyoudonothaveaworkingrelationshipwithadentist.

Directreimbursement

Insurancecompaniesneedtorecognizeusasproviders. Notsuccessfulatfilingthestateinsurance.

Medicaiddoesnotallowahygienisttobillforexams.

Insurancecompaniesnotrecognizingusasproviders.

Employeesandfacility Findingqualifiedemployeeswithagoodworkethic! Findingaplacethatisoperationalandstaff.

Financial Creatingasustainablefinancialbusinessmodel. -

PatientFollow-UpCare Patientcompliancewithfollowupcarewithadentist.

Difficultforpatientstofollowthroughwithreferralsbecauseoffinances,languagebar-

riers,andlackoftransportation.

MobileEquipment -

Thesettingupofthemobileofficecanbeheavyworkandonehastobecarefultonotinjureoneself.Workinginamobilesettingcanbehardonthebodyduetothefactthe

chairsarenotadjustable.

Noobstacles -Ihavenotexperiencedobstacles.

Ihavenotfoundanyyet.

TableV:ThemesandRepresentativeQuotationsfromtheOpen-EndedQuestionsonBen-efitsandObstaclestoCollaborativePracticeDentalHygiene(n=28)


concluSion

Itisimportanttostudyinnovativewaysofdeliv-eringoralhealthcaretoincreaseaccesstocareforunserved and underserved populations. This studyprovidedafoundationofknowledgeforfutureinves-tigationsrelatedtoCPDH,practiceacts,underservedpopulations, at riskgroupsanddirect access care.AlthoughCDHPsinNewMexicoandMinnesotawereverysimilarincharacteristics,servicesandopinions,due to differences in state laws regarding practice

healthcarefacilitiesorinstitutionswhererespon-dentspracticedwerenot located indentalhealthprovider shortage areas. These data provide anoutstandingexampleofhow legislation lifting re-strictions for direct access results in expandingservicesandincreasingaccesstooralhealthcareforunservedandunderservedpopulations.Infact,in2011therewereabout33.3millionunderservedindividualsresidingindentalhealthprovidershort-ageareasindicatinghowgreatthisneedis.36

MostCPDHmodelshadbeen inoperationfor5ormore years, in fact, nearly one third of CPDHmodelshadbeen thriving formore than8years.These data imply this alternative practice modelisfinanciallyviableandsuccessful.IfCPDHmod-els were not efficacious, one would suspect thatCDHPs would not continue to practice. However,14oftheCDHPscontactednolongerpracticedinthismanner,therefore, investigatingthisattritionwould be advantageous to the future success ofdirectaccessmodels.

Considering that CDHPsmust refer patients toadentistatleastonceayear,itislogicaltohavemore than 1 dentist provide services within thecollaborative practice model. This option allowstheCDHPandthepatienttohavemorethanonechoice foranoralhealth care team.Overall, col-laborative dentists were supportive of collabora-tive dental hygiene services, however, one-thirdofCDHPsinNewMexico“stronglydisagreed”thatfinding a dentist willing to participate was easy.Perhapsthisfindingrelatestothepracticesetting.Dentists in New Mexicomight not be as accept-ingofthisdeliverymodelduetouncertaintiessur-rounding responsibilities, financial concerns andpatientcareneeds.However,resultsindicatedthatoncethecollaborativeagreementwasestablished,thedentistwassupportive.Conversely,dentistsinMinnesotamight bemore receptive to collabora-tivepracticebecauseCDHPsarenotprovidingser-vicesinaprivatepracticesetting.

Futureoutcomesofdirectaccessmodels couldbepositivelyaffectedbyincludingeducationaboutdirect access, collaborative practice models, di-rect reimbursement, practice acts and successfullegislation in entry-level dental hygiene programcurricula. Direct access states could be studied,variousmodelsreviewed,andadvantagesanddis-advantagesdiscussedtoaidnewgraduatesincon-sidering this type ofmodel early in their career.Inarecentstudyof6MaineIndependentPracticeDental Hygienists’ (IPDH) it was found they feltunderpreparedforthistypeofpracticeandrecom-mendedchangesintheundergraduateeducationalcurricula.37 Changes included havingmore publichealth exposure, business skills education, com-munication background and exposure to alterna-

tivepracticesettings.37Also,anelectivecourseforthoseinterestedinIPDHwassuggested.37

Creatingoptimallawsandregulationsdetermin-inghowandbywhomoralhealthcareisprovidedare essential.38 In fact, state legislatures shouldamendexistinglawstomaximizeaccessincludingallowingallieddentalprofessionalstousethefullextentoftheireducation,workinavarietyofset-tings,whileallowingtechnology-supportedremotecollaborationandsupervision.38Thischargewillbefulfilledthrougheducatingthefutureworkforceofdentalhygienistsinlegislativeadvocacyinadditiontotheaforementionedcurriculasuggestions.

Withchangesbeingmadeinthewayhealthcareisprovidedinourcountry,inparticular,thePatientProtection andAffordableCareAct, the future ofdeliveringoralhealthcareserviceswillultimatelychangeand concernsaboutaccess tooral healthcare providers will becomemore prevalent.39 Al-though there isa lackofagreementaboutwork-forceexpansion tomeet theneedsof theunder-servedandvulnerablepopulations,advancesmustbemade to do so.38 Policymakers favor scope ofpracticeexpansionforlowandmid-levelprovidersasawayto improveaccesswhile loweringpricesforcare.9

Thefirststudylimitationwasnonresponseerror(surveyfatigue)suggestingthatiftheparticipantisfrustratedwiththeprocess,thesurveymightnotbecompleted.40SelectioneffectswereapotentialthreattoexternalvaliditybecauseallCDHPsinalldirectaccessstateswerenotincludedinthesam-ple.Also,thesmallsamplesizerestrictedexternalvalidityandgeneralizationtotheentirepopulationof CDHPs.40 Reactive effects, or the HawthorneEffect,was a potential threat to external validitybecausesubjectsknewtheywereparticipating ina study.40 Sources of error for online surveys in-cludenonresponseerrorfrompeopleinthesamplewhowould have provided additional answers im-pactingtheresultsandmeasurementerrorwherepoorwordingofquestionseffectsparticipant’sre-sponses.40Lastly,potentialparticipantscouldhavelackedcomputerskillsandmightnothavereceivedthesurveyduetomislabelingasspam.


settings, NewMexico CDHPs were able to provideneededoralhealthcareservices inhealthprovidershortageareas.Policymakersshouldchampionlessrestrictivepracticelawsincreasingaccesstocareforunserved and underserved populations. Results ofthis study indicated that concernsaboutcollabora-tivecarecanbeovercomeandqualitycarecanbedelivered byCDHPs for thewelfare of the popula-tionstheyserve.ItseemsthatCPDHisaviablean-swertoincreasingaccesstocareandisanoptionforpatientswhomightotherwisegowithoutcare.

Kathleen O. Hodges, RDH, MS, is Professor Emeri-tus, Department of Dental Hygiene, Division of Health Sciences, Idaho State University. Ellen J. Rogo, RDH, PhD, is a Professor, Department of Den-tal Hygiene, Division of Health Sciences, Idaho State University. Allison C. Cahoon, RDH, MS, is a Private Practice Practitioner in New Mexico. Karen Neill, RN, PhD, SANE-A, is an Associate Director for Graduate Studies and Professor, School of Nursing, Division of Health Sciences, Idaho State University.

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2. BorrellLN,CrawfordND.Socialdisparitiesinperiodon-titis among United States adults.Community Dent Oral Epidemiol.2008;36:383-391.

3. U.S.DepartmentofHealthandHumanServices.Ana-tionalcalltoactiontopromoteoralhealth.[Internet].2003Apr[cited2013Aug2].Availablefrom:http://www.surgeongeneral.gov/topics/oralhealth/national-calltoaction.html

4. KellySE,BinkleyCJ,NeaceWP,GaleBS.Barrierstocare-seekingforchildren’soralhealthamonglow-in-comecaregivers.Am J Public Health.2005;95(8):1345-1351.

5. NashDA,NagelRJ.Confrontingoralhealthdispari-tiesamongAmericanIndian/Alaskannativechildren:Thepediatricoralhealththerapist.Am J Public Health.2005;95(8):1325-1328.

6. QuandtSA,ChenH,BellRA,AndersonAM,SavocaMR,KohrmanT,GilbertG,ArcuryT.Disparitiesinoralhealth status between older adults in amultiethnicruralcommunity:Theruralnutritionandoralhealthstudy.J Am Geriatr Soc.2009;57(8):1369-1375.

7. American Dental Hygienists’ Association. Access tocarepositionpaper.[Internet].2001[cited2015Apr21].Availablefrom:http://www.adha.org/resources-docs/7112_Access_to_Care_Position_Paper.pdf

8. AmericanDentalHygienists’Association.Directaccessstates.[Internet].2014[cited2015Jan20].Availablefrom:http://www.adha.org/resources-docs/7513_Di-rect_Access_to_Care_from_DH.pdf

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10.NewMexicoDentalHealthCareBoard.Statutes,rules,andregulations.[Internet].2015Jan[cited2015Apr21]. Available from: http://www.rld.state.nm.us/boards/Dental_Health_Care_Rules_and_Laws.aspx

11.Minnesota Board of Dentistry. Minnesota statutes.[Internet].2013[cited2015Apr21].Availablefrom:https://www.revisor.mn.gov/statutes/?id=150A.10

12.AstrothDB,Cross-PolineGN.PilotstudyofsixColora-dodentalhygieneindependentpractices.J Dent Hyg.1998;72(1):13-22.

13.FreedJR,PerryDA,Kushman,JE.Aspectsofqualityofdentalhygienecareinsupervisedandunsupervisedpractices.J Pub Health Dent.1997;57(2):68-75.

14.KushmanJE,PerryDA,FreedJR.Practicecharacter-isticsofdentalhygienistsoperatingindependentlyofdentistsupervision. J Dent Hyg.1996;70(5):194-205.

15.PerryDA,FreedJR,KushmanJE.Characteristicsofpa-tientsseekingcarefromindependentdentalhygienistpractices.J Pub Health Dent.1997;57(2):76-81.

16.NationalInstituteofDentalandCraniofacialResearch.Health disparities roundtable summary. [Internet].2014 [cited 2015 Apr 29]. Available from: http://www.nidcr.nih.gov/NewsAndFeatures/Announce-ments/HealthDisparitiesRoundtable.htm

17.KellySE,BinkleyCJ,NeaceWP,GaleBS.Barrierstocare-seekingforchildren’soralhealthamonglow-incomecaregivers.Am J Public Health.2005;95(8):1345-135.

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27.U.S. Census Bureau. State and county quick facts.Minnesota 2013. [Internet]. 2015 [cited 2015 Apr29].Availablefrom:http://quickfacts.census.gov/qfd/states/27000.html

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30.ShillingL,DixonJ,KnaflK,GreyM,IvesB,LynnM.Determining content validity of a self-report instru-ment foradolescentsusingaheterogeneousexpertpanel.Nurs Res.2007;56(5):361-366.

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Oraldiseasesremainwidespreaddespiteimprove-ments in preventive strategies, and are particularlycommon among individualswith low socioeconomicstatus.1Whilemultiplefactorscontributetooraldis-ease, oral health literacyhas gained increased rec-ognition as a strong social determinant of health,reflectingmultipleconstructs inherent inculture/so-ciety,education,andhealthsystems.2Oralhealthlit-eracy isdefinedas“thedegreetowhich individualshavethecapacitytoobtain,process,andunderstandbasichealthinformationandservicesneededtomakeappropriateoralhealthdecisions.”3Becausehealthlit-eracyhasbeenidentifiedasamorerobustpredictorofanindividual’shealthstatusthandemographicfac-tors(e.g.,age,income,employment,education,andrace/ethnicity),2 theAmericanDentalHygienistsAs-sociationandothernationalorganizationshaveiden-tified improvingpatientoralhealth literacyasatoppriority.1-6

AssessingDentalHygienists’CommunicationTechniquesforUsewithLowOralHealthLiteracyPatientsPriscillaFlynn,RDH,MPH,DrPH;KelseySchwei,PhD;JeffreyVanWormer,PhD;KaitlynSkrzypcak,BS;AmitAcharya,BDS,MS,PhD

AbstractPurpose:ThisprimaryaimofthisstudywastoassesscommunicationtechniquesusedwithloworalhealthliteracypatientsbydentalhygienistsinruralWisconsindentalclinics.Asecondaryaimwastodeterminetheutilityofthesurveyinstrumentusedinthisstudy.Methods:Amixedmethodsstudyconsistingofacross-sectionalsurvey,immediatelyfollowedbyfocusgroups,wasconductedamongdentalhygienistsintheMarshfieldClinic(Wisconsin)servicearea.Thesurveyquantifiedtheroutineuseof18communicationtechniquespreviouslyshowntobeeffectivewithloworalhealthliteracypatients.Linearregressionwasusedtoanalyzetheassociationbetweenroutineuseofeachcommunicationtechniqueandseveralindicatorvariables,includinggeographicpracticere-gion,oralhealthliteracyfamiliarity,communicationskillstraininganddemographicindicators.Qualita-tiveanalysesincludedcodemappingtothe18communicationtechniquesidentifiedinthesurvey,andgeneratingnewcodesbasedondiscussioncontent.Results: Onaverage,the38studyparticipantsroutinelyused6.3communicationtechniques.Dentalhygienistswhousedanoralhealthliteracyassessmenttoolreportedusingsignificantlymorecommu-nicationtechniquescomparedtothosewhodidnotuseanoralhealthliteracyassessmenttool.Focusgroupresultsdifferedfromsurveyresponsesasfewdentalhygienistsstatedfamiliaritywiththeterm“oralhealthliteracy.”Motivationalinterviewingtechniquesandusinganintegratedelectronicmedical-dentalrecordwereadditionalcommunicationtechniquesidentifiedasusefulwithloworalhealthliteracypatients.Conclusion:Dentalhygienistsinthisstudyroutinelyusedapproximatelyone-thirdofthecommunica-tiontechniquesrecommendedforloworalhealthliteracypatientssupportingtheneedfortrainingonthistopic.Basedonfocusgroupresults,thesurveyusedinthisstudywarrantsmodificationandpsycho-metrictestingpriortofurtheruse.Keywords:oralhealthliteracy,communicationtechniques,dentalhygienistsThisstudysupportstheNDHRApriorityarea,Health Promotion / Disease Prevention: Assessstrate-giesforeffectivecommunicationbetweenthedentalhygienistandclient.

research

introDuction

Noting that oral health literacy is amultifactorialconstruct,theAmericanDentalAssociationsupportstheuseofa theoretical frameworkdesigned to im-proveoralhealthliteracyat3pointsofintervention:cultureandsociety,theeducationalsystem,andthehealthsystem.4Thehealthsystemholdspromiseasaninterventionpointfordentalprovidersasthereisstrong evidence that patients usually identify theirdentalteamastheirmosttrustedsourceoforalhealthinformation.2,7Further,recentreportspurportthattheoralhealthteambearsasignificantresponsibilitytoimproveoralhealthliteracyintheirpatients.8-10Thisisnoteworthybecauseeffectivecommunicationskillsofclinicalcareprovidersarecriticaltoimprovingpatienthealthoutcomes.1,7-16Threerecentstudies,conduct-edatthenationalandstatelevels,measureddentalteams’ use of 18 communication techniques showntobeeffectivewithlowliteracypatients.All3stud-iesusedavariationofthesamesurveyandreported


limited use of these recommended communicationtechniques.8-10

Stateandnationalstudiesofdentalclinicians’com-municationtechniquesarehelpfulindetectingbroad-ertrends,butarelessrelevantatregionalorsystemslevelswhere, due to organizational differences thataffectprovider-patientinteractionsduringclinicalen-counters,oralhealthimprovementinterventionsaremost likely to occur.15No published studies to datehave examined dental hygienists’ communicationtechniqueswithinan integratedhealthcaresystem.This isan important researchgap toaddress inor-dertoguidesubsequentinterventionsdesignedtoin-creasedentalhygienists’useofeffectivecommunica-tiontechniques,particularlyforlowliteracypatients.Theprimaryaimofthisstudywastoassesstherou-tineuseofcommunicationtechniquesrecommendedforusewithloworalhealthliteracypatientsbydentalhygienistsintheMarshfieldClinicHealthSystemandgeneralMarshfield area, aswell as to identify indi-catorsof routineuseof these communication tech-niques. The results will determine the need for aninterventionfordentalhygienistsregardingcommu-nicationtechniquesusedwithlowliteracypatients.

The survey instrument used in this study wasadaptedfromaninstrumentusedin3previousstud-ies measuring provider communication techniqueswithloworalhealthliteracypatients.10Althoughthesurveyinstrumentwaspilottestedonalargenumberofindividuals,nopsychometrictestresultshavebeenreported on the survey instrument.Onemethod ofassessingthevalidityofasurvey(i.e.,toassurethattheinstrumentmeasureswhatisintended)istoaskparticipantstheirthoughtprocessesastheyanswereditemsimmediatelyaftersurveycompletion.17,18Whileacomprehensivepsychometricanalysiswasbeyondthescopeofthisresearchproject,thefacevalidityofquestionsspecifictooralhealthliteracywereofinter-est.Asecondaryaimofthisstudy,therefore,wastodeterminetheutilityofthesurveyinstrument.Toac-complishthisaim,focusgroupswereconductedim-mediatelyafteradministrationofthesurvey.


Design and Sample

Thisstudyusedamixedmethodsapproachthatconsisted of a cross-sectional survey followed byfocus groups with dental hygienists. Participantswererecruitedfrom8of9dentalcenterswithintheMarshfieldClinicHealthSystemandoperatedbytheFamilyHealthCenterofMarshfield,Inc.,aswellasoneindependentdentalcenterinthecityofMarsh-field,Wisconsin(notaffiliatedwithMarshfieldClinic).All Marshfield Clinic Health System dental centersare Federally Qualified Health Center (FQHC) clin-ics that provide subsidized care based onfinancialneed.Eligibleindividualsforthisstudyweredental

hygienists,part-timeor full-time, fromthe totalof9centers.Studyprocedureswerereviewedandap-provedbytheMarshfieldClinicInstitutionalReviewBoard(IRB)anddeemedexemptbytheUniversityofMinnesotaInstitutionalReviewBoard.

Recruitment and Procedures

Anemailinvitationwasinitiallysentfromthestudycoordinator to eligible individuals that describedstudyprocedures,includingthelocationofthefocusgroupscheduledateachclinic.Onedaypriortothescheduled focusgroup,a reminderemail invitationwassenttoeligibleindividualsthatincludedanelec-troniclinktothestudysurvey.Wherereliableinter-net connectionswere unavailable, participants hadtheoptionofcompletingthestudysurveyonpaperprior to participating in the focus group. All studydatawerecollectedduringthefirstquarterof2014.

Quantitative Measures

Thesurveyused inthisstudywasadaptedfromaninstrumentdraftedbytheNationalAdvisoryCom-mittee onHealth Literacy inDentistry andused inonenational10and2statestudies.8,9Thesurveyin-cluded18communicationtechniquesrecommendedbytheAmericanMedicalAssociationaseffectiveforcommunicating with low literacy patients.19 Ques-tions were grouped into 2 domains: interpersonalcommunication (5 techniques) and teach-back (2techniques).Theadditional11itemsaretechniquesshowntobeusefultoenhancepatientcommunica-tion and were grouped into 3 additional domains:patient-friendlymaterials and aids (3 techniques),assistance(5techniques),andpatient-friendlyprac-tice(3techniques).10

A small representative group of Minnesota andWisconsindentalhygienistsreviewedthesurveyin-strumentforfacevalidity.Whenfacevalidityofsur-veyquestionshasnotbeenevaluated, researcherscannotbecertainthatparticipantsunderstandeachitem.Concernwasexpressedthatdentalhygienistsin thestudy’sgeographicareamaynotbe familiarwith theterm“oralhealth literacy”orwith theas-sessmentmethodstomeasurepatientoralhealthlit-eracyreferredtointhesurvey.Apilotsurveyamongaconveniencegroupofpracticingdentalhygienistsin Minnesota and Wisconsin (n=6) confirmed thatmostwerenotfamiliarwiththeseterms.Asaresult,onequestionwasaddedthatusedtheterm”commu-nicationtechniques”inplaceoftheterm”oralhealthliteracy.”Inaddition,thestudyaddedfocusgroupsfollowingsurveyadministrationtoevaluatetheutil-ityofthesurvey.Specifically,adiscussionofseveralsurveyquestionswasusedtoexplorecomprehensionand trace thesocialprocesses that influencedpar-ticipants’responses.18Theintentwastodetermineifadditionaltermsusedinthesurveyneededfurther


clarificationordefinition,andifothercommunicationtechniquesusedbydentalhygienistsweremissingfromtheinstrument.

Inadditiontothecommunicationtechniqueques-tions,demographicinformation,questionsaboutoralhealthliteracyfamiliarity,pastcommunicationskillscourseparticipationandascertaininginterestinfu-ture intervention participationwere included.10 Re-sponseoptionswereona5-pointLikertscale,andeach item contained a sub-question on perceivedeffectiveness of the technique.Based on the scor-ingmethodologydesignedforthesurvey,thedepen-dentvariableinthisstudywastheaveragenumberofroutinelyusedcommunicationtechniques.10Foragiven communication technique, “routine use”wasoperationalizedasaresponseof“mostofthetime”or“always.”Thenumberofroutinelyusedtechniqueswasthensummedtocreateanindexscoreof0to18. Indicator variables included region of practicewithintheMarshfieldClinicservicearea(i.e.,North,CentralorSouth),age,numberofyearsasadentalhygienist,familiaritywith,useoforalhealthliteracyassessmentandpreviousparticipationinacommu-nicationskillscourse.

Qualitative Measures

The purpose of the focus groups was to deter-mine utility of the current survey. Eight separatefocusgroupswereheldatall butonedental clinic(participantsatthiscliniccompletedthesurveybutdeclinedfocusgroupparticipation).Thefocusgroupdiscussion guidewas designed by the principal in-vestigator. Focus groupswere conducted by eitherthe principal investigator or the study coordinator,bothofwhomhadpriorfocusgroupfacilitationex-perience.Aninitialtrainingsessionwasheldtocali-brate adherence to thediscussionguide, andbothresearcherswerepresentatthefirstfocusgrouptoimprovesubsequentfidelity.Focusgroupswere30to45minutes in lengthandtypically included2to8participatingdentalhygienistsateachclinic.Eachsession included a brief introduction of proceduresandparticipationguidelines,followedbyaseriesofqualitative,semi-structuredquestionsfromthefacil-itatortoguidethediscussion.Participantsansweredfreelyandresponseswereaudio-videorecorded.Fo-cusgroupsincludeddiscussionsofthefollowinggen-eraltopics:

• Dental hygienists’ understanding of the terms“oralhealthliteracy”and“motivationalinterview-ing”

• Methodsofassessingpatientoralhealthliteracy• Impactoforalhealthliteracyassessmentonhy-gienist’scommunicationtechniques

• Otherrecommendedoralhealthliteracyresourc-esthatmightbehelpful,ifavailable

Analyses

All quantitative analytical procedures were con-ductedwithSASVersion9.3(Cary,NC).Participantcharacteristics were reported descriptively. Giventhesmallsamplesizeandexploratorynatureofthisstudy, no attempts were made to impute missingvariablesorconductmultivariablemodeling.Univari-atelinearregressionmodelswerecreatedtoexam-inetheassociationbetweeneach indicatorvariableseparatelyandthenumberofcommunicationtech-niquesusedroutinely.Thenumberofcommunicationtechniquesusedroutinelywasmodeledasacontinu-ousoutcomevariable.

Qualitative analyses were conducted with NVivoqualitativedataanalysissoftware(QSRInternationalPtyLtd.Version10,2014).Digitalaudiofilesweretranscribedbyanindependentfirm.Thecontentwasmapped toan initial setof codescorresponding tothecommunicationdomainsrepresentedinthesur-vey (i.e., assistance, interpersonal communication,teach-back, patient-friendly materials and patient-friendlypractice).20Contentemergingfromthedis-cussionthatcouldnotbemappedtotheinitialsetofcodeswasassignednewcodeswithstandarddefini-tionscreatedtoassureconsistencybytheresearch-ers.Thestudyteam(principalinvestigatorandstudycoordinator) individually codedeachof the8 tran-scripts.Eachcodedtranscriptwassubsequentlyre-viewedbythestudyteam,discrepanciesweredis-cussed,andfinalcodeswereassignedbyconsensus.

reSultS

Survey Findings

Invitations were sent to 40 eligible dental hy-gienists with 38 (95%) agreeing to participate inthesurveyand35(92%)attendingafocusgroup.Sample characteristics are reported in Table I. Allparticipants were female and the majority werenon-Hispanic White with 1 American Indian/Alas-kan Native and 2 Asian participants. The mean(±SD)numberof communication techniquesusedroutinelywas6.3±2.1(range3 to11).Thedetailofresponsestoeachitemoncommunicationtech-niquesisreportedinTableII.Limitingthenumberof concepts,using simple language, and speakingslowlywere techniquesusedroutinelyby thema-jority of respondents. Communication techniquesleastusedwereaskingpatients if theywould likea familymemberor friend involved in thediscus-sion,drawingpicturesorusingprintedillustrationsincludingunderliningkeypointsonprintedmateri-als,andfollowing-upwithpatientsbytelephoneoraskingoffice staff to call. The technique thatwasusedleastwasaskingpatientshowtheylearnbest.Communication techniques that were used moreroutinelywerealsogenerallyperceivedtobemoreeffective.


AsreportedinTableIII,findingsfromtheregres-sionanalysesindicatedthatgeographicpracticere-gionandtheuseoforalhealthliteracyassessmentsweretheonlysignificantindicatorsofthenumberofcommunication techniquesused routinely.Specifi-cally,dentalhygienistsfromtheSouthernregionoftheMarshfieldClinicserviceareahadthegreatestuseofcommunicationtechniques,withthoseintheCentralandNorthernregionsusing1.8(p=0.044)and1.3(p=0.1),respectively,fewertechniquesonaverage.Inaddition,dentalhygienistswhoreport-edusingoralhealthliteracyassessmentsalsousedanaverageof1.6(p=0.033)morecommunicationtechniquesrelativetodentalhygienistswhodidnotreportusingoralhealthliteracyassessments.Oth-er indicatorshadrelativelyweakassociationswithcommunicationtechniques.

Focus Group Findings

Themost frequently used codes and sub-codeswerethoseemergingfromthediscussionsascom-paredtotheinitialsetofcodesmappedtothesur-veycommunicationdomains.Additionalcodesthatarose from the focus group conversations were“motivational interviewing strategies” and “oralhealthliteracy”withassociatedsub-codes.Motiva-tional interviewing isdefinedasa“formofcollab-orative conversation for strengthening a person’sownmotivationandcommitmenttochange.”21Den-talhygienistsinallfocusgroupsindicatedroutinelyassessing patient receptiveness to engaging in acollaborativeconversationaboutoralhealthbehav-ioral change. These results were coded as “moti-vational interviewing strategies.” A representativequotewas,“…asyou’retalkingtothemyoucanfindoutthethingsthatwillmotivatethem.”Participantsinallfocusgroupsdiscussedtheirreasonsforpro-vidingoralhealthinstructiontopatientsregardlessofthepatient’sassessedreceptivenesstobehaviorchange.Theseexchangeswerecodedas“senseofduty”(i.e.,dentalhygienistdeliversamessageshefeels is expected of her and part of her job) and“mismatchedpriorities”(i.e.,patientanddentalhy-gienistprioritizeoralhealthdifferently).Apartici-pantquote representativeof “senseofduty”was,“I’vegottotellyou(thepatient)this.It’smyjob.”Representative quotes of “mismatched priorities”were:

• “Youstill talk to themanddo itoverandoveragain,andtheystillcomebackandsay‘Idon’tbrush.’Andifyouaskwhy,theysay,‘Ijustdon’tcare.’”

• “And that’s what a lot of people say, ‘I don’twanttobelectured.Idon’tneedthatlecture.’”

• “It’snotabigdealtothembutit’sabigdealtous.”

Theoralhealthliteracycodeusedthestandardoral

health literacy definition: “the capacity to obtain,processandunderstandbasicoralhealthinforma-tionandservicesneededtomakeappropriatehealthdecisions.”1Noneofthedentalhygienistsparticipat-inginafocusgroupexpressedfamiliaritywiththeterm“oralhealthliteracy.”Arepresentativeanswerwas,“Itjustseemsselfexplanatory.Ithinkofitasjustmakingsurethatyourpatientsareunderstand-ing…butI’veneverheard…theterm‘healthliterate’or ’oralhealth literacy.’”Extensivediscussionsoc-curred in all focus groups describing themultiplefactorsaffectingpatientoralhealthliteracy.Theseincludedbarrierssuchastimeconstraintsforeitherthepatientorthedentalhygienist,explanationsofwhypatientscan’tchange,orhowdentalhygienistssucceeded at moving patients toward behavioralchange.

Whenaskedifthedentalhygienistsusedahealthliteracyinstrumenttomeasurethehealthliteracyoftheirpatients,arepresentativequotewas,“Idon’trememberwhatIput(inthesurvey),butitwaslikeotherthanquestioningthem,that’stheonlythingasfarasatool.It’sjustusingyourwords.”

Ofthe5initialcodesrepresentativeofthesurveycommunication domains, patient-friendly materi-alswascodedmostfrequentlyasdentalhygienistsstatedtheyroutinelyusedradiographsorothervi-

Characteristics n=38Region

NorthCentralSouth

14(37%)10(26%)14(37%)

Age(y) 38.5±8.7Race

WhiteNon-White

35(92%)3(8%)

Hygienistexperience(y) 13.6±8.0Familiaritywithoralhealthliteracy

FamiliarNotfamiliar

18(47%)20(53%)

UseoralhealthliteracyassessmentYesNoUnavailable

16(42%)18(47%)4(11%)

PreviouscommunicationscourseYesNoUnavailable

8(21%)29(76%)1(3%)

Valuesarereportedasmean±standarddeviationorfre-quencycount(percentsample).

TableI:DescriptiveCharacteristicsofStudyParticipants


Domain(Communicationtechnique)n=38

Count(Percentage)

Never Rarely Occasionally MostoftheTime Always Perceived

EffectivenessInterpersonalCommunication*Present2to3conceptsatatime** 0 1(3) 2(5) 26(68) 8(21) 20(54)

Askpatientswhethertheywouldlikeafamilymemberorfriendinvolvedinthediscussion

5(13) 13(34) 17(45) 3(8) 0 15(39)

Drawpicturesoruseprintedillustrations 6(16) 17(45) 14(37) 1(3) 0 12(32)

Speakslowly 0 0 7(18) 26(68) 5(13) 26(68)Usesimplelanguage 0 0 0 15(39) 23(61) 32(84)Teach-BackMethod*Askpatientstorepeatinformationorinstructionsbacktoyou

0 5(13) 20(53) 10(26) 3(8) 19(50)

Askpatientstotellyouwhattheywilldoathometofollowinstructions

1(3) 6(16) 16(42) 9(24) 6(16) 9(24)

Patient-FriendlyMaterialsandAids*Useavideoordigitalvideodisc 0 27(71) 4(11) 5(13) 2(5) 5(13)

Handoutprintedmaterials 0 3(5) 25(66) 9(24) 1(3) 14(37)

Usemodelsorradiographstoexplain 0 0 9(24) 23(61) 6(16) 34(90)

Assistance*Underlinekeypointsonprintmaterials 6(16) 16(42) 12(32) 4(11) 0 10(26)

Followupwithpatientsbytelephonetocheckunderstandingandadherence

12(32) 13(34) 12(32) 1(3) 0 11(26)

Readinstructionsoutloud 1(3) 13(34) 6(16) 13(34) 5(13) 16(42)Askofficestafftofollowupwithpatientsforpostcareinstructions

17(45) 16(42) 3(8) 1(3) 1(3) 4(11)

Writeorprintoutinstructions 0 11(30) 23(61) 1(3) 2(5) 15(40)

Patient-FriendlyPractice*Askpatientshowtheylearnbest 8(21) 21(55) 9(24) 0 0 10(26)

ReferpatientstotheInternetorothersourcesforinformation

4(11) 15(39) 15(39) 4(11) 0 3(8)

Useatranslatororinterpreter** 1(3) 7(19) 1(3) 6(16) 22(60) 33(87)

TableII:DentalHygienists’CommunicationTechniqueUseandPerceivedEffectiveness

*Basiccommunicationtechniques**n=37


Indicatorvariables

Numberofcommunicationtechniquesused

ModelR2

Region(n=36)NorthCentralSouth

–1.29±0.76,p=0.100–1.77±0.85,p=0.044

ref.0.13

Age(n=34) –0.06±0.04,p=0.111 0.08Dentalhygienistexperience(n=35) –0.06±0.04,p=0.199 0.05

Familiaritywithoralhealthliteracy(n=36)FamiliarNotfamiliar

0.39±0.70,p=0.580ref. 0.01

Useoralhealthliteracyassessment(n=32)YesNo

1.56±0.70,p=0.033ref. 0.14

Previouscommunicationscourse(n=35)YesNo

0.48±0.84,p=0.576ref. 0.01

TableIII:UnivariateLinearRegressionModelsDepictingtheAssociationbetweenEachIndica-torVariableandtheNumberofCommunicationTechniquesUsedAmongSurveyRespondents

Valuesarereportedaspointestimate±standarderror,p-value, R2. Positive values indicate more communicationtechniquesused relative to the referencecategory (ora1-unit increase for continuous indicators) and negativevaluesindicatelesscommunicationtechniquesusedrela-tivetothereferencecategory.Boldedvaluesdenotepointestimatewassignificantatp<0.05.

sualmaterialsasaroutinecommunicationstrategy.The other 4 survey domains including assistance,interpersonalcommunication,patient-friendlyprac-ticeand teachbackwereminimally coded in sev-eral,butnotinallfocusgroups.

The last question in the focus group script al-loweddental hygienists to commentonadditionaltoolsorstrategiesthattheyfoundhelpful,aswellasthosethattheywouldliketoimplementintheirpractice. This discussion was robust in all focusgroups.Onetoolmentionedinthemajorityoffocusgroupsasusefulwastheintegratedelectronicmed-ical and dental record (IEMDR). Dental hygienistsstated that the IEMDR provided information thatsupportedaholisticapproachtooralhealtheduca-tion. Patientswith chronic disease co-morbidities,suchasdiabetesandperiodontaldisease,appearedmostreceptivetothisapproach.

DiScuSSion

Thisstudyfoundstatisticallysignificantdifferenc-esinthenumberofcommunicationstrategiesusedbydentalhygienistswithloworalhealthliteracypa-tients in 3North CentralWisconsin geographic re-gions.DentalhygienistspracticingintheCentralre-gionwereleastlikelywhilethoseintheSouthregionweremostlikelytouseavarietyofcommunicationstrategies.Nodifferencewasfoundindentalhygien-istsreportingfamiliaritywithoralhealthliteracy,butastatisticallysignificantdifferenceinthosereportinguseof anoral health literacyassessment toolwasfound. Because focus group results indicated thatmanydentalhygienistsdidnotunderstandthedefi-nitionsofeitheroralhealthliteracyororalhealthlit-eracyassessmenttools,theresearchersarenotcon-fident that the survey results accuratelymeasuredoralhealthliteracyknowledge.

Compared to other studies using the same sur-vey,dentalhygienistsinthisstudyusedfewercom-municationstrategiescomparedtoMarylanddentalhygienists8anddentistsacrossthenation.9,10Theav-eragenumberofstrategiesutilizedinthisstudywas6.3 compared to 6.95 forMaryland dental hygien-ists,87.9forMarylanddentists9and7.1inanationalstudyofdentists.10Themostfrequentlyusedtech-niquebydentistsanddentalhygienistsinthecurrentstudywas“simplelanguage,”with91%ormoreofprovidersreportingroutineuseofthistechnique.14,16Anotherconsistentresultwasroutineuseofmodelsorradiographswith73to77%usingthistechnique,and“readinginstructionsaloud,”whichrangedfrom46to49%acrossallstudies.The leastusedtech-niquewas“askingpatientshowtheylearnedbest,”with0%inthisstudy,and4.9%inthenationalstudyofdentists.10

TheloweruseofcommunicationstrategiesinthisWisconsinsamplemayreflectthefactthatdentalhy-

gienistsinthisstudywerelesslikelytohavetakenacommunicationcourseaftergraduation(21%)com-paredtoMarylanddentalhygienists(66%)andden-tists(60%),aswellasdentistsnationally(27%).8-10

Despitefewerthanhalfofsurveyrespondentsin-dicatingthattheywerefamiliarwiththeconceptoforalhealth literacy,moredetailed focusgroupdis-cussions suggested that those unfamiliar with theexplicitoralhealthliteracyterminologywereatleastawareoftheunderlyingchallengeofloworalhealthliteracy in their patients. Survey results indicatedthat themajority of hygienists did not assess theoralhealthliteracyleveloftheirpatients.Yetfocusgroup results showed thatmany dental hygienistsused an informal approach of asking open-endedquestions,asproposedbySchiavo.14Thisapproachreflectsfamiliaritywithsomeelementsusedinmo-tivational interviewing,acommunicationandcoun-seling approach shown to be effective in helpingpatients change various health behaviors includingoralhealth.22-24Further,theavailabilityanduseofanIEMDRthatallowshygieniststousethisinformationfortargetededucationforpatientswithchronicmed-ical-dentalco-morbiditieswasavailabletoalldental


concluSion

Dentalhygienistsinthisstudyroutinelyusedaboutone-thirdoftherecommendedcommunicationtech-niques for oral health literacy patients. This resultwaslessthanthetechniquesreportedinpriorstud-iesofMarylanddentalhygienistsanddentistsnation-ally.Focusgroupresultsindicatedthatnotallsurveyitemswereclearand thesurveycouldbeupdatedbyaddingrecentcommunicationtechniquesrelatedtomotivationalinterviewinganduseofanintegrat-edelectronicmedical-dental record.More researchis needed to study the psychometric properties ofthe survey instrument, to assess the effectivenessofdentalhygienistcommunication techniquesonalargerscale,and todeterminehowcommunicationtechniquesaffectpatientbehavioralchange,andinturn,oralhealthoutcomes.

Priscilla Flynn, RDH, MPH, DrPH, is an Assistant Professor in the Division of Dental Hygiene at the University of Minnesota, School of Dentistry. Kelsey Schwei, PhD, is a National Library of Medicine funded Oral Health Informatics Postdoctoral Fellow within Institute for Oral and Systemic Health at the Marsh-field Clinic Research Foundation and an Adjunct As-sociate Professor for various universities across the United States. Jeffrey VanWormer, PhD, is an As-sociate Research Scientist in the Center for Clinical Epidemiology and Population Health at the Marsh-field Clinic Research Foundation. Kaitlyn Skrzypcak, BS, is a senior at Marquette University majoring in Biomedical Sciences and is a research assistant in a neuroscience research laboratory focused on the neurobiology behind the link between stress and psychiatric illness at Marquette University. Amit Acharya, BDS, MS, PhD, is the Director of the Insti-tute for Oral and Systemic Health, the Director of the Dental Informatics Postdoctoral Fellowship Program, and a tenure-track Dental Informatics Scientist at the Biomedical Informatics Research Center, Marsh-field Clinic Research Foundation.

hygienistsinthisstudy.Focusgroupdiscussionscon-sistentlyreflectedthevalueanduseoftheIEMDRbydentalhygienists.Asbothmotivationalinterviewinganduseofelectronicmedical-dentalrecords inpa-tient education becomemore widely used in clini-calpractice,exploringandincludingtheseelementsforcommunicationinfuturesurveysmayprovideamoreholisticviewofcontemporarydentalandden-talhygienepractice.Inaddition,furthercoordinationandtrainingtorecordeducationalandcommunica-tion strategies used and how they are associatedwithoralhealthoutcomesisalsoneeded.25,26Toad-dressourprimaryaim,wefoundalowernumberofroutinely used communication strategies by dentalhygienistsbygeographicregionintheNorthCentralWisconsin service area. These results support theneedtodesignandimplementaninterventiononef-fectivecommunicationwith loworalhealth literacypatients.Inaddition,basicinformationonoralhealthliteracyandoral health literacyassessment shouldbeincorporatedintotheintervention.

Basedonourqualitativefocusgroupfindings,sur-vey questions referring to oral health literacy andwhetherpatientoralhealthliteracyisassessedlikelyrequireclarificationtoassurethatrespondentsfullycomprehend these terms. A more comprehensiveassessmentofconstructvalidityforthesurveytoolwouldassurethatoralhealthliteracy-specificques-tionswillbewordedtoimproveuniversalunderstand-ing.Addingmotivational interviewingtothesurveyas an additional communication strategywould beuseful,asmotivationalinterviewinghasbeenshowntobeeffectivewithloworalhealthliteracypatients.27Goal-setting isan importantaspectofmotivationalinterviewing and assessingwhether dental hygien-ists record patient intentions for behavior changeand whether stated goals are met would also behelpfulinfuturestudies.21,22Inaddition,arelativelynewcommunicationmediumisusingtheIEMDRtoeducate patients about the link between oral andgeneralhealth,whichmaybeusefulindentalprac-ticeswhereitisavailable.Addressingoursecondaryaim, the utility of the survey instrumentwould beimprovedbymakingthesemodificationsfollowedbypsychometric testing of the instrument in a repre-sentativesampleofdentalhygienistsbeforefurtheruse.25,26

Limitations

Thisstudywasprimarilylimitedbythesmallsam-plesizeandcross-sectionalsurveydesign,whichlim-itedthesensitivitytostatisticallydetectsomeasso-ciationsandprecludedcause-and-effectconclusions.Therobustsurveyresponseratewasrepresentative

ofthetargetpopulation,butcannotbegeneralizedduetothehomogeneityofthestudysetting.Com-parativefindingsfromthisstudysuggesttheremaybesubstantialregionalvariationindentalhygienists’useofcommunicationtechniques.Theself-reportedsurveytoolusedinthisstudyhasnotbeenvalidated,thus recall and self-presentation biases are also athreat to validity. Future research should examinemoreobjectivemarkersoftheuseoforalhealthlit-eracycommunication techniquesbydentalhygien-ists(e.g.,recordingdirectinteractionswithpatients)inordertogaugetheirassociationwithself-reporteduseofsuchcommunicationtechniques.


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2. PodschunG.Nationalplantoimprovehealthliteracyindentistry.Calif Dent Assoc J.2012;40(4):317-320.

3. U.S.DepartmentofHealthandHumanServices.HealthyPeople2010:understandingandimprovinghealth.U.S.DepartmentofHealthandHumanServices.2000.

4. AmericanDentalAssociationCouncilonAccessPreventionandInterprofessionalRelations.HealthLiteracyinDentist-ryActionPlan2010-2015.AmericanDentalAssociation.2009.

5. HorowitzAM,KleinmanDV.Oralhealthliteracy:apath-waytoreduceoralhealthdisparitiesinMaryland.J Public Health Dent.2011;72:S26-S30.

6. AmericanDentalHygienists’Association.NationalDentalHygieneResearchAgenda.2007.

7. LubalinJS,Harris-KojetinLD.WhatDoConsumersWantandNeedtoKnowinMakingHealthCareChoices?Med Care Res Rev.1999;56(Suppl1):67–102.

8. HorowitzAM,ClovisJC,WangMQ,KleinmanDV.Useofrecommendedcommunication techniquesbyMarylanddentalhygienists.J Dent Hyg.2013;87(4):212-23.

9. MayburyC,HorowitzAM,WangMQ,KleinmanDV.UseofcommunicationtechniquesbyMarylanddentists.J Am Dent Assoc.2013;144(12):1386-96.

10.RozierG,HorowitzA,PodschunG.Dentist-patientcommu-nicationtechniquesusedintheUnitedStates:theresultsofanationalsurvey.J Am Dent Assoc.2011;142(5):518-530.

11.AgencyforHealthcareResearchandQualiity(US).Healthliteracyinterventionsandoutcomes:anupdatedsystem-aticreview.March2011.

12.Horowitz AM, Kleinman DV. Oral health literacy: thenewimperativetobetteroralhealth.Dental Clin N Am.2008;52:333-4.

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14.SchiavoJH.Oralhealthliteracyinthedentaloffice:theun-recognizedpatientriskfactor.J Dent Hyg.2011;85(4):248-255.

15.WhiteS,ChenJ,AtchisonR.Relationshipofpreventivehealthpracticesandhealthliteracy:anationalstudy.Am J Health Behav.2008;32(3):227-242.

16.LeeJY,DivarisK,DeWaltDA,etal.Caregivers’healthlit-eracyandgapsinchildren’sMedicaidenrollment:findingsfromtheCarolinaOralHealthLiteracyStudy.PLoS One.2014;9(10):e110178.

17.FinkA.TheSurveyHandbook.ThousandOaks,CA:SagePublications,Inc.2003.

18.O’BrienK.Improvingsurveyquestionnairesthroughfocusgroups.In:MorganD,editor.SuccessfulFocusGroups.NewburyPark,CA:SagePublications.1993.105-136p.

19.SchwartzbergJG,VanGeestCA,WolfMS.Communicationtechniquesforpatientswithlowhealthliteracy:asurveyofphysicians,nurses,pharmacists.Am J Health Behav.2007;(31Suppl1):S96-S104.

20.MorganD.SuccessfulFocusGroups.NewburyPark:SagePublications.1993.

21.RollnickS,MillerW,ButlerC.MotivationalInterviewinginHealthCare:HelpingPatientsChageBehavior:GuilfordPress.2007.

22.MartinsR,McNeilD.Reviewofmotivational interview-ing in promoting health behaviors. Clinical Psy Rev.2009;29:283-93.

23.Weinstein P, Spiekerman C, Milgrom P. RandomizedEquivalenceTrialof IntensiveandSemiannualApplica-tionsofFluorideVarnishinthePrimaryDentition.Caries Res.2009;43(6):484-490.

24.VanWormerJ,BoucherJ.Motivationalinterviewinganddietmodification:areviewoftheevidence.Diabetes Ed.2004;30:404-416.

25.AsanO,YeH,AcharyaA.Dentalproviders’andpatients’perceptions of the impact ofHealth InformationTech-nology’s in the dental care setting. J Am Dent Assoc.2013;144:1022-1029.

26.SchleyerT,SongM,GilbertG,etal.Electronicdentalrecorduseandclinicalinformationmanagementpatternsamongpractitioner-investigatorsintheDentalPractice-BasedRe-searchNetwork.J Am Dent Assoc. 2013(144):49-58.

27.WeinsteinP,HarrisonR,BentonT.Motivatingmotherstopreventcaries:Confirmingthebeneficialeffectsofcoun-seling.J Am Dent Assoc.2006;137:789-793.

referenceS


U.S.nationalhealthcarereformpresentstheden-talprofessionwithnewopportunitiestoexamineitscurrentplaceandfutureroleinthehealthcareenvi-ronment.Scopeofpracticeconcernsareattheheartofthedebate.1,2Oralhealthcareproviders,notablydental hygienists and dentists, are poised to con-tribute substantially to innovative service deliverymodelsthatstresspreventionandintegrateprimarycarewithoralhealthservices.3,4ThisdesignationiscriticallyimportantgiventheagingoftheU.S.popu-lation. Increased numbers of patientswith chronicconditions are expected that will benefit from pa-tient-centered, evidence-based screening,monitor-ingandcarecoordination.5Moreover,asauthorita-tivelydocumentedbytheInstituteofMedicine,oralhealth and general health are inextricably linked.6Notably,diabetesisariskfactorforperiodontaldis-ease and, when poorly controlled, can complicateperiodontaltreatmentoutcomes.7

ViewsofDentalProvidersonPrimaryCareCoordinationatChairside:APilotStudyMaryE.Northridge,PhD,MPH;ShirleyBirenz,RDH,MS;DanniM.Gomes,RDH;CynthiaA.Golembeski,MPH;ArielPortGreenblatt,DMD,MPH;DonnaShelley,MD,MPH;StefanieL.Russell,DDS,MPH,PhD

AbstractPurpose:Thereisaneedforresearchtofacilitatethewidespreadimplementation,disseminationandsustainedutilizationofevidence-basedprimarycarescreening,monitoringandcarecoordinationguide-lines,therebyincreasingtheimpactofdentalhygienists’actionsonpatients’oralandgeneralhealth.Theaimsofthisformativestudyaretoexploredentalhygienists’anddentists’perspectivesregardingtheintegrationofprimarycareactivitiesintoroutinedentalcare,andassesstheneedsofdentalhygienistsanddentistsregardingprimarycarecoordinationactivitiesanduseofinformationtechnologytoobtainclinicalinformationatchairside.Methods:Thisqualitativestudyrecruited10dentalhygienistsand6dentistsfrom10NewYorkCityareadentalofficeswithdiversepatientmixesandvolumes.ANewYorkUniversityfacultydentalhygienistconductedsemi-structured,in-depthinterviews,whichweredigitallyrecordedandtranscribedverbatim.DataanalysisconsistedofmultilevelcodingbasedontheConsolidatedFrameworkforImplementationResearch,resultinginemergentthemeswithaccompanyingcategories.Results: Thedentalhygienistsanddentistsinterviewedaspartofthisstudydonotuseevidence-basedguidelinestoscreentheirpatientsforprimarycaresensitiveconditions.Overwhelmingly,dentalprovid-ersbelievethattobaccouseandpoordietcontributetooraldisease,andreportusingelectronicdevicesatchairsidetoobtainweb-basedhealthinformation.Conclusion:Dentalhygienistsarewellpositionedtohelpfacilitategreaterintegrationoforalandgen-eral health care.Challenges include lackof evidence-basedknowledge, coordinationbetweendentalhygienistsanddentists,andsystems-levelsupport,withopportunitiesforimprovementbaseduponatheory-drivenframework.Keywords: dental hygienist, primary care, interoperability, technology, evidence-based guidelines,chairsidescreeningThisstudysupportstheNDHRApriorityarea,Health Services Research: Evaluatestrategiesthatpo-sitionandgainrecognitionofdentalhygienistsasaprimarycareprovidersinthehealthcaredeliverysystem.

research

introDuctionAccordingtotheU.S.DepartmentofLabor,there

were196,520licenseddentalhygienistsand97,990generaldentistsemployedintheU.S.in2014.8With9,960licenseddentalhygienistsinNewYorkand48active dental hygienists per 100,000 population in2011,NewYork isconsistentwith thenationalav-erageof50dental hygienistsper100,000popula-tion, notwithstanding wide regional variation.9 Thevast majority (95%) of dental hygienists in NewYorkworkinprivatedentaloffices,underscoringtheimportanceoftargetingthissetting.8Thus,thepo-tentialimpactofsupportingdentalhygieniststoun-dertake primary care activities at chairside on thehealthofbothNewYorkandU.S.residentsoverallissubstantial,especiallyforpopulationswithlimitedaccesstoprimarycareproviders.

Anurgentneedexiststoexpandtheprimarycareworkforce,giventheconsiderableincreaseinpatient


volumesnowbeing realizedwithmandatory insur-anceprovisionsthathavetakeneffectunderthePa-tientProtectionandAffordableCareAct.10Evidence-basedapproachestoimplementdentalofficesystemchangesthattakeintoaccounttheresource,staffingandtimeconstraintsthatdentalhygienistsandden-tistsfacemaybeonepotentialmechanismforlever-agingoralhealthproviderstoconductprimarycareactivities in dental offices. Evidence-basedprimarycareguidelinesarenotyetastandardpartofdentalvisits.Yetuntilcarecoordinationactivitiesbetweendentalandmedicalprovidersarecloselyintegrated,thepotentialofdentiststo“scopeup,”asitwere,tobecomeamoreactivepartoftheprimarycarework-force,and“scopedown”todentalhygienistscertainprimarycarescreening,monitoringandcarecoordi-nationfunctionswillremainuntapped.2

Therationaleforthisstudyisthatdentalhygien-istswanttomoreactivelyengagewiththeirpatientsaround the prevention of and screening for diabe-tesandhypertension. Theyalso seek togain con-fidence inprovidingtobaccocessationservicesandnutritioncounseling.Accordingly,theyneedsimple,evidence-basedtoolsthat,withtrainingandtechni-calassistance,theycanimplementwiththetimeandresourcesavailabletothemduringdentalvisits.11-18The development of a web-based clinical decisionsupporttoolforusebydentalhygienistsatchairsidehasthepotentialtoaugmenttheprimarycarework-force, improvescreeningforprimarycaresensitiveconditions, provide decision support for evidence-based patient management, improve coordinationofcarethroughtimelyreferrals,andensuregreaterconsistencyinthedeliveryofhealthpromotionanddisease prevention in dental settings, as per find-ings in community health centers.19,20 In essence,aweb-basedclinicaldecisionsupport system isaninformation technology-based system designed toprovideexpertsupporttoimproveclinicaldecision-making.Buttotranslateintoimprovedpatientcareoutcomes,formativestudiesareneededoftheden-talpracticeenvironmenttoadaptthetechnologytotheintendedsetting.

This is critical, asmanyadults visit a dental of-fice inagivenyear,butnotaprimaryhealthcareprofessional, providing an opportunity to leveragedentalproviderstomeetgeneralhealthneeds.21Theapproximately196,520dentalhygienistsintheU.S.areespeciallywellsituatedtoserveaspatientcarecoordinatorsandpositivelyinfluencequalityofcare,notablyforlow-incomeandolderadultpatientswhomayrequireassistanceinnavigatingthehealthcaresystem.Often interactingwithpatientsduring longappointment sessions and over extended periodsof time,dentalhygienists’education inandknowl-edgeof theoral-generalhealthconnectionenablesthem to provide trusted, patient-centered care.22Their scope of practice typically involves: taking a

comprehensivehealthhistory,includingmedicationsandtherapies;screeningforearlystagesofdisease,e.g.,takingbloodpressureandpulsereadings;andassuming a primary role in patients’ oral-generalhealtheducation.

Thereisaneedforresearchtofacilitatethewide-spreadimplementation,disseminationandsustainedutilizationofevidence-basedprimarycarescreening,monitoringandcarecoordinationguidelines,therebyincreasing the impact of dental hygienists’ actionsonpatients’oralandgeneralhealth.Theaimsoftheformativestudypresentedherearetoexploreden-tal hygienists’ and dentists’ perspectives regardingtheintegrationofprimarycareactivitiesandroutinedentalcare,andassesstheneedsofdentalhygien-istsanddentistsregardingprimarycarecoordinationactivitiesanduseofinformationtechnologytoobtainclinicalinformationatchairside.


Conceptual Framework

Theconceptualframeworkinformingthisresearchis theConsolidated Framework for ImplementationResearch(CFIR).23ACFIRtechnicalassistanceweb-siteisavailableforindividualsconsideringusingtheCFIR to evaluate an implementation or design animplementationstudy.24TheCFIRprovidesamenuofconstructsthathavebeenassociatedwitheffec-tive implementationandcanbeusedinarangeofapplications.24For instance,cultureandtension forchangearepartoftheinnersettingdomain;knowl-edgeandbeliefsabouttheinterventionandself-ef-ficacy are part of the characteristics of individualsdomain.

Figure1presentsthe5majordomainsoftheCFIR.Figure2identifiesthesedomainsfortheresearchathand.Thefiguresarenecessarily simplificationsofcomplicated implementationprocessesand thedo-mainsinvolved,andareelaboratedelsewhere.23,24Weelectedtobeconcretetoaidunderstanding.Hence,thedomainsdepictedinFigure2anddiscussednextaretobeinterpretedasexamples,ratherthancom-prehensiverenderings.

This study is centrally focused on the views ofdentalproviders.Nonetheless,improvingthehealthandwell-beingofpatientsisthemissionofallhealthcareentities,andpatientattitudesandcharacteris-ticsmayinfluenceproviderbehavior.23Hence,Figure1overtlydepictsdentalprovidersworkinghand-in-handwithpatientstoenhanceprimarycarecoordi-nationatchairside.

AlsoexplicitlyincludedinbothFigures1and2istheprocessofadaptation.AccordingtoDamschro-deretal,absentadaptation,interventionsareusu-


allyapoorfitforanygivensetting.23Thus,theyareoftenresistedbytheindividualswhowillbeaffectedbytheintervention.23Toaddressthischallenge,thefollowingformativeresearchstudywasconductedtogaintheviewsofdentalprovidersonprimarycarecoordinationatchairsidebeforedesigningaclinicaldecisionsupporttoolwiththeiractiveengagement.

Research Design and Informed ConsentProcedures

Thisexploratorypilotstudydesignutilizedaninno-vativeandadaptivequalitativeapproach.Thestudywas descriptive in design and drew on purposivesampling of dental providers within the investiga-tors’networkstoexaminetheperspectivesofdentalhygienistsanddentistsregardingtheintegrationofprimarycareactivitiesintoroutinedentalcare.25Thismulti-sitestudyemployedmaximumvariationsam-plingtorecruitdentalhygienists(n=10)anddentists(n=6)fromheterogeneousNewYorkCityareaden-taloffices(n=10)representingdiversepatientmixesandvolumes,practicetypes,andneighborhoodcon-texts.

Purposefulsamplingofinformation-richcasesfa-cilitates gaining in-depth knowledge, maximizingvariation/heterogeneity of perspectives and expe-riencesof the research topicsathand,andensur-ingcross-locationcomparabilityandgeneralizabilityof thedata.Participantswereselected toestablisha typicalsample inorder togainarichandvarieddescriptionofdentalhygienists’anddentists’expe-riencesof theirworkenvironment from informants

whowerewillingtoopenlydiscusstheseissues.25

At the beginning of each interview session, in-formedconsentandHealthInsurancePortabilityandAccountabilityActauthorizationformsweredistrib-utedandsignedbytheparticipants.Theseformsas-suredparticipantsthattheinformationtheyprovidedwouldbekeptconfidentialandexplicatedthescope,aims, methods and participation conditions of thestudy.Theparticipantswerealsoinformedthattheywere freetowithdrawfromthestudyatanytime,andthat theywouldbecompensated$50 for theirparticipation.

Key Informant Interviews

ANewYorkUniversityfacultydentalhygienistcon-ducted semi-structured, in-depth interviews,whichwere digitally recorded and transcribed verbatim.Ten interviewswereconductedwithdentalhygien-istsand6 interviewswereconductedwithdentiststoaskthemtheiropinionsaboutworkingwiththeirpatientstoidentifyandmanagediabetes(highbloodsugar), hypertension (highbloodpressure),useoftobaccoproductssuchascigarettesandcigars,andproblemareasoftheirdietssuchasheavyconsump-tionofsugarydrinks,allofwhichmayleadtooralhealthcareproblems.

The interviewer utilized a topic guide that wascomprisedofnon-directivequestions,whichsoughtto elicit accounts or descriptions of standard caredynamics and the potential utility of an electronicclinical decision support tool. The topic guide was

Figure1:The5MajorDomainsoftheCFIRforaGeneralImplementationScienceScenario

Figure2:The5MajorDomainsoftheCFIRforthePresentStudy


based upon CFIR constructs and refined accordingtotheexpertinputoftheresearchteamandsenioradvisoryboardmembers.23,24 Itemsqueried includ-ed:currentpracticesregardingprimarycarescreen-ing, management, and care coordination activitiesfordiabetesandhypertension;activitiesconductedandreferralsmadeforsmokingcessationandnutri-tioncounseling;thephysicalenvironmentandsocialcontext of the dental offices; patientmanagementservicesandsystems;structuralbarrierstotechnol-ogyadoption;andperceivedandactualchallengestoprimary care screeningat chairside.Each inter-viewlastedfrom45to60minutes.

Therecordedinterviewswerethenuploadedontoasecurewebsiteandtranscribedverbatimbyapro-fessional firm. Upon receipt, each transcript wasreadbyatleast2studypersonnelandeveryinter-viewdigitalfilewasplayedbackinordertoincreaseunderstandingof thenuancesof the researchpar-ticipants’ languageandmeaningsandattendmorecloselytorespondents’feelingsandviews.

Qualitative Analysis

Thestudyteamhasdevelopedamethodofcon-ducting thematic content analysis of qualitativetext thatallows for the systematic identificationofthemes present, reveals the relationships amongthese themes while keeping them in context, andensuresthatthecodesandtheirapplicationtothetext are valid and reliable.26-30 ATLAS.ti qualitativedatasoftware,version7,wasusedasadataman-agementtooltofacilitatedataretrieval,coding,the-maticanalysis,memosanddisplaysaspartof theanalysis.31

First,a“startlist”ofaprioricodes(thatis,priortobeginningtheanalysis)wascreatedbasedonques-tionsandtopics fromtheresearch instrument.Re-spectivethemesweredevelopedbythestudyteammembers,whoincludeddentalhygienistsandden-tists,afterconductinganin-depthliteraturereviewonrelevanttopics,holdingdiscussionswithotheroralhealth professionals (including experts that servedas senior advisory boardmembers), and envision-ingcharacteristicsanddynamicsrelatedtofacilitat-ingthegreaterintegrationoforalandgeneralhealthcare.Aspartofthedescriptivelevelofanalysis, invivo codes or indigenous categories were incorpo-rated,whichareconceptsthatusetheactualwordsoftheresearchparticipantsratherthanbeingnamedbytheresearchers.32

Followingthefirstcyclecodingmethod,or initialcoding, focused codingwas employed as a secondcycle analytic process.30 Focused coding searchesfor themost frequentorsignificant initial codes todevelopthemostsalientcategoriesinthedatacor-pusandrequiresdecisionsaboutwhichinitialcodes

makethemostanalyticsense.29Eachincidentinthedataiscomparedwithotherincidentsforsimilaritiesanddifferences.Incidentsfoundtobeconceptuallysimilar are grouped together under a higher-leveldescriptivecontent.Theoreticalcodingthenassistedinspecifyingthepotentialrelationshipsbetweencat-egoriesandshiftingtheanalyticnarrativetowardaCFIRtheoreticalorientation.30

Emergent Themes

Dataanalysisconsistedofmultilevelcoding,whichresulted in emergent themes with accompanyingcategories.Eightto10generalizedcodeswereiden-tified that generally corresponded to the primarydomainsofthetopicguide.Contentanalysisguidedthedevelopment, testingandrefinementofacod-ing scheme that enabled systematic identificationand conceptual definition of themain themes andsubthemes displayed in the transcripts, alongwiththe relationships among the themes. Because theinvestigatorswereinterestedinsimilaritiesanddif-ferencesbetweentheviewsofdentalhygienistsandtheviewsofdentists,thenumberofdentalhygien-istsandthenumberofdentistswhoendorsedeachtheme were totaled separately, and quotes wereselected and identified by the individuals involved(dentalhygienistsordentists)tobothillustratethethemeandpresentanyalternateviews.

reSultS

Study Participant Characteristics

Theself-reportedcharacteristicsofthedentalhy-gienistsanddentistswhoparticipatedinthekeyin-formant interviews, along with salient informationabout the dental offices where they practice, areprovidedinTableI.Notably,thedentistsinterviewedhad considerablymore years of professional expe-rience than did the dental hygienists interviewed.Thisalsospeakstotheeraswhenthesedentalprac-titionerswere trained (3 or 4 decades ago for thedentistsversuslessthanadecadeagoto3decadesago for the dental hygienists). Few dental provid-ersinterviewedworkinofficesthatacceptMedicaid,andonlyaboutone-halfwork indentalofficesthatacceptprivate insurance.Arangeofpracticetypeswererepresentedinthestudysample,meaningthatthepurposivesamplingwaseffectiveingaininginputfromdentalproviderswhoworkinavarietyofdentaloffices.Finally,alloftheparticipantsreportedown-ingsmartphones,meaningthattheyhadthetechno-logicalcapabilityofaccessinghealthinformationorusingaclinicaldecisionsupportsystematchairside.

Qualitative Findings

ThemainfindingsofthekeyinformantinterviewswithdentalprofessionalsaresummarizedinTableII,


alongwithillustrativequotesthatsupportthefind-ings,andalternateviewquotes,whereapplicable.

Screening for Diabetes and Hypertension

At the time the key informant interviews wereconducted (2013), screening for diabetes and hy-pertensionwas not deemed by the participants tobeespeciallyrelevantforthedentalpracticeswheretheyworked.

DentalHygienist:“Onascalefrom1to10,barelyaverage,becausemostofourclienteleareworkingprofessionalswhotendtobealittlebitmoreactive.Any health situation that they have, they usuallyhavetakenadvantageoftheirinsuranceandhaditcheckingout,sotheybringittoourattentiongladly.”

Nonetheless,thereweremanyalternateviewsex-pressed.

DentalHygienist:“Ithinkit’sveryimportant.Thepatientsdon’tseetheirdoctorsusually,sosincetheyseeusmorewewouldmakeachangeforthem.”

Further,thekeyinformantsreportedthattheirpa-tientsweregenerallyresponsivetobeingofferedre-ferralsbythemtoprimarycareproviders,especiallythedentists.

Dentist:“Ifthere’saproblemandIseethattheremightbesomethingthatIdon’tfeelcomfortablewithorthatthepatientshouldbeaddress,eithersome-how they’renot feelinggoodand for some reason

thatdayitseemslikeitmaybeanissueandwetooktheirbloodpressureandwetellthemtheybettergotoseesomebodytoday,yeah,wegoaheadandusu-allyhaveprettygoodcompliance.Oh,Ididn’tknowthatdoc,thankyouverymuch.Letmegoaheadandseesomebody in thenextweekorsoor thatday.Yeah,generally,Idon’tgethassled.Onceinawhilein the past, I don’t know, peoplemight follow-up,notfollow-up,butingeneral,peopletakeouradvice.Yeah,yeah.”

Othermainfindingswerethatthedentalprovid-ersintervieweddonotalwaysencouragetestingforpatientswhohavenotbeenscreenedfordiabetesorhypertension,andinfrequentlyseeoraldiseasethattheybelieveisrelatedtodiabetesorhypertension.

DentalHygienist:“Well,ImeanIdon’thavealotof patientswho have diabetes that I know of, butthosewhohaveit,it’sveryrelevant.Theydefinitelyhaveoralconditionsrelatedtotheirdiabetes.”

Evenwhendentalprovidersexaminepatientswithbloodpressuresinthehypertensiverange,theyonlycounseltheminsofarasreferringthemtoseetheirprimarycarephysicians.Allofthedentalprovidersinterviewedfailedtociteevidence-basedguidelinesindecidingwhatbloodpressurereadingistoohightoperformdentaltreatment.

Dentist: “Yeah. Yes. Yes, there is, and I—but Imust admit that I don’t routinely screen for highbloodpressureeither.IwouldsayI’dbevery—I’dbeconcernedaboutanythingsystolicof160andabove.”

CharacteristicDentalHygienists(n=10) Dentists(n=6)Mean(SD) Median(Range) Mean(SD) Median(Range)

Numberofyearsofprofessionalexperience 10.8(10.8) 6(2to33) 32.8(5.1) 33.5(28to40)Numberofpatientstreateddaily 11.4(5.9) 10(6to30) 8.4(1.0) 8(7to10)Numberofdentalprofessionalsperoffice 6(3.8) 4(3to16) 6.3(4.3) 4.5(4to16)Minutesallottedperpatient 46.2(15.1) 47.5(17.5to60) - -

n(Percent) n(Percent)AcceptsMedicaid 2(20%) 0(0%)Acceptsprivatedentalinsurance 7(70%) 3(50%)Grouppractice* 2(20%) 2(33%)Generalpractice* 5(50%) 2(33%)Holisticpractice* 1(10%) 1(17%)Prosthodonticspractice* 5(50%) 2(33%)Ownsasmartphone 10(100%) 6(100%)Ownsbothasmartphoneandatablet 4(40%) 3(50%)

*Morethanonetypeofpracticemayapply

TableI:Self-ReportedCharacteristicsofDentalHygienistsandDentistsWhoParticipatedInKeyInformantInterviewsandtheDentalOfficesWhereTheyPractice,NewYorkMet-ropolitanArea,2013


Mainfinding Illustrativequotesfromhygienistsanddentists

Alternateviewquotesfromhygienistsanddentists,whereapplicable

Screeningfordiabetesandhypertensionisnotespeciallyrelevantforthedentalpracticeswheretheparticipatingdental

providerswork

DentalHygienist:Onascalefromonetoten,barelyaverage,becausemostofourclienteleareworkingprofessionalswhotendtobealittlebitmoreactive.Any

healthsituationthattheyhave,theyusu-allyhavetakenadvantageoftheirinsur-anceandhaditcheckin’out,sotheybring

ittoourattentiongladly.

Dentist:Idon’tgenerallyscreenmyself.Ifweweresuspect—inotherwords,ifsomethinghappened,andithadnot

initiallybeenreportedinamedicalhistory,wewould,therefore,maybehavethem

checkedatthatpoint.

DentalHygienist:Ithinkit’sveryimpor-tant.Thepatientsdon’tseetheirdoctorsusually,sosincetheyseeusmorewewouldmakeachangefor‘em.

Dentist:Ithinkit’sveryimportanttodothat[screenforhypertension].Obviously,inourprofession,wecan’treallyworkonsomeonewhoisnotstable.Itwillsur-faceinasenseoflotsoffactors—stress,anxiety,bleeding,andotherfactors.Itcanaffectthetypeofanesthesiaweuse,ofcourse,inordertostillperformthat

particularprocedurethatday,soIthinkit’simportanttoscreenforit,yes.Yeah.

Patientsweregenerallyresponsivetobeingofferedreferralstoprimarycareproviders

bydentalproviders

DentalHygienist:Theylikethatthey’rebe-ingtakencareof.

Dentist:Ifthere’saproblemandIseethattheremightbesomethingthatIdon’tfeelcomfortablewithorthatthepatientshouldbeaddress,eithersomehowthey’renotfeelinggoodandforsomereasonthatdayitseemslikeitmaybeanissueandwetooktheirbloodpressureandwetellthemtheybettergotoseesomebody

today,yeah,wegoaheadandusuallyhaveprettygoodcompliance.Oh,Ididn’tknowthatdoc,thankyouverymuch.Letmegoaheadandseesomebodyinthenextweekorsoorthatday.Yeah,generally,Idon’tgethassled.Onceinawhileinthepast,Idon’tknow,peoplemightfollow-up,notfollow-up,butingeneral,peopletakeour

advice.Yeah,yeah.

DentalHygienist:Nottoohappy.Becausetheythinkthatweareexaggerating.Theythinkthatisirrelevanttotheirdentalvisit.

Dentalprovidersdonotalwaysencouragetestingforpatientswhohavenotbeenscreenedfordiabetesorhypertension

DentalHygienist:Ihave.Notonaregu-larbasis,butIhaveespeciallyifthere’s

somekindoforalimplicationorIgetsomeotherkindofcuesthenIwill,butnotona

regularbasis.

Dentist:Iguessitdependsonthepatient’sage,sex,risk,againfamilyhistory.There’sapartonthere.Wedon’tnecessarilyen-courageitunlessthere’s—we’reassumingthatthey’reundermedicalcareandthatthey’rebeingscreenedforallthat.

DentalHygienist:Yes.Idefinitely.Evenwhentheydon’thaveamedicaldoc-torlisted,Iencouragethemtogosee

somebodyatleastonceayear.IfIfeltlikemaybetheyweredescribingsomesymp-toms,thenIwouldsay,youknow,itwouldbeagoodideatogoseeyourprimarycare

physician.

Numberofinterviewswithdentalhygien-istswherefindingwasendorsed

Numberofinterviewswithdentistswherefindingwasendorsed

Totalnumberofinterviewswherefindingwasendorsed

6/10 3/6 9/167/10 6/6 13/165/10 6/6 11/167/10 4/6 11/167/10 5/6 12/1610/10 6/6 16/167/10 4/6 11/166/10 3/6 9/169/10 5/6 14/16

TableII:SummaryofMainFindingsofKeyInformantInterviewswithDentalProfession-als,NewYorkMetropolitanArea,2013




Participatingdentalprovidersinfrequentlyseeoraldiseasethattheybelieveisrelated

todiabetesorhypertension

DentalHygienist:Well,ImeanIdon’thavealotofpatientswhohavediabetesthatIknowof,butthosewhohaveit,it’sveryrelevant.Theydefinitelyhaveoralcondi-

tionsrelatedtotheirdiabetes.

Dentist:HowoftendoIseehypertensionissues,highbloodpressureproblems,tis-sue,anxiety,bleeding?Nottoooften.NottoooftendoIseesomeonethathashy-pertensionissues.Idon’tknow.IfIthrewoutanumberlike,Idon’tknow,Idon’tknow.I’dsayabout20,25percentoffthetopofmyhead.IfIlookinthechartandseethey’rehypertensive,that’sprobably

myanswer.Allright?

DentalHygienist:Iwouldsayoften,butbecauseit’srelatedtotheirmedication.Iseedrymouthalot,xerostomia,becauseofthemedicationthatpeopleareonfor

diabetesandhypertension.

Dentist:Goodpercentageoftheperiodon-talcasesprobablyhavesomediabetesorpre-diabetic,anybodyover40,let’ssay.

Participatingdentalproviderscounselpatientsinthehypertensiverangeonlyin-sofarasreferringthemtoseetheirprimary

carephysicians

DentalHygienist:HowIconsult?LikeIsaybeforeifIknowtheyaretakingthemedi-cationandtheystillhavesomeproblemsIcanreinforceonthegoingbacktothedoctorforchangingthemedication.

Dentist:Idon’treallycounselthem.No.Wellagain,onlyifthey’reuncontrolled.ThenIdefinitelycounselthemtoseetheirphysicians,butno.Notspecificintermsof

whattheyshouldbedoing.

DentalHygienist:Diet,exercise,haveaphysicaltohaveitdefinitelycheckedbytheirphysician.Icounselthemthatthisneedstobeaddressedimmediately.I

makeitamatterofurgency.

Dentist:Diet.Lifestyle.Diet,lifestyle,andreferral.

Participatingdentalprovidersdonotciteevidence-basedguidelinesindeciding

whatbloodpressurereadingistoohightoperformdentaltreatment

DentalHygienist:IguessnomatterwhichreadingIget,ifIfeltlikeanythingwas

overlike140over90,Iwouldhavetoaskmydoctor,andshewouldletmeknowwhetherwhatshefeltwasokaytotreat.Inmyownopinion?Tobehonest,IguessIwouldsaylike,Imean,90isprettyhigh.Iwouldsaylikemaybe155overlike95orsomethingorahundred.Somethinglikethatwouldmakemereallynervous.No.

Dentist:Yeah.Yes.Yes,thereis,andI—butImustadmitthatIdon’troutinelyscreenforhighbloodpressureeither.IwouldsayI’dbevery—I’dbeconcernedaboutany-

thingsystolicof160andabove.

Participatingdentalprovidersbelievethatitisimportantfortheirdentalcolleaguesto

screenandtreatfortobaccouse

DentalHygienist:I’dsayprettyimportant.It’svery—smokingbringsaboutmanyriskfactorsforhealthingeneral,soit’sagoodideato.Notifitmakesmoreworkfor

them.[Laughs]

Dentist:Ithinkit’s,again,ifit’sanyprac-tice,grouppractice,andIguesswe’reoutthereaspractitioners,healers,insociety,weshouldcontinuetospreadthewordandeducatethepopulationthatsmokingisnotgoodforyouanddoourbesttotrytocutitdownamongstourwholepopulationinthe

officethatwesee.

DentalHygienist:‘Causeitseemstobesomethingthathastohappenoutsideoftheoffice,andwhich[sighs]—there’sno

monetarybenefit.

Dentist:Somesay,“I’dliketotry.Whatdoyouhavetooffer?”Otherssay,“I’mstilljustgonnakeepdoingit.Givemesomepaperworkandstuff,”andthentheyjustwalkoutoftheoffice.Ithinkthatmostof‘emagreethatit’snotgoodforthem,butit’sdifficulttomotivatepeopletotrytostopsmoking,beitthroughmechanismsofpaperwork,literature,chewinggums,ormaybegiving‘emsomethingalittle

stronger.

TableII:SummaryofMainFindingsofKeyInformantInterviewswithDentalProfession-als,NewYorkMetropolitanArea,2013(continued)




Participatingdentalprovidersoftenseedentaldiseasethattheybelieveisrelated

topoordiet

DentalHygienist:Iwouldsayoften.Notallthetime,butIdothinkthattherearesomepatientsthatbecauseoftheirdietthey’reatahigherriskforcaries.Iftheyhaveanyhealthissues,itjustexacerbateslikethewhole.They’reatriskfordecay.

Dentist:Often.Inthecollegeagestudent,theygooffwithperfectteethandcomebackwithallsortsoftroublefromlatenightswithabottleofCokeandM&M’s.

DentalHygienist:ChildrenwillbemoreofanissueorplacewhereIwouldseethat,butwedon’tseethatmanychildren.

Dentist:Notveryoften,buteveryonceinawhile.

Participatingdentalprovidersusetheirphonesorotherdevicesatchairsidetoob-tainclinicalinformationrelatedtothecare

oftheirpatients

DentalHygienist:WebMD.WebMDandPubMed...Buthonestly,Iuseasearchen-gine,andthenIgotolikeacoupledifferent

onestogetwhatI’mlookingfor.

Dentist:IhaveHippocratesonmyphonetolookupdrugs,butgenerallyIdon’tuse

itmuchmore[than]that.

DentalHygienist:Notreally.I’mahygien-ist,30years.Ahygienist.30years,okay?IprettymuchgowithwhatIknow.[Laugh-ingtogether]I’mbeingreallyhonest.IfIgetstumped,IwillGoogleawordoratopic,butIprettymuchgowithwhatI

know.Notreally,no.

Dentist:Youknow,it’sinteresting.Idon’tnecessarilygoonline.Icometotheschoolsincewe’refortunatetoworkinafacultypracticeI’llgotomycolleagueswhoareoralsurgeonsororalmedicine.Ispeaktothemdirect.IfigureI’llgotothemdirect.

TheyknowmorethanIdo...

TableII:SummaryofMainFindingsofKeyInformantInterviewswithDentalProfession-als,NewYorkMetropolitanArea,2013(continued)

Screening and Treatment for Tobacco Use

Mostoftheparticipatingdentalprovidersbelievethat it is important for their dental colleagues toscreenandtreatfortobaccouse.

Dentist: “I think it’s, again, if it’s any practice,grouppractice,andIguesswe’reoutthereasprac-titioners,healers, insociety,weshouldcontinuetospread the word and educate the population thatsmokingisnotgoodforyouanddoourbesttotrytocutitdownamongstourwholepopulationintheofficethatwesee.”

Nonetheless,alternateviewswereexpressed,in-cludingasenseoffatalismaroundreimbursement.

DentalHygienist:”Becauseitseemstobesome-thingthathastohappenoutsideoftheoffice,andwhich[sighs]—there’snomonetarybenefit.”

Relevance of Diet and Use of Technology

Most of the participating dental providers oftensee dental disease that they believe is related topoordiet,especiallyamongyoungerpatients.

Dentist:“Often.Inthecollegeagestudent,theygooffwithperfectteethandcomebackwithallsortsoftroublefromlatenightswithabottleofCokeandM&M’s.”

Importantly, the overwhelming majority of par-ticipantsusetheirsmartphonesorotherdevicesatchairsidetoobtainclinicalinformationrelatedtothecareoftheirpatients.

DentalHygienist:“WebMD.WebMDandPubMed.Buthonestly,Iuseasearchengine,andthenIgotolikeacoupledifferentonestogetwhatI’mlookingfor.”

Findings Relative to the CFIR

Thepresentstudyfocusedprimarilyontheviewsofdentalproviders(individualsinvolved)aroundpri-mary care coordination at chairside (the interven-tion), but it also touchedon other domains of theCFIR. For instance, dental providers were directlyqueriedaboutincentivestofollowprofessionalguide-lines,partofthedomainknownastheoutersettingthatincludestheconstruct,externalpoliciesandin-centives.23,24While2dentalhygienistsmentionedre-ceiving incentives for selling certaindentaldevicesor procedures, none of the participantsmentionedreceivingincentivestofollowprofessionalguidelines.

DentalHygienist:“[Laughs]Canyourepeatthat?Therearen’tincentives.It’sallpatientcareoriented.Myincentiveisthatmyofficeisverypatientcareori-entedsoIdon’thavetoworryaboutanythingelse.Iknowaboutwhat’sbestforthepatient,thepatient’sgonnaget,whetherornottheycanaffordit.”


DiScuSSion

Oneoftheimportanttake-homemessagesfromthisformativestudyisthattherearemultipleandsignifi-cantmissedopportunitiesatdentalofficestoscreen,manageandreferpatientsthatmightbenefitfrompri-marycaretreatmentand/ortobaccouseandnutritioncounseling.TheCFIR(Figure1)providesapragmaticstructure for approaching the complex, multi-level,anddynamicprocessesnecessaryforsuccessfullyim-plementingandadaptingprimarycarecoordinationatchairside in dental offices, toward improving patientcareoutcomes.23

Anothermajorfindingisthatdentalhygienistsarenotbeingsupportedtoprovidepatientcareattheleveloftheirfullscopeofpractice.Self-identifiedchallengesthatprohibitdentalhygienistsfromprovidingtheirpa-tientswiththehighestqualitystandardofcare(includ-

Dentist:“Incentives?Incentivesistheykeeptheirjob[laughs].Everybody’sgotethicalstandards.Wedon’t. No. But we do promote wellness as a gen-eralholisticrule.Butthereisn’tanyspecificfinancialcompensationtothehygienist.I’mnotaversetothatidea,andwe’vetalkedaboutofferingdifferentprod-ucts, including oral cancer screening, which I willoftendomyself.Rightnow,theoralcancerscreen-ingisusuallydonebythedoctor,andIwouldn’tsaythehygienistsareinvolvedwiththat.Orsomeoftheothertests.”

Inaddition,thereweremanyoffice-relatedchal-lenges that were identified to conducting primarycare activities in dental offices, especially by thedentalhygienists,whichfallunderthedomainoftheinnersetting.

DentalHygienist:“Timeisalwaysachallengeinahygieneappointment.Itseems,especiallysinceI’mbeingtaped,thisismything,thattheykeepaddingmoreresponsibilitiesinthehygienedepartmentandlesstimeandsalary.‘Causethere’salotthatwedobecauseweare thefirst lineof dental health careprofessional. There’s a lot that the doctor expectsustodobeforethepatientgetsinhischair,butourfocusandspecialtyiscleaningteeth.”

Butwhatcameacrossmemorablyintheinterviewsis thatdentalhygienistspossessedvaluesorientedtowardpatient-centeredcare,includingbutnotlim-itedtooralhealthcare.

DentalHygienist:“Inmyyearsofhygiene,mypa-tientsappreciatethefactthatIseemtocare.That’swhatIwastaughtinhygieneschool:thatwewerethecarersorthecaregivers.TheylikewhenIseemconcernedabouthowtheyfeel,andhowtheirhealth,andwanttotalktothemmoreabouttakingcareofthemselves,andnotjusttheirteeth.”

ingscreening,monitoring,andcarecoordinationofdi-abetesandhypertension)includeresourceconstraints,lackofconfidenceintheirknowledgeortraining,prob-lemswithpatientcomplianceandtruthfulness,lackofinstitutionalorsystems-levelsupport,andperceptionoftheseactivitiesasfallingwithinthedomainsofotherhealthprofessionals.

Finally,itisnoteworthythatalloftheparticipatingdentalhygienistsanddentistsreportedusingelectron-icdevicesatchairsidetoobtainweb-basedhealthin-formationincaringfortheirpatients.Theuseofclinicaldecisionsupportatchairsideisawell-documentedap-proachtoincreasingprovideradherencetoguideline-recommendedscreening,treatmentandreferral,andmaybeeasilyintegratedintoanelectronicdentalre-cord.33Unfortunately,theireffectivenessinimprovingpatientmorbidityacrossclinicalsettingsisonlymod-est,atbest.34

Still, thedentalprofession isembarkingonanewerawithregardtoelectronichealthrecords.35TheNewYorkUniversityCollegeofDentistry recently institut-edelectronichealthrecords in itsdentalclinics.It isexpectedthatbothdentalhygienistsanddentistswillgainconfidenceinexpandingtheirscopesofpracticetoincludeprimarycarescreeningandreferralinthissetting, and that disseminationof theseactivities todentalofficeswillbeabettedbythisdevelopment.

Limitationsofthisformativestudyincludethetar-geted recruitment strategy,whichwas supported bylocalprofessionalcontactswithinthesocialnetworksoftheinvolvedstudypersonnel.Thus,theparticipantswerenotnecessarilyrepresentativeofdentalprofes-sionalsintheNewYorkCityareaoverall.Forinstance,thedentistsinterviewedhadallbeenpracticingforaminimumof28years.Further,thispilotresearchpri-oritizedin-depthqualitativedataoveralargersamplesize, thus limiting the scopeofperspectives,experi-ences, and demographics represented. Finally, thefindingspresentedhererepresentanarroweraccountof the key informants’ perspectives and experiencesthatwerepresentinthefulldatacorpus.Nonetheless,thestudyfindingsselectedfordisseminationheremayconstituteabasisforfuturesystematicresearch.

Insummary,thesefindingssuggestthatincreasingthe role of dental hygienists in primary care coordi-nationatchairsideand incorporatingevidence-baseddentistryintopatientcareatdentalofficeswillrequirethecommitmentofawiderangeofindividualsinboththeinnersettingoftheinvolveddentalpracticesandthe outer setting of the primary care practices withwhichtheypartner(Figure1).Byleveragingtheexist-ingworkforcethatalreadyplaysacentralrole inof-feringpreventiveservices,patienteducationandcarecoordination,dentalhygienistsmayyetplayanevenmoresignificantroleinimprovingthehealthandwell-beingoftheirpatientsandthepublicatlarge.


concluSion

Dentalhygienistsoccupyauniqueandvitalroleinprovidingtrustedpatient-centereddentalcareandarewell positioned tohelp facilitate thegreater integra-tion of oral and general health care coordination. Atheory-drivenapproachtoimplementingprimarycarecoordination at chairside holds promise for success-fullyadaptingevidence-basedtechnological interven-tionstodentaloffices.Buildinguponthesefindings,aweb-basedclinicaldecisionsupportsystemwasdevel-oped.36Fundingisbeingsoughttoevaluatethedevel-opedclinicaldecisionsupportsystemwiththeactiveengagementofdentalhygienistsanddentists.Thisim-plementationresearchagendaseekstosupportdentalhygienists in primary care coordination at chairside,withtheultimategoalofimprovingpatientoutcomes.

Mary E. Northridge, PhD, MPH, is an Associate Pro-fessor, Department of Epidemiology & Health Promo-tion, New York University College of Dentistry. Shir-ley Birenz, RDH, MS, is a Clinical Assistant Professor, Dental Hygiene Program and Department of Epidemi-ology & Health Promotion, New York University Col-lege of Dentistry. Danni M. Gomes, RDH, is a Clinical Instructor, Dental Hygiene Program, New York Univer-sity College of Dentistry. Cynthia A. Golembeski, MPH, is a Research Assistant, Department of Epidemiology & Health Promotion, New York University College of Dentistry. Ariel Port Greenblatt, DMD, MPH, is Project Director, Department of Epidemiology & Health Promo-

acknowleDgmentS

DiScloSure

Theauthorsaregratefultotheparticipantsinthisstudy who were forthcoming about their roles andchallenges,andmembersofthesenioradvisoryboardwho gave of their expertise and researchmaterialstowardadvancingpatient-centeredcareatchairside.

Theauthorsweresupportedintheresearch,analy-sis,andwritingofthispaperbytheNationalCenterfor Advancing Translational Sciences of the US Na-tionalInstitutesofHealthfortheprojecttitled,Prima-ryCareScreeningbyDentalHygienistsatChairside:DevelopingandEvaluatinganElectronicTool (grantUL1TR000038)andbytheNationalInstituteforDen-talandCraniofacialResearchandtheOfficeofBehav-ioralandSocialSciencesResearchoftheUSNationalInstitutesofHealthfortheprojecttitled,IntegratingSocialandSystemsScienceApproachestoPromoteOralHealthEquity(grantR01-DE023072).

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Itiswidelyknownthatdentalhygienistscanbeeffectively taught expanded functions and thosefunctionscanbedeliveredeffectivelyandsafely.1During1972to1974,theForsythExperimentcodenamed “Project Rotunda,” gathered data demon-stratingsafetyandefficacyofdentalhygienistad-ministeredlocalanesthesia.Atotalof19,173localanesthetic administrationswere given during theprojectwithonly3minorshort-termadversereac-tionsanda92%firstattemptsuccessrate.2

The body of literature relating to the adminis-trationof localanesthesiabydentalhygienists islackinginmorerecentstudies.Earlystudieswereaimedatevaluatingthesafetyandefficacyofden-tal hygiene administered local anesthesia alongwithuse,impact,andprovideranddentistpercep-tions.In1992,Cross-Polineetalconductedasur-veyofColoradodentalhygienistswhocompletedacontinuingeducationcourseinlocalanesthesiaad-

AnEvaluationofPermitLLocalAnesthesiawithinDentalHygienePracticeinMassachusettsKatherineA.Soal,CDA,RDH,MSDH;LindaBoyd,RDH,RD,EdD;SusanJenkins,RDH,MS,CAGS;DebraNovember-Rider,RDH,MSDH;AndrewRothman,MS,EIT

AbstractPurpose:ThepurposeofthisdescriptivestudywastoassessdatapertinenttothePermitLlocalanes-thesialicenseamongpracticingdentalhygienistsinMassachusetts,providinganoverviewofcharacter-istics,practicebehaviors,barriersforobtainingthepermitandself-perceivedcompetency.Methods:Aconveniencesampleofdentalhygienists(n=6,167) identifiedthroughapublicallyavail-abledatabasewereinvitedtoparticipateinaweb-basedsurvey.ThesurveyconsistedofdemographicandPermitLspecificquestions.Itemsregardingopinionswereratedusinga5-pointLikertscalewhilefrequenciesandpercentileswereusedtoevaluatedemographicsandpractice-basedinformation.Spear-man’sRankcorrelationwasperformedtodetermineassociationbetweenvariables.Results: A10%(n=615)responseratewasattainedwith(n=245)non-PermitLholdersand(n=370)PermitLholders.Respondentsreportedsignificantdifferencesindemographicsandopinionsbetweennon-PermitLholdersandPermitLholders (p<0.01)andbetween thosecertified throughcontinuingeducationorcurriculumbasedprograms(p<0.01).Significantrelationshipswerefoundindemograph-ics(p<0.01)andpractice(p<0.05)itemsinrelationtothelengthoftimethePermitLhasbeenheld.ThemesfromthedataandcommentsindicatemultiplefactorsinfluencingobtainingornotobtainingthePermitL.Conclusion:TheresultsofthisstudyprovideanoverviewofPermitLlocalanesthesiaadministrationthatisgenerallycomparabletopreviousstudiesandoffersnewinsightsintowhysomeMassachusettsdentalhygienistschoosenottopursuecertification.ThisstudyhighlightsthepotentialtoincreasetheprevalenceofthePermitL,addressbarrierstopursuingthePermitL,andfurtherevaluateself-perceivedbarriers.Keywords:localanesthesia,dentalhygienists,continuingeducation,professionaldelegationThisstudysupportstheNDHRApriorityarea,Professional Education and Development: Investigatecurriculummodelsfortrainingandcertificationofcompetencyinspecialtyareas(e.g.,anesthesiology,developmentallydisabled,forensics,geriatrics,hospitaldentalhygiene,oncology,pediatrics,periodon-tology,andpublichealth).

research

introDuctionministration.3Levelsofeducationwerereportedas8%certificate,45%Associate,and45%Bachelordegreeswith76%ingeneralpracticeand17%inaperiodontalpractice.Inaself-reportedpostcoursequestionnaire88%(n=96)wereadministeringlo-calanesthesiaasneededforpatientcareandtheremaining12%(n=12)statedreasonsfornotad-ministeringincluding;employerresistance,patientresistance,andpracticetype.3

In 2000,DeAngelis andGoral reported the re-sults of aquantitative surveydesigned to assessArkansas dental hygienists’ use of local anesthe-sia.4Certificationwasheldby97%forat least1year,andof those,92%were ingeneralpracticeand7%inperiodontalpractice.Levelsofeducationwerereportedas8%certificate,23%Associates,67%Bachelorsand2%Master’sdegrees.Delega-tion of local anesthesia for dental hygiene pro-cedureswas reported at 94% (n=109) and 68%


(n=109) for dental procedures.When the dentalhygienistswereaskedtheiropinionregardingthestatement, “Local anesthesia is not needed fordentalhygieneprocedures,”90%(n=284)ofthosecertifiedeitherdisagreedorstronglydisagreed.Asignificantcorrelation(p<0.001)was foundwhenthe same question was asked of those with andwithoutcertification.4

Anderson evaluated use of local anesthesia bydental hygienistswho completed continuing edu-cationcourseinMinnesotaduring1996.5Theself-reporteddatarevealeda95%delegationratefordentalhygieneproceduresanda65%delegationrateforthedentist’patientswith89.6%(n=242)ingeneralpracticeand7.8%(n=21)inperiodon-talpractice.Associatedegreeswereheldby90%(n=204)andBachelordegreesby9%(n=25)withno significant relationship between educationallevelandsuccessful injections(p=0.87).Theval-ue of local anesthesia administration in practicewasreportedasveryvaluableby58%,and87%believedtheskillwouldhavevaluewhenseekingemployment. Success was measured by achiev-ingadequateanesthesia,andratesof90to100%werereportedby76%withnosignificantrelation-shipbetweenyears sincegraduationand levelofsuccess (p=0.24). The most frequently reportedcomplicationwashematomaby5.9%(n=16)with87.8% (n=239) reporting no complications and86%aspirateallthetime.5

Ina2005surveybySchofieldetal,informationwasrequestedfromstatelicensingboards(n=26)regarding disciplinary actions against dental hy-gienistsinvolvingtheadministrationoflocalanes-thesia.6Thenumberofdisciplinaryactionsagainstdental hygienists involving the administration oflocalanestheticsreportedbyallparticipatingstatelicensingboards(n=18)waszero.6

In2011,Boynesetal conducteda randomizednationwidesurveyofdentalhygienists(n=1,200)evaluatingdentalhygienelocalanesthesiaeduca-tionandadministration.7Theresultsreveal86.4%(n=431)dentalhygienistsperceivedaneedforlo-calanesthesiafordentalhygieneprocedureswith76.1%ingeneralpractice,7.8%periodontalprac-ticeand8.4%inanacademicsetting.Ofthosead-ministeringlocalanesthetics,67.3%weretrainedin a curriculum-based program and 32.3% in acontinuing education program.7 The study estab-lished5regionsintheU.S.toevaluatelocalanes-thesiause.Region5includedthewesternstatesofAlaska,Arizona,California,Hawaii,Idaho,Nevada,Oregon,UtahandWashington.Thisregionreport-ed93.8%ofdentalhygienistsadministerlocalan-esthesiaand61%alsoadministeredanesthesiatothedentist’spatients.Region1consistingofthenortheasternstatesofConnecticut,Delaware,Mas-

sachusetts,Maryland,Maine,NewHampshire,NewJersey,NewYork,Pennsylvania,RhodeIslandandVermontreported32.1%ofdentalhygienistsad-ministeringand30.4%administeringfortheden-tists’patients.7Themeanyearof implementationofdentalhygieneadministeredlocalanesthesiaforregion5is1978and2003forregion1.

Despite the findings of several studies demon-stratingsafetyandefficacyofdentalhygienead-ministeredlocalanesthesia,3-5,8Massachusettsre-mainedbehindthemajorityofstatesinlegalizingthe practice. Washington State was the first topasslegislationallowingtheadministrationoflocalanestheticsbyadentalhygienistin1971,followedbyNewMexicoin1972andthemajorityofstateswestoftheMississippiRiverbythelate1990s.9Itwas not until 2004 that Massachusetts approveddental hygiene administered local anesthesia un-derdirectsupervisionviathePermitLlocalanes-thesia license.9 The Permit L local anesthesia li-censeallowsdentalhygieniststoadminister localanesthesia by nerve block and infiltration and isobtainedaftersuccessfulcompletionofacontinu-ingeducationorcurriculum-basedtrainingcourse.Aminimumof35hoursofinstructionincludingnoless than12clinicalhoursarerequired tosatisfythe requirements set forth by theMassachusettsBoardofRegistrationinDentistry.10

Todate,therehasnotbeenastatewideevalua-tionofthePermitLexceptforasinglelocalanes-thesiaquestionposedinthe2007“AReportontheCommonwealth’sDentalHygieneWorkforce.”11Thissurveyrevealed12%(n=381)ofdentalhygienistsarePermitLholders.Ofthenon-PermitLholders(n=4,114)64.4%(n=2,650)reportedtheydidnotintendtobecomecertified.Themainreasonscitedwere lack of interest (32.9%, n=871), increasedliability(28.2%,n=747),nomonetarycompensa-tion (14.1%, n=373), cost (13.4%, n=355) andfear(11.5%,n=304).9AsMassachusettsisalate-comer to thenational localanesthesiaarenaandafterpracticingforsolongwithoutthePermitL,anevaluationoftheperceivedbarriersandmotivatingfactorssurroundingobtainingornotobtainingthePermitLwillprovideinsightintoitsimpact.

The purpose of this study was to gather datapertinent to Permit L practice among dental hy-gienistsinMassachusettsprovidinganoverviewofthecharacteristicsofPermitLholdersandindicateself-perceived barriers to obtaining the Permit L.Thisstudyassessed2researchquestions:

1.WhatarethecharacteristicsofPermitLholdersinMassachusetts?

2.Whataretheself-perceivedbarrierstopursu-ingthePermitL?



reSultS

Research Design

This cross-sectional,onepoint in time,descrip-tiveweb-basedsurveyresearchevaluatedPermitLandnon-PermitLholdingdentalhygienistsinMas-sachusetts.Thesurveywasdesignedtoincludeonlythosedentalhygienistswhowerecurrentlypractic-inginMassachusettsandresidinginMassachusetts,Connecticut,NewHampshireorRhodeIsland,andfurther identified 3 independent variables: thosewithandwithoutthePermitL.Thosewhodidhavethe Permit L were separated by type of Permit Ltraining program they attended; either continuingeducation-based or curriculum-based. The surveyadministered tonon-Permit Lholders consistedof6demographicquestionsand12Permit L specificquestions.Fourofthe12questionsthatrequestedopinionswereratedusinga5-pointLikertscale.Af-teridentifyingwhichPermitLtrainingprogramtheyattendedthePermitLholderswereasked20ques-tionsrelatedtothePermitL,5ofwhichwereratedusinga5-pointLikertscale.Baseduponthe liter-ature,12,13 content validity indexes were obtainedfromapanelof6expertstoensurecontentvalidityof the survey instrument.AnS-CVI scoreof 0.87wasobtainedfornon-PermitLholderquestionsand0.8wasobtainedforthePermitLholderquestions.The study received IRB approval with an exemptstatus fromHumanSubject Committee ofMCPHSUniversity.

Sample Inclusion/Exclusion Criteria

AlldentalhygienistswhowereregisteredinMas-sachusettsandresidinginMassachusetts,Connect-icut,NewHampshireorRhodeIslandatthetimeofthe surveywere invited to participate (n=6,167).ThemailingaddresseswereobtainedfromtheMas-sachusettsBoardofRegistrationinDentistryviaapublicallyavailabledatabase.Theinclusioncriteriatoparticipatewere:currentlypracticinghygienistsinMassachusettsand,ifacurrentPermitLholder,trainingatanaccreditedprograminMassachusetts.ThetotalnumberofPermitLholdersregisteredinMassachusettsandresiding in theaforementionedstates(n=2,180)represented35%ofthepotentialsampleofpermitLholders.

Data Collection

A postcard invitation to participate in theweb-based survey was mailed to all dental hygienists(n=6,167) in September 2013. Concurrently, aninvitationwaspostedontheMassachusettsDentalHygienists’Association(MDHA)websiteandpartici-pantswererecruitedin-personattheMDHAannualsession.Ablaste-mailwasdeliveredbyMDHAwithafollow-upe-mailreminderthreeweekslater.

Data Analyses

Datawerecollectedon-lineviaSurveyMonkey®,downloaded as Excel spreadsheets and importedintoSTATA®version12statisticalanalysissoftware.Descriptivedatasummarizeddemographiccharac-teristics and Likert-scaled questions. Spearman’sRankcorrelationtestingwasusedtodetermineas-sociationbetweenvariablesandthelevelofsignifi-canceforalldataanalyseswassetat<0.05.

Demographics

An overall response rate of 10% (n=615) wasattained with 245 non-Permit L holders and 370Permit L holders. The non-Permit L holding re-sponders(n=245)represented6.1%ofthe3,987non-PermitLholdersandthePermitLholdingre-sponders(n=370)represented16.9%ofthe2,180Permit L holders currently licensed in Massachu-setts and residing inMassachusetts,Connecticut,NewHampshire orRhode Island. Themajority inbothcategorieswere female (98%), thePermitLholdersweregenerallyyoungerwith61%(n=227)aged 45 or under and 87% (n=212) of non-Per-mit Lholderswereaged41orover.Thenumberof years in practice was fairly evenly distributedexcept for those who had been in practice for 1to5yearsaccountingfor20%(n=121)ofthere-spondents of which 90% (n=109) were Permit Lholders.Thirty-sevenpercent(n=135)ofPermitLholders anticipated being in practice longer than20yearscomparedto15.7%(n=39)non-PermitLholders.Associatedegreeholdersweremoreprev-alent in the non-Permit L holder category (70%)whileBachelor (38%)andMaster (14%)degreesweremore prevalent in the Permit L holder cat-egory.Most(67%)workedingeneralpractice,andof those stating an academic work setting 93%(n=41)werePermitLholders.Otherpracticetypesreported(n=50)includedmulti-specialty,oralsur-gery,hospital/rehab,communityhealthcenter,andcorporatesettings.DemographicdataarereportedinTableI.

Opinions and Descriptive Data ofNon-Permit L Holders

TableIIshowsthedescriptivedatafornon-Per-mit L holders. The vast majority (99.5%) of thenon-PermitLholdersreportedthePermitLwasnotaconditionofemployment,and79%(n=172)werenotplanningtobecomecertified.Themainreasonsfornotbecomingcertifiedwere:notneededintypeofpractice(17.5%),notplanningtostayinprac-ticelongenoughtouse(14.5%),fearofadminis-teringlocalanesthetics(14%),cost(12.25%)andnofinancialgain(13%).Employerresistanceand


Non-PermitLHolders(0) PermitLHolders(0) Totaln(Percent) n(Percent) n(Percent)

GenderFemaleMale

244(99%)1(<1%)

361(97.5%)9(2.5%)

605(98%)10(2%)

Age<2121to2526to3031to3536to4041to4546to5051to5556to6061to65>66

0(0%)0(0%)13(5%)9(3.5%)11(4.5%)25(10%)46(19%)55(22.5%)53(22%)26(10.5%)7(3%)

1(0.25%)36(9.75%)47(12.5%)52(14%)40(11%)51(13.75%)50(13.5%)47(12.75%)26(7%)11(3%)9(2.5%)

1(0.25%)36(6%)60(9.75%)61(10%)51(8%)76(12%)96(15.5%)102(16.5%)79(13%)37(6%)16(3%)

Yearsinpractice<11to56to1011to1516to2021to2526to3031to3536to40>40

0(0%)12(5%)21(9%)20(8%)18(7.5%)33(14%)28(11.5%)41(17%)47(19%)22(9%)

21(6%)109(29%)69(19%)34(9%)22(6%)31(8%)28(7.5%)26(7%)20(5.5%)10(3%)

21(3.5%)121(20%)90(15%)54(9%)40(6%)64(10.5%)56(9%)67(11%)67(11%)32(5%)

Anticipatednumberofyearsremaininginpractice<11to56to1011to1516to2021to2526to3031to3536to40>40

3(1.25%)49(20%)57(23%)63(26%)34(14%)23(9.25%)7(3%)4(1.5%)4(1.5%)1(0.5%)

3(1%)36(10%)63(17%)61(16%)70(19%)32(9%)44(12%)29(8%)20(5%)10(3%)

6(1%)85(14%)120(19.5%)124(20%)104(17%)55(9%)51(8%)33(5.5%)24(4%)11(2%)

HighestlevelofeducationAssociates’Bachelors’Masters’PhD

171(70%)58(23.5%)14(6%)1(0.5%)

177(48%)139(38%)52(14%)0(0%)

348(57%)197(32%)66(10.75%)1(0.25%)

TypeofpracticeGeneralAcademicPeriodontalPublichealthPedodonticProsthodonticPHDHOther

173(70.5%)3(1%)12(5%)6(2.5%)13(5.5%)5(2%)7(3%)

26(10.5%)

236(64%)41(11%)26(7%)18(5%)12(3.25%)7(2%)5(1.25%)24(6.5%)

409(67%)44(7%)38(6%)24(4%)25(4%)12(2%)12(2%)50(8%)

TableI:DemographicsofDentalHygienistsPracticinginMassachusettsnovalueinpracticerankedlowest at 2.25% (n=4)each. Dominant themesfrom the comments(n=21) provided in rela-tion to not becoming cer-tified were related to theaforementioned reasons.Of those planning to takethe certification course(n=45),53%(n=25)citedstaying competitive in thejob market, and 40.5%(n=19)citedself-improve-ment as the reason. Theprimary reason for notobtaining the Permit L af-ter taking a certificationcoursewaswaitingbeyondthe2yeardeadline(38%)and other reasons (n=6),suchasnotwantingtheli-abilityandlettingthePer-mitLlapse.Whenaskediftheir employers would al-lowthemtoadministerlo-calanesthetics if theyob-tainedthePermitL,59.5%(n=143) strongly agreed/agreed. In regards toself-perceived ability 77%(n=188) strongly agreed/agreed with the state-ment, “I feel as though Iwouldbeabletocompletethe certification course,pass the NERB exam andobtainthePermitL.”TableIIIshowstheLikert-scaledopinions of non-Permit Lholders.

Opinions andDescriptive Data ofPermit L Holders

DescriptivedataforPer-mitLholdersareshowninTablesIVandV.ThePermitLasaconditionofemploy-mentwasreportedby22%(n=80),and42%(n=153)reported holding the Per-mitLlongerthan5years,ofwhich65%(n=100)at-tended a continuing ed-ucation-based program.Although 72% (n=263)were administering localanesthetics,28%(n=104)


n(Percent)WasthePermitLaconditionofemployment?

YesNo

1(0.5%)242(99.5%)

HaveyoutakenthePermitLcourse?YesNo

26(11%)219(89%)

Whattypeofcoursedidyoutake?CurriculumbasedContinuingeducationbasedBoth

14(54%)10(38%)2(8%)

HaveyoutakentheNERBexam?YesNo

8(34%)16(67%)

IfyouhavetakenthecertificationcourseanddonothavethePermitL,whatisyourprimaryreason?

WaitedtoolongInapplicationprocessFailedNERBexamEmployerresistanceDidnotneedOther

10(38%)6(23%)2(8%)1(4%)1(4%)6(23%)

Areyouplanningtotakethecertificationcourse?YesNo

45(21%)172(79%)

Ifyouareplanningtotakethecertificationcourse,whatisyourprimaryreason?

StaycompetitiveinthejobmarketSelfimprovementCurrentemploymentrequirementOther

25(53%)19(40.5%)1(2%)2(4.5%)

Ifyouarenotplanningtotakethecertificationcourse,whatisyourprimaryreason?

NotneededintypeofpracticeNotplanningtostayinpracticelongenoughFearofadministeringlocalanestheticsNofinancialgainCostIncreasedliabilityToolongoutofschoolEmployerresistanceNovalueinpracticeOther

30(17.5%)25(14.5%)24(14%)23(13%)21(12.25%)12(7%)8(5%)4(2.25%)4(2.25%)21(12.25%)

TableII:DescriptiveStatisticsofNon-PermitLHolders

werenotadministering localanestheticswith37%(n=38)ofthosereportingadministrationwasnotneededinthetypeofpracticewheretheywereemployed.Otherreasonsfornotad-ministering(n=29)included:notpracticingun-derdirectsupervision,workinginanacademicsetting,lackofopportunityandpracticepolicy.Delegationoflocalanesthesiabythesupervis-ingdentistwasreportedat85%(n=305) fordentalhygieneproceduresand42%(n=150)foroperativeorsurgicalprocedures.Thetypesof injectionsadministeredweregenerallydis-tributedevenlyexceptforthegreaterpalatine,nasopalatine,and infraorbital.Other injectiontypes(n=18)includedanteriormiddlesuperioralveolarnerveblock,Gow-Gatesandpapillary.Asuccessfulinjectionwasdefinedasonethatachievesthedesiredlevelofanesthesiaonthefirst attempt with 68.5% (n=197) reportingsuccessratesof95to100%.Nolocalorsys-temicpatient complicationswere reportedby81% (n=241)with tachycardia themost fre-quently reportedcomplicationat6%(n=18).Other complications (n=13) included patientanxiety,trismus,nausea,traumaorhematomalocalizedtotheinjectionsite,andnumbnessofthemandibleafteraposteriorsuperioralveo-lar injection. Frequencyof aspiration prior todepositionoflocalanestheticswasreportedtobe100%by79%(n=229).Safeneedlerecap-pingusinga singlehand techniqueor recap-ping device was used by 94% (n=282), andincidence of percutaneous needle sticks waszero for87%(n=260).Needlebreakagewasexperienced by 1% (n=4) and formal com-plaintstotheBoardofRegistrationinDentistrywerereportedby2.5%(n=9).

The self-perceived opinions of the PermitL holders are shown in Table VI with similarresults reported between the 2 educationalforums. Among the Permit L holders, 84%(n=310)stronglyagreed/agreedthePermitLwasvaluablewhenseekingemployment,and88%(n=322)stronglyagreed/agreedthePer-mitLwasvaluableinpractice.Localanesthe-sia as necessary for non-surgical periodontaltherapy(NSPT)wasstronglyagreed/agreedtoby 97% (n=356), and 81% (n=290) strong-lyagreed/agreedthey feltcompetent in theirlocal anesthesia administration. The type ofeducationalprogramattendedfortrainingad-equately prepared most with 89% (n=322)stronglyagreeingoragreeing.

Correlations

Spearman’sRhocorrelationsusedtoassessre-lationshipsbetweendemographics,practices,andopinionsareshowninTablesVIItoIX.Significant

relationships were found between demographicsand opinions of non-Permit L holders and PermitL holders. The Permit L holders are likely to be:younger(p<0.01),havebeeninpracticeforfeweryears (p<0.01) and have more years remaininginpractice(p<0.01).Theyarealsomorelikelytoagreethandisagreethatlocalanesthesiaisneces-saryforsomedentalhygieneprocedures(p<0.01)


SA A U D SD

n n(Percent)

n(Percent)

n(Percent)

n(Percent)

n(Percent)

ThePermitLisvaluableinpractice 245 42(17%) 98(40%) 65(26.5%) 33(13.5%) 7(3%)Local anesthesia is necessary for someproceduressuchasNSPT 245 104

(42.5%)107

(43.5%) 14(6%) 14(6%) 6(2%)

MysupervisingdentistwouldallowmetoadministerlocalanestheticsifIobtainedthePermitL

241 64(26.5%) 79(33%) 53(22%) 30(12.5%) 15(6%)

IfeelasthoughIwouldbeabletocom-plete the certification course, pass theNERBexamandobtainthePermitL

244 87(36%) 101(41%) 38(16%) 15(6%) 3(1%)

LikertScaleused:1=StronglyAgree(SA),2=Agree(A),3=Undecided(U),4=Disagree(D),5=StronglyDisagree(SD)

TableIII:OpinionsofNon-PermitLHolders

CUBased CEBased Totaln(Percent) n(Percent) n(Percent)

HowlonghaveyouheldthePermitL?<1year1to3years4to5years>5years

18(10%)74(41.5%)33(18.5%)53(30%)

9(5%)42(22%)39(20.5%)100(52.5%)

27(7%)116(31.5%)72(19.5%)153(42%)

WasthePermitLaconditionofemployment?YesNo

39(22%)138(78%)

41(22%)149(78%)

80(22%)287(78%)

Onaverage,howoftenareyouadministeringlocalanesthetics?Atleastonceaday1to3timesaweek4to6timesamonthNotadministering

23(13%)42(24%)54(30%)59(33%)

20(10.5%)63(33%)61(32.5%)45(24%)

43(12%)105(29%)115(31%)104(28%)

Ifyouarenotcurrentlyadministering,whatisyourprimaryreason?NotneededintypeofpracticeDonotfeelconfidentEmployerresistanceOther

25(43%)8(14%)13(22%)12(21%)

13(28%)6(13%)10(22%)17(37%)

38(37%)14(13%)23(22%)29(28%)

Doesyoursupervisingdentistdelegatelocalanesthesiafordentalhygieneprocedures?YesNo

143(82%)31(18%)

162(87.5%)23(12.5%)

305(85%)54(15%)

Doesyoursupervisingdentistdelegatelocalanesthesiaforoperativeorsurgicalprocedures?YesNo

68(39%)105(61%)

82(45%)101(55%)

150(42%)206(58%)

Havetherebeenanyformalcomplaintsfiledinrelationtoyouradministrationoflocalanesthetics?YesNo

6(3.5%)169(96.5%)

3(1.5%)179(98.5%)

9(2.5%)348(97.5%)

HowsoonafterobtainingthePermitLdidyoufeelconfidentinyourabilitytosafelyandeffectivelyadministerlocalanesthetics?

ImmediatelyWithin3months4to12monthsOveroneyear

89(51%)33(19%)24(14%)28(16%)

75(41%)60(33%)30(16%)18(10%)

164(46%)93(26%)54(15%)46(13%)

TableIV:DescriptiveStatisticsofCurriculum(1)andContinuingEducation(2)BasedPer-mitLHolders


CUBased CEBased Totaln(Percent) n(Percent) n(Percent)

Onaverage,whatisthesuccessrateofyourlocalanesthesiaadministration?95to100%85to94%75to84%51to74%<50%

89(68%)28(21%)10(8%)4(3%)0(0%)

108(69%)35(22%)9(6%)5(3%)0(0%)

197(68.5%)63(22%)19(6.5%)9(3%)0(0%)

Whatpatientcomplications,localorsystemic,haveyouencounteredasaresultofyourlocalanesthesiaadministra-tion?

NoneTachycardiaExtensiveIAorPSAhematomaSyncopeTemporaryparesthesiaAllergicreactionLocalanestheticoverdoseVasoconstrictoroverdosePermanentparesthesiaFacialparalysisOther

110(81%)6(4%)3(2%)5(3.5%)3(2%)

1(<0.5%)0(0%)0(0%)0(0%)0(0%)8(7%)

131(81%)12(7.5%)7(4%)3(2%)4(2.5%)0(0%)0(0%)0(0%)0(0%)0(0%)5(3%)

241(81%)18(6%)10(3%)8(2.5%)7(2.5%)1(<0.5%)0(0%)0(0%)0(0%)0(0%)13(4.5%)

Whattypesofinjectionsdoyouadminister?InfiltrationMSAIAASAPSALongbuccalMental/incisiveGPNPIONotadministeringOther

125(70%)123(69%)119(67%)116(65%)109(61%)101(57%)93(52%)38(21%)37(21%)36(20%)42(23%)5(3%)

148(78%)134(70.5%)127(67%)127(67%)118(62%)119(63%)113(59%)65(34%)57(30%)49(25%)25(13%)13(7%)

273(74%)257(70%)246(67%)243(66%)227(62%)220(60%)206(56%)103(28%)94(25%)85(23%)67(18%)18(5%)

Howfrequentlydoyouaspiratepriortodepositionoflocalanesthetics?100%95to99%85to94%75to84%51to74%>50%Never

103(77%)17(13%)6(5%)1(0.5%)2(1%)4(3%)1(0.5%)

126(82%)11(7%)3(2%)5(3%)0(0%)7(4%)3(2%)

229(79%)28(10%)9(3%)6(2%)2(0.5%)11(1.5%)4(1.5%)

Doyoupracticesafeneedlerecappingusingaone-handedtechniqueorrecappingdevice?YesNo

130(92%)11(8%)

152(95%)8(5%)

282(94%)19(6%)

Howmanytimeshaveyoureceivedapercutaneousneedlestickwhileadministeringlocalanesthetics?Never1234

117(84%)18(13%)3(2%)0(0%)2(1%)

143(90%)15(9%)0(0%)2(1%)0(0%)

260(87%)33(11%)3(1%)2(0.5%)2(0.5%)

Howmanytimeshaveyouexperiencedneedlebreakageduringdepositionoflocalanesthetics?Never12

137(98%)2(1.5%)1(0.5%)

159(99.5%)0(0%)1(0.5%)

296(99%)2(0.5%)2(0.5%)

TableV:LocalAnesthesiaPracticeStatisticsofCurriculum(1)andContinuingEducation(2)BasedPermitLHolders


CurriculumBased

nSA A U D SD

n(Percent) n(Percent) n(Percent) n(Percent) n(Percent)ThepermitLisvaluablewhenseekingemployment 178 93(52%) 56

(31.5%) 19(11%) 9(5%) 1(0.5%)

ThePermitLisvaluableinpractice 178 101(57%) 51(28%) 14(8%) 12(7%) 0(0%)LocalanesthesiaisnecessaryforsomeproceduressuchasNSPT 177 124(70%) 47(26%) 3(2%) 3(2%) 0(0%)

Ifeelcompetentinmyadministrationoflocalanesthetics 175 79(45%) 57(33%) 22(12%) 10(6%) 7(4%)

ThetypeoftrainingprogramIattendedadequatelypreparedmetoadministerlocalanesthetics

176 104(59%) 50(29%) 18(10%) 4(2%) 0(0%)

ContinuingEducationBased

nSA A U D SD

n(Percent) n(Percent) n(Percent) n(Percent) n(Percent)ThepermitLisvaluablewhenseekingemployment 189 100(53%) 61

(32.25%)25

(13.25%) 2(1%) 1(0.5%)

ThePermitLisvaluableinpractice 188 110(58.5%) 60(32%) 12(6.5%) 4(2%) 2(1%)

LocalanesthesiaisnecessaryforsomeproceduressuchasNSPT 190 135(71%) 50(26%) 2(1%) 2(1%) 1(<1%)

Ifeelcompetentinmyadministrationoflocalanesthetics 182 75(41%) 79

(43.5%) 11(6%) 14(8%) 3(1.5%)

ThetypeoftrainingprogramIattendedadequatelypreparedmetoadministerlocalanesthetics

184 107(58%) 61(33%) 7(4%) 6(3%) 3(1%)

LikertScaleused:1=StronglyAgree(SA),2=Agree(A),3=Undecided(U),4=Disagree(D),5=StronglyDisagree(SD)

TableVI:OpinionsofPermitLHolders

andthePermitLisvaluableinpractice(p<0.01).Amongnon-PermitLholders,thosewhoaremorelikelytoagreethandisagreethattheirsupervisingdentistwouldallowthemtoadministerlocalanes-theticsareyounger(p<0.05),havebeen inprac-ticeforfeweryears(p<0.05)andhavemoreyearsremaining inpractice(p<0.05).Thenon-PermitLholderswhoareolder(p<0.01),havemoreyearsinpractice(p<0.01),andfeweryearsremaininginpractice(p<0.01)aremorelikelytodisagreethanagreewithapositiveself-perceivedability toob-tainthePermitL.

ThePermitLholdersdemonstratednosignificantdifferencesbetweenthecurriculumandcontinuingeducation-based training programs in regards topracticeandopinionitems.Significantcorrelationswerefoundamongthedemographicdatashowingthosetrainedinacurriculumprogramarelikelytobe younger (p<0.01), have fewer years in prac-tice(p<0.01),havemoreyearsremaininginprac-tice (p<0.01), have held the Permit L for longer(p<0.01)andreportthePermitLwasaconditionofemploymentthanthosetrainedinacontinuingeducationprogram.ThelengthoftimethePermitLhasbeenheldyieldedsignificantcorrelations in

severalareas.ThosewhohaveheldthePermitLforlongeraremorelikelytobeolder(p<0.01),havemoreyearsinpractice(p<0.01),havefeweryearsremaining inpractice(p<0.01),holdaBachelors’or Masters’ degree, and less likely to report thePermitLasaconditionofemployment (p<0.05).They also report higher administration successrates(p<0.05)andhigherdelegationratesforop-erative and surgical procedures (p<0.05). Thosewho have held the Permit L for longer aremorelikelytoagreethandisagreethatlocalanesthesiais necessary for some dental hygiene procedures(p<0.05) and aremore likely to agree than dis-agreewithapositiveself-perceivedcompetencyinadministeringlocalanesthetics(p<0.05).

DiScuSSion

The demographic characteristics of respondentsinthissurveyweresimilartothe2011Massachu-settsDepartmentofPublicHealthprofileofdentalhygienistsinregardstogender,age,yearsinprac-ticeandlevelofeducation.14Atthetimeofthissur-veytherewere2,345PermitLholdersrepresenting35.4%ofallcurrentlylicenseddentalhygienistsinMassachusetts (n=6,616), which is similar to the


Spearman’sRankCorrelationCoefficient(p)

Age -0.4**YearsInPractice -0.45**Yearsremaininginpractice 0.28**Local anesthesia is neces-sary for some dental hy-giene procedures such asNSPT

-0.3**

ThePermitL isvaluable inpractice -0.45**

*p<0.05fortrend**p<0.01fortrend

TableVII:SelectedCorrelationTrendTestsBetween Demographics and Opinions ofNon-PermitLHoldersandPermitLHolders

Spearman’sRankCorrelationCoefficient(p)

Age Yearsinpractice

Yearsremaininginpractice

Localanesthesiaisnecessaryforsomedentalhy-gieneproceduressuchasNSPT

0.07 0.02 -0.05

ThePermitLisvaluableinpractice -0.05 -0.09 -0.00

MysupervisingdentistwouldallowmetoadministerlocalanestheticsifIobtainedthePermitL

0.13* 0.14* -0.14*

IfeelasthoughIwouldbeabletocompletethecer-tificationcourse,passtheNERBexamandobtainthePermitL

0.24** 0.29** -0.3**

TableVIII:SelectedCorrelationTrendTestsBetween Demographics and Opinion Vari-ablesofNon-PermitLHolders


regionalresultsofBoynesetalwhoreported32.1%ofdentalhygienistsadministeringintheNortheast-ern states.6Demographic andpractice items suchas gender, age and years in practicewere similartothosereportedbyAnderson,5DeAngelisandGo-ral,4andCross-Polineetal.3Practice types in thisstudy differed from most in that 64% (n=236)worked in general practice whereas Anderson re-ported 89.6%,5 Boynes et al 76.1%,7 DeAngelisandGoral92%,4andCross-Polineetal76%.3How-ever, the greater variety of practice settings thathaveemergedmayaccountforthisdifference.Thelevelsofeducation in thisstudyshowsignificanceamongthosewhohaveheldthePermitLforlonger(p<0.01)whichmaybeaffectedbythecertificationoffacultyinitiallyneededtoteachtheskill.

This study, when compared to the 2007 Mas-sachusettsDepartmentof PublicHealth survey,11reveals79%(n=172)arenotplanningonbecom-ingcertifiedascomparedto64.4%(n=1,936)andfinds similarity in the reasons for not becomingcertifiedsuchasfear,costandnomonetarycom-pensation.Thissurveyalsofoundfewerwhocitedincreasedliability(7%vs.28.2%),withthemainreasonsfornotbecomingcertifiedbeingnotneed-ed in type of practice (17.5%) and not planningto stay in practice long enough to use (14.5%).Employerresistanceat2.25%(n=4)rankslowestalongwithnovalueinpracticeasreasonsfornotbecomingcertified.ThisstudyandDeAngelisandGoral4 foundsignificantdifferences inopinionre-gardingthenecessityoflocalanesthesiabetweencertifiedandnotcertified.

Theprimaryreasonfornotadministeringreport-edby28%(n=104)of thePermitLholderswasnotneededintypeofpractice(37%)andemploy-er resistance (22%). Cross-Poline et al reported12%ofthosecertifiedwerenotadministeringdueto employer or patient resistance, practice type,and patients’ not needing anesthesia.3 Andersonalso reported similar reasons for not administer-ing.5Delegationoflocalanesthesiafordentalhy-giene(85%)anddental(42%)proceduresarebe-lowthosereportedbyAnderson(95%,65%)5andDeAngelisandGoral(94%,68%),4butabovetheregionalresultsofBoynesetal(32.1%,30.4%)7thatincludedstateswheredentalhygienistadmin-isteredlocalanesthesiawasnotlegal.Asignificantrelationship between delegation for dental proce-duresandlengthoftimethePermitLhasbeenheld(p<0.01)wasfoundbythisstudy.Successachiev-inganesthesiaonthefirstattempt95to100%ofthe time was reported by 68.5% of the Permit Lholderswhichisbelowthe92%overallfirstattemptsuccess rate reportedbyLobene2whileAnderson5reportedasuccessrateof76%,90to100%ofthetime.Thisstudyfoundasignificantrelationshipbe-tween level of successful injections and length of

time thePermit Lhasbeenheld (p<0.01)butnorelationshipbetweensuccessandeducationalleveloryearsinpracticewhichcorrelateswiththefind-ings of Anderson.5 Aspiration rates of 100%werereportedby79%ofPermitLholderswhereasAn-dersonfound86%wereaspiratingallthetime.Thislowerrateofaspirationmaybethedeterminingfac-torfortachycardiabeingreportedasthemostfre-quentcomplication.

Themain differences between Permit L holdersandnon-PermitLholdersliewithindemographicsof


concluSion

This current study of Massachusetts dental hy-gienists raises concern over prevalence and use ofthePermit Lasdemonstratedby lowernumbersofdentalhygienistsadministeringlocalanestheticsandlowerdelegationrates.Significantdifferencesinopin-ionsexistbetweennon-PermitLholdersandPermitLholdersastothevalueofthePermitLandtheneedforlocalanesthesiaduringsomedentalhygienepro-cedures.

Katherine A. Soal, CDA, RDH, MSDH, is an associ-ate professor, Department of Dental Hygiene, Quin-sigamond Community College. Linda Boyd, RDH, RD, EdD, is a professor. Susan Jenkins, RDH, MS, CAGS is an associate professor. Debra November-Rider, RDH, MSDH, is an adjunct assistant professor. Andrew Rothman, MS, EIT, is an adjunct faculty. All are at the Forsyth School of Dental Hygiene, MCPHS University.

Spearman’sRankCorrelationCoefficient(p)Curriculum(1)andContinuingEducation(2)BasedProgram

YearsPermitLHeld(<1year,1to3years,4to5years,>5years)

Age 0.61** 0.41**Yearsinpractice 0.78** 0.49**Yearsremaininginpractice -0.37** -0.22**YearsPermitLheld 0.27** -Levelofeducation 0.08 0.14**ValueofPermitLwhenseekingemployment -0.01 0.06PermitLaconditionofemployment 0.2** -0.13*Frequencyofadministration 0.01 0.01DelegationforDHprocedures 0.08 0.00Delegationforoperativeorsurgicalprocedures 0.05 0.11*Administrationsuccessrate -0.02 0.14*Frequencyofaspiration -0.04 0.01Safeneedlerecapping -0.06 -0.03Frequencyofneedlestick -0.09 0.01Localanesthesia isnecessary forsomedentalhygieneproceduressuchasNSPT -0.01 -0.12*

ThePermitLisvaluableinpractice -0.03 -0.05Self-perceivedcompetenceinadministration -0.002 -0.11*Self-perceivedefficacyoftrainingprogram -0.001 -0.01Timetofeelconfidentinadministration -0.04 -0.01


TableIX:SelectedCorrelationTrendTestsBetweenDemographic,Practice,andOpinionVariablesofPermitLHolders

age,yearsinpracticeandyearsremaininginprac-tice,anddifferencesinopinionregardingthevalueof the Permit L in practice and the need for localanesthesiaduringsomedentalhygieneprocedures.ThebarrierstoobtainingthePermitLalsoliewithindemographics and opinions of value, but may becombinationsofmanyfactorsassuggestedbycom-mentsprovidedbynon-PermitLholders.

The limitationsof thisstudy includethe lowre-sponserate(10%)whichmaybeprimarilyduetothesinglepostcardinvitationandthelimitationsofthe MDHA email list. The accuracy of self-report-eddatawithitspotentialforbiasremainsanissuethroughoutsurvey-basedresearchandmost likelyalsocontributedtothelimitationsofthisstudy.Theuse of social media for accessing the populationof interest may improve the response rate in fu-turestudiesandtheuseofsocialmediainresearchstudiesmayproveaninterestingareaofinvestiga-tion.Areasforfutureresearchincludesurveyingthedentists in Massachusetts to gather and evaluateopinionsandpractices in relation to thePermit L,itsuse,value,andfactorsinfluencingitslowpreva-lence. Generating interest in local anesthesia ad-

ministrationwithcontinuingeducationcoursesthatdirectlyaddressthereasonsfornotbecomingcerti-fiedoradministeringmay increasetheprevalenceanduseofthePermitL.


1. Nash D, Friedman J. A review of the global lit-eratureondentaltherapistsinthecontextofthemovement to add dental therapists to the oralhealthworkforce intheUnitedStates.W.K.Kel-loggFoundation.2012.

2. LobeneRR,evaluationofresults.In:TheForsythExperiment. Cambridge, MA: Harvard universitypress.1979.88-89p.

3. Cross-PolineGN,PassonJC,TillissTS,StachDJ.Effectivenessofacontinuingeducationcourseinlocalanesthesiafordentalhygienists.J Dent Hyg.1992;66(3):130-136.

4. DeAngelisS,GoralV.Utilizationoflocalanesthe-sia by Arkansas dental hygienists, and dentists’delegation/satisfactionrelativetothisfunction.J Dent Hyg.2000;74(3):196-204.

5. Anderson JM. Use of local anesthesia by dentalhygienistswhocompletedaMinnesotaCEcourse.J Dent Hyg.2002;76(1):35-46.

6. Scofield JC, GutmannME, DeWald JP, CampbellPR. Disciplinary actions associated with the ad-ministrationof local anesthetics againstdentistsanddentalhygienists.J Dent Hyg.2005;79(1):8.

7. BoynesSG,ZovkoJ,BastinMR,GrilloMA,Shin-gledeckerBD.Dentalhygienists’evaluationoflo-calanesthesiaeducationandadministrationintheUnitedStates.J Dent Hyg.2011;85(1):67-74.

8. Sisty-LePeauN,BoyerEM,LutjenD.Dentalhy-gienelicensurespecificationsonpaincontrolpro-cedures.J Dent Hyg.1990;64(4):179-185.

9. Localanesthesiaadministrationbydentalhygien-istsstatechart.AmericanDentalHygienists’As-sociation[Internet].2011[cited2015April13].Availablefrom:https://www.adha.org/resources-ocs/7514_Local_Anesthesia_Requirements_by_State.pdf

10.Administrationofanesthesiaandsedation.Boardofregistrationindentistry.MassachusettsDepart-mentofPublicHealth[Internet].2014[cited2015April13].Available from:http://www.mass.gov/courts/docs/lawlib/230-249cmr/234cmr6.pdf

11.A reporton thecommonwealth’sdentalhygieneworkforce. Massachusetts Department of Pub-licHealth.[Internet]2008[cited2015April13].Available from: http://www.mass.gov/eohhs/docs/dph/com-health/dental-hygiene-workforce.pdf

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

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referenceS


Asindividuals,worldviewsareprofoundlyshapedbythe traditions thatdefine familyandcountryoforigin,school, religiousandotherexperiences thatcharacter-izeupbringing.Thus,culturalexperiencesshapeunder-standingandperceptionsofotherswhodiffer,inrelationtospokenlanguages,race,ethnicity,religiousaffiliation,socialandintellectualstatus,andsexualorientation.Thebeliefsthatindividualsholdareconstructedthroughso-cial interactionsandare likely to remainunquestioneduntilindividualsexperiencesituationsthatcausereflec-tionorquestioning.

Facultyacrossalllevelsofschoolinghaveobservedtheincreasingdiversityamongstudentpopulations.1How-ever,itisnotuncommonthatfacultyhavevaryingde-greesoffamiliaritywithculturalgroupsunlikethosewithwhomtheyhavebeensocialized.Howcanfacultybeas-suredthattheyareteachingtheirstudentsinaculturallyresponsivemannerunless theyknowabout their ownknowledge,beliefsandskillstowardsotherswithwhomtheyhavenotsharedexperienceswithduringourfor-mativeyears?Ensuringtheprovisionofeducationalex-periencesthatreflectculturalsensitivityandawareness

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

AbstractPurpose:TheCommissiononDentalAccreditationrequiresthatdental,dentalhygieneanddentalassistingschoolsoffereducationalexperiencestoensurethatprospectivedentalhealthcareprovidersbecomeculturallycompetent,sociallyresponsiblepractitioners.Toassertthatthesemandatesaremetrequiresthatthefacultyareknowledge-ableandcapableofprovidingthistypeoftraining.Currently,littleisknownabouttheculturalcompetenceofthestateofFloridaallieddentalfaculty.ThepurposeofthisstudywastoassesstheculturalcompetenceamongthedentalhygieneanddentalassistantfacultyinthestateofFlorida.Methods:Onehundredninety-threefacultywereinvitedtotaketheKnowledge,EfficacyandPracticesInstrument(KEPI),avalidatedmeasureofculturalcompetence.Respondentsincluded77(74%)full-timeand27(26%)part-timefaculty.Datawereanalyzeddescriptivelyandreliabilities(Cronbach’salpha)werecomputed.Results: MeanscoresandinternalestimatesofreliabilityontheKEPIsubscaleswere:knowledgeofdiversity3.3(α=0.88),culture-centeredpractice3.6(α=0.88)andefficacyofassessment2.9(α=0.74).Theparticipant’sscoreof3.6ontheculture-centeredpracticeexceedsscoresamongdentalstudentsandfacultywhoparticipatedinprevi-ousstudiessuggestingtheallieddentalfacultyhaveagreaterawarenessofsocioculturalandlinguisticallydiversedentalpatients’oralhealthneeds.Participants’scoreonknowledgeofdiversitysubscalessuggestsaneedformod-eratetraining,whiletheirscoreontheefficacyofassessmentsubscaleindicatesaneedformoreintensetraining.Conclusion:Assessingfacultybeliefs,knowledgeandskillsaboutculturalcompetencyiscriticallyimportantinensuringthataccreditationstandardsarebeingmetandrepresentsonestepintheprocessofensuringthatfac-ultydemonstratethetypeofsensitivityandresponsiveness,whichcharacterizesbehaviorsassociatedwithculturalcompetence.Keywords:culturalcompetence,facultydevelopment,quantitativeanalysis,surveyresearcThisstudysupportstheNDHRApriorityarea,Professional Education and Development: Identifythefactorsthataffectrecruitmentandretentionoffaculty.

research

introDuctionrequires,asaninitialstep,determiningone’sknowledgeaboutgroupsofpeoplewhoaresocio-culturallyandlin-guisticallyunlikehimselforherself.

Many researchershave reportedhowa lack of cul-turalawarenessnegatively impactspatientcare.2Overthelast15years,nationalhealthcareassociationshavehighlightedtheimportanceofpatient-centeredcareandreducinghealthcaredisparities.3,4Culturallycompetentpractitionershavethepotentialtoreduceracialandeth-nichealthdisparities.Theyareoftenbetterpositionedtospeakthelanguageofculturaldiversepatients,moresensitivetoculturaldifferences,andmorelikelytoensuretheprovisionofqualityofhealthcare.5TheCommissiononDentalAccreditation(CODA)hasrespondedtotheur-gencyofeliminatingracial/ethnicdisparitiesbyrevisingitscompetencies.6CODAmandates thatdental,dentalhygieneanddentalassistingschoolsprovidetrainingtoensurethatprospectivedentalhealthcareprovidersbe-comeculturallycompetent,sociallyresponsiblepractitio-ners.Whilethesechangesarelaudable,littleisknownaboutthefacultywhoareprovidingthislevelofrequirededucation.Areviewoftherecentliteraturerevealedsys-


tematicreviewsofeducationalinterventionsdirectedatimprovingculturalcompetency,anexplorationofthedif-ferentexaminationmethodsnowusedtoevaluatecul-turalcompetenceamongdentalstudentsandresidentsandreviewsofvariousculturalcompetencymeasures.7-11Studiesthatdescribetheculturalcompetenceofdental,dentalhygieneanddentalassistingfacultywerenotap-parent.

Assessingculturalcompetencereferstodeterminingthelevelofagreementamongparticipantsintheirratingsofbehaviors,attitudesandknowledgeaboutindividualswhoaresocio-culturallyandlinguisticallydissimilar.Cur-rently,littleisknownabouttheculturalcompetenceofthestateofFloridaallieddentalfacultywhoeducatethestate’sallieddentalprofessionalworkforce.Thepurposeofthisstudywastoassesstheculturalcompetenceamongallieddentalfaculty,specificallythedentalhygieneanddentalassistingfacultyinthestateofFlorida.Theuseofsuchanassessmentissupportedbytheassumptionthatifdentalhygienistsanddentalassistantsareculturallycompetent,thattheyaremorelikelytoworkeffectivelywithindividualswhoaresocio-culturallyandlinguisticallydissimilarfromthemselves.Additionally,thisassessmentcouldbeusefulinguidinginstructionalorcurricularrevi-sionstoensurethepreparationofculturallycompetentdentalhygienistsandassistants.

The importanceofneedsassessmenthasalsobeenunderscored in the literature about faculty develop-ment.12-23Thescopeoffacultydevelopmentneedsrangefromenhancingpedagogyandassessment,topromotingscholarship,andadvancingcareers.However,italsoin-cludesmeasuringthefaculty’slevelofculturalcompeten-cysothatthepotentialneedforenhancingknowledge,influencingbeliefsandaugmentingskillscanbeidenti-fied.Facultydevelopmentisboundtobemoreeffectiveifbasedontherealorperceivedneedsofthefaculty.24Moreover,thestrategyofsurveyingfacultytoassesstheirneedsisacommonandnecessaryelementoffacultyde-velopmentprograms.Dentaleducationalliteratureisalsorelativelyweakinthisall-importantareaofresponsibil-ity.Needsassessment isvaluablewhen responding toinstitutionalneedsthataremostrelevanttotheirmis-sion.Findings fromaneedsassessmentbolsteredonecollege’smenuofservicesandwereusedtodevelopnewservicestosupportstudentlearning.25AlsoasnotedbyValley,needsassessmentsfindingswereinstrumentalindevelopingfacultydevelopmentprogramsforinstructorsworkingpart-time,acommonoccurrenceinallieddentaleducationalprograms.26


reSultS

Thefirsttaskinconductingthisstudywastobuildadatabaseofpotentialparticipants.TobeginthatprocessandwiththeassistanceoftheFloridaAlliedDentalEduca-tors,alistofalloftheschoolsthatteachdentalhygieneanddentalassistinginthestateofFloridawasacquired.Institutionalreviewboardapprovalwasobtainedfromthe

Thepopulationwascomprisedof93(48%)full-timeand100(52%)part-timefacultyfrom31dentalhygieneanddentalassistingschoolsacrossthestateofFlorida.Of these, 117 completed the survey, for a responserateof61%.Ofthe117surveys,104wereusablefortheanalysis.Thesamplewas94(90%)femaleand10(10%)male,82 (79%)White,22 (21%)minority,19(18%)25to39yearsofage,85(82%)40andover,98(93%)married,7(7%)single,77(74%)full-timeand27(26%)part-timefaculty.

ThemeanscoresfortheKEPIsubscalesare:knowl-edgeofdiversity3.3,culture-centeredpractice3.6andefficacyofassessment2.9(TableI).

InternalestimatesofreliabilityontheKEPIsubscalesare: knowledge of diversity α=0.88, culture-centeredpracticeα=0.88,andefficacyofassessmentα=0.74.Theestimatesofinternalreliabilityrangingfrom0.74to0.88areconsideredacceptable instudies thatseek topro-motechangesinpractice.

ScorerangesontheKEPIsubscalesholdimplicationsforpracticeandtraining.Scoresfrom3.5to3.8suggestthat faculty are moderately skilled and need minimaltraining.Scoresbetween3.0tolessthan3.5indicateaneedformoderatetraining.Scoresbetween2.5tolessthan3.0indicateaneedformoreintensetraining.Scoresbelow2.5suggestaneedforthehighestleveloftraining.

UniversityofFloridaprior tobeginningthestudy.Next,eachprogramdirectorwascontactedviaemailtorequesta listof full-timeandpart-timefaculty,alongwiththeirfirstandlastnameandcorrespondingemailaddress.Afterthepopulationparticipantdatabasewascomplete,allpar-ticipants(n=193)wereinvitedtotaketheKnowledge,Ef-ficacyandPracticesInstrument(KEPI).27Thesurveywassentelectronically toparticipantsusing theprofessionalandencryptedversionofSurveyMonkey.

KEPI,avalidatedmeasureofculturalcompetency,con-sistsof27itemsandprovidesmeanscoresfor3subscalesrelated to cultural competence:efficacyofassessment,knowledgeofdiversityandculture-centeredpractice.Thescalemeasuresbeliefs,knowledgeandskills relative tocultural competence. Items are scored using a 4-pointLikert scalewhere1=lowest and4=highest.Scores onknowledgeofdiversityreflectsanindividual’sunderstand-ingofsocioculturalandlinguisticallydiversegroupswhileculture-centeredpracticereflectsawarenessofsociocul-turalandlinguisticallydiversedentalpatients’oralhealthneeds.Participants’scoresonefficacyofassessmentpro-videsameasureofhowcapabletheybelievetheyareindeterminingculturallydiversepatients’oralhealthneeds.Datawereanalyzeddescriptively.Means,standarddevia-tionsandCronbach’salphawerecomputedforeachsub-scale.Thepotentialassociationsbetweenthedemograph-icvariablesandtheKEPIsubscalescoreswereexplored.


TheresultsshowtheallieddentalfacultyinFloridaaremoderatelyskilledandneedminimaltrainingonthecul-ture-centeredpracticesubscale,maybenefitfrommod-eratetrainingontheknowledgeofdiversitysubscaleandare lessskilledontheefficacyofassessmentsubscalewithsuggestinganeedformoreintensetrainingcom-paredtotheculture-centeredpracticeandknowledgeofdiversitysubscales.

Therewerenostatisticallysignificantrelationshipsbe-tweentheKEPIsubscalesandtheexploratoryvariablesofgender,race/ethnicity,maritalstatus,ageandemploy-mentstatus.

DiScuSSion

Thefindingsamongallieddentalhygieneanddentalassistingfacultyaresimilartowhathasbeenobservedamonginpreviousstudies in2oftheKEPIsubscales:knowledgeof diversity andefficacyof assessment.24,27ComparedtostudiesconductedwithdentalstudentsinFlorida,andwithdentalfacultyinFlorida,Nebraska,Ten-nessee,OregonandWashington,themeanscoreof3.3ontheknowledgeofdiversitysubscaleamongthedentalhygienist/dentalassistingfacultyarecomparabletoden-talstudentandfacultyscoreswhichrangedfrom3.2to3.4.Participants’meanscoreof2.9inefficacyofassess-mentiscomparabletodentalstudentandfacultyscoresthatrangedfrom2.6to3.0.Theparticipants’scoreof3.6ontheculture-centeredpracticeexceedsscores inotherstudies,whichrangedfrom2.3to2.8.Thisfindingsuggeststheallieddentalfacultyhaveagreateraware-nessofthesocioculturalandlinguisticallydiversedentalpatients’oralhealthneedscomparedtodentalstudentsanddental school facultywhoparticipated inpreviousstudies.

Thehighermeanscoresontheculturecenteredprac-ticesubscalesuggeststhatthissampleofalliedfacultyismoreculturallycompetentthandentalstudentsanddentalfaculty.Whetherthelatterresultisduetotrainingorsocializationintotheprofessionisunknown.Scoresfortheseparticipantsontheculture-centeredpracticesub-scalesuggestthatfacultyaremoderatelyskilledandthus

StateofFlorida,DentalHygieneandDental

AssistingFaculty

DentalStudentsa(M(SD)/α)

DentalStudentsb

(M(SD)/α

FloridaDentalStudents(M(SD)/α)

DentalStudentsc(M(SD)/α)

DentalStudentsd(M(SD)/α)

FloridaDentalFaculty(M(SD)/α

Knowledgeofdiversity

3.3(0.4)/0.88

3.2(0.5)/0.85

3.3(0.4)/0.87

3.3(0.4)/0.80

3.1(0.4)/0.84

3.4(0.4)/0.83

3.3(0.4)/0.82

Culture-centeredpractice

3.6(0.6)/0.88

2.1(0.6)/0.82.

2.4(0.6)/0.72

2.1(0.56)/0.76

2.1(0.5)/0.73

2.3(0.6)/0.70

2.5(0.6)/0.76

Efficacyofassessment

2.9(0.4)/0.74

2.8(0.5)/0.90

2.8(0.6)/0.92

3.0(0.5)/0.89

2.6(0.6)/0.93

.8(0.7)/0.92

3.0(0.5)/0.89

TableI:ComparisonofKEPISubscaleMeanScores,StandardDeviationandReliabilitybySample

a-dDenotesotherstateswheredentalstudentshaveparticipatedinsimilarstudies.Pseudonymshavebeenassignedtoprotecttheanonymityoftheseschools.

donotneedasmuchtrainingasindividualswhoscore3.0orlower.Participants’scoreonknowledgeofdiversitysubscalessuggestsaneedformoderatetraining,whiletheirscoreontheefficacyofassessmentsubscaleindi-catesaneedformoreintensetraining.ThisstudyshouldbereplicatedacrossallallieddentalschoolsintheU.S.todetermineifthesefindingsarerepresentative.

Rarely do professional schools assess if faculty aremeeting the needs of an ever-changing, diversifiedstudentbody.Additionally,mostacademicfaculties,in-cludingallieddentalhealthproviders,arerelativelyun-preparedtonavigateuniversitycultureormeettheuni-versity’s expectations for success.22,28 These problemsarefurtherexacerbatedwhenitbecomesapparentthatlittleisknownaboutthelevelofculturalcompetencebe-liefsamongtheworkforcethatistrainingtheprospectivegroupsofdentalhygieneanddentalassistingpractitio-ners.

Manyhealthcaredisciplines,suchasdentalandallieddentalprograms,facefacultyshortagesandmaydrawfaculty members from private dental practice. Com-poundingthisproblemisthatdentalhygieneprogramstypically do not encourage students to seek academiccareers.Programsusuallydonoprovideformalteach-ingexperienceoropportunities for scholarship.There-fore,askingdentalhygienestudentstoconsideracareerinacademicsoftendiffersfromtheirinitialplantoenterclinicalpractice.28Determiningthepresentlevelsofcul-turalcompetenceamongfacultyshouldbeconsideredanessentialstepinrespondingtotheCODAmandate.Find-ingsfromthisstudycanbeusedtoguidefacultydevel-opmentinitiativesaimedatenhancingtheculturalcom-petenceoftheallieddentalhealthcarefacultyinFlorida.Thissurveycouldalsobedisseminatednationallytoalldentalhygieneandassisting faculty togaugebaselinelevels.

Thefindingsfromthisstudyhaveseveralimplications.FirstitisimportanttoassesshowwellthecurriculumismeetingtheCODAstandards.Second,becausecompe-tenceisreallyanassessmentofbeliefs,knowledgeandskills,itisimportanttoassessfacultyandstudentbeliefs,


knowledgeand skills to determinewhat competenciesneedtobetaught.Third,anassessmentoffacultybeliefs,knowledgeandskillsisusefulwhenanalyzingthecurrentcurriculumandwhileconsideringchangestocontentandteachingpracticetoevaluateifandhowwellcompeten-cies are being taught.Outcomes froma rigorous andsystematicanalyticalprocessthatarebothcredibleandreplicablecanguidecurriculumchangesandfacultyde-velopmentinitiatives.Dentaleducatorscanbenefitfromusingstandardizedandvalidassessmentmethodsthatarecitedintheliteraturetoevaluatecurriculum.

Bothsocietaldemandandaccreditationmandatesre-quire thatdentistrybroaden itseducationalmission tofocusontheneedsofunderserved,un-servedand in-creasinglyculturallydiversepopulations.Toensurethatresourcesdirectedtowardstheseinitiativesarebeinguti-lizedandareadequate,itisadvisabletobeginbyassess-ingtheknowledgeoffaculty.Knowingthatthissamplehasastrongawarenessofsocioandlinguisticallydiversedentalpatients’oralhealthneedssuggeststhat this isoneareawillnotrequireanadditionalcommitmentoftrainingtime.Futureeffortsshouldfocusonstrengthen-ingparticipants’understandingofsocio-culturalandlin-guisticallydiversegroupsandtheirbeliefintheirabilitytodetermineculturallydiversepatientoralhealthneeds.

It iscautionedthatthescoresonthisscalearenotsufficienttoguaranteeculturalcompetenceastherecanbeadifferencebetweenself-reportedknowledge,beliefsandskillsanddisplayingsensitivitytoculturaldifferences.Scoresonthescaleprovideanindicationofindividual’sintenttodemonstrateculturalsensitivity.Thisscalecanhelpidentifythosewholackanawarenessofcultureandotherswhomaybepronetomakingculturalassumptionsthatmayhindercare.ItisalsorecommendthatscoresonthisscalebeusedintandemwithadditionalinitiativesofferedbyKleinandBenson.29Theyrecommendengag-ingfacultyinmini-ethnographiessothattheycanbetterunderstandpatientslivesina“localworld,”andappreci-atewhat“isatstakeforpatients,theirfamilies,and,attimes,theircommunities,andalso…forthemselves.”29Toaidinstrengtheningtheenactmentofculturalcom-petence,thefollowingquestionsarerecommendwhentalkingwithculturallydiversepatients:

• Whatdoyoucallthisproblem?• Whatdoyoubelieveisthecauseofthisproblem?

• Whatcoursedoyouexpectittotake?Howseriousisit?

• What do you think this problem does inside yourbody?

• Howdoesitaffectyourbodyandyourmind?• Whatdoyoumostfearaboutthiscondition?• Whatdoyoumostfearaboutthetreatment?29

concluSion

AlliedFloridadentalfaculty’sscoresontheKEPIcul-ture-centeredpracticessubscalewerethehighest,sug-gestingtheyaremoderatelyskilledinthisareaofculturecompetence.Theirscoresontheknowledgeofdiversitysubscale suggest a need for moderate training, whilescoresonefficacyofassessmentcall formore intensetraining.Findingsfromthisstudydemonstratethe im-portance of assessing faculty cultural competency be-liefs,knowledgeandskillsandisonestepintheprocesstowardsensuring that facultydemonstrate the typeofsensitivityandresponsiveness,whichcharacterizesbe-haviorsassociatedwithculturalcompetence.

Linda S. Behar-Horenstein, PhD, is a Distinguished Teaching Scholar and Professor, Colleges of Dentistry, Education, Veterinary Medicine, & Pharmacy, Director of CTSI Educational Development & Evaluation and co-Director of the HRSA Faculty Development in Dentistry at the University of Florida. Cyndi W. Garvan, PhD, is a Research Associate Professor in the College of Nursing at the University of Florida. Yu Su, MEd, is a doctoral student in the College of Education at the University of Florida. Xiaoying Feng, BS, is a doctoral student in the College of Education at the University of Florida. Frank A. Catalanotto, DMD, is a Professor, College of Dentistry at the University of Florida.

DiScloSure

Thisprojectwassupported,inpart,bytheHealthResourcesandServicesAdministration(HRSA)oftheU.S.DepartmentofHealthandHumanServices(HHS)under(Award#1D86HP24477-01-00,Facultydevel-opment supporting academic dental institution cur-riculumfor21stcentury.Awarded$2,552,191).Thisinformationorcontentandconclusionsarethoseoftheauthorandshouldnotbeconstruedastheofficialpositionorpolicyof,norshouldanyendorsementsbeinferredbyHRSA,HHSortheU.S.Government.

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A systematic analysis of the global prevalenceoftype2diabetesfoundthenumberofadultswithdiabetesdoubledovera30yearperiod,increasingfrom153million in 1980 to 347million in 2008.1TheWorldHealthOrganization(WHO)estimatesdi-abeteswillbetheseventhleadingcauseofdeathin2030.2In2012,therewasanestimated1.7millionnewcasesofdiagnoseddiabetesamongU.S.adults20yearsandolder.3Between2009to2012,utiliz-ingfastingglucoseorA1clevels,37%or86millionAmericansaged20yearsorolderhadprediabetes,51%ofthosewereaged65yearsorolder.3Inad-dition,theCentersforDiseaseControlmostup-to-datescientificdataestimates8.1millionindividualsor27.8%oftheU.S.populationhaveundiagnoseddiabetes.3

Theestimatedcostassociatedwithdiagnosedandundiagnoseddiabetes in2012,wasover$322bil-

UtilizingaDiabetesRiskTestandA1cPoint-of-CareInstrumenttoIdentifyIncreasedRiskforDiabetesInanEducationalDentalHygieneSettingLoriJ.Giblin,RDH,MS;LoriRainchusoRDH,MS;AndrewRothman,MS,EIT

AbstractPurpose:Theobjectiveofthispilotstudywastodemonstratethenumberofpatientsatincreasedriskfortype2diabetesdevelopmentusingavalidatedsurvey;andtoassesstherateofcomplianceforA1cscreeninginaneducationaldentalhygienesetting.Methods:Thiswasadescriptivestudyusingapurposivesampleofpatientsinanacademicdentalhy-gieneclinic,whowere18yearsorolder,notdiagnosedwithprediabetesortype2diabetes.UtilizingtheAmericanDiabetesAssociationadopteddiabetesrisksurvey,patientsdeterminedtobeatincreasedriskfortype2diabeteswereofferedtheopportunityforfurtherassessmentbyhavingtheirA1ctestedusingapointofcareinstrument.Patientsdemonstratinganincreasedriskforprediabetesortype2diabetes,witheitherthesurveyorthepointofcareinstrument,werereferredtotheirprimaryphysicianforfurtherevaluation.Results: Atotal179ofthe422solicitedpatientsagreedtoparticipateintheAmericanDiabetesAssocia-tionadopteddiabetesrisksurvey.Accordingtothesurveyguidelines,77participantswereconsideredincreasedriskfortype2diabetesforanat-riskprevalenceof48%(95%ConfidenceInterval(CI):40to56%).Theat-riskparticipantswerethenaskedtohaveanA1ctestofwhich45agreed(compliancerate58%,95%CI:47to70%).UsingAmericanDiabetesAssociationA1cparameters,60.98%(n=25)indicatedaprediabetes(5.7to6.4%)range,and4.88%(n=2)indicatedadiabetes(≥6.5%)range.Conclusion:Utilizing theAmericanDiabetesAssociationadopteddiabetes risk survey inanydentalsettingcouldprovidepatientswithinvaluablehealthinformation,andpotentiallyimproveoverallhealthoutcomes.Keywords:type2diabetes,prediabetes,diabetesrisk,pointofcareinstrument,A1c,diabetesrisktest,dentalsettingThisstudysupportstheNDHRApriorityarea,Health Promotion/Disease Prevention: Validateandtestassessment instruments/strategies/mechanismsthat increasehealthpromotionanddiseasepre-ventionamongdiversepopulations.

research

introDuction

lion,including$244billioninmedicalcostsand$78billion in decreased productivity.4 This cost trans-lates toaneconomicburdenof overa$1,000 foreveryAmerican.4

Diabetes can lead tomore serious health com-plications like blindness, kidney damage, cardio-vasculardiseaseandlowerlimbamputations.3Theprevalence and effect of diabetes are compellingenough tostress theneed forearlydiagnosisandtreatment.Earlydiagnosiscanalleviatemanyofthecomplicationsassociatedwithdiabetesandpreventdiseaseprogression.3

Identification of Prediabetes and Diabetes

DiabetescanbediagnosedbasedonA1corfast-ingplasmaglucoselevel,thefastingplasmaglucoseor the 2-h plasma glucose value subsequent to a


75-goralglucose tolerance test.5,6 There isan in-creasedriskofdevelopingtype2diabetesbasedonolderage,obesityand lackofphysicalexercise inindividualswithhypertensionand,inparticular,ra-cial/ethnic subgroups (AfricanAmerican,AmericanIndian,Hispanic/LatinoandAsianAmerican).7Mostoften there is a lengthy periodwithout symptomspriortothediagnosisoftype2diabetes.7

InHealthyPeople2020,theU.S.DepartmentofHealthandHumanServices includesscreening fortype2diabetesasoneof the topmeasures tobeimplementedinthehealthcaresystem.8AspartoftheU.S.healthcaresystem,thedentalprofessioncanplayanintegralrolewithimplementation.

Diabetes and Periodontal Disease

Diabetes and periodontal disease are 2 chronicdiseasesconsideredtobebiologicallylinked.9,10Peri-odontal disease is a chronic inflammatory diseaseof thesupportingtissuesof theteethandthepri-mary causeof tooth loss forolderadults.11,12 It isestimated 47% of U.S. adults 30 years and olderhave periodontitis, the destructive form of peri-odontaldisease.13Evidenceover the last15 to20yearssupportsanassociationbetweenperiodontalinflammationandglycemiccontrolamongindividu-als,withorwithoutdiabetes,andthecomplicationsassociated with diabetes.10 There is a well-estab-lishedunderstandingthatperiodontaloutcomesareaffectedbyhyperglycemia.10Additionally,evidenceincreasingly supports a likely association betweensystemicinflammationandoralmicrobialagentsincirculation.10

The Dental Office as a Gateway to Medical Screenings

Prediabetesanddiabetesare2conditionswherescreeningandearlyrecognitionwouldbebeneficialto prevent public health burdens.7 The increasingpublichealthburdenofdiabetesrequiresacollab-orative approach among health care providers, inordertoidentifyandmanageitscomplications.10Asurveyof1945practicingdentistsintheU.S.sug-gested dentists thought medical screenings wereimportantandwerewillingtoincorporatescreeningsformedicalconditionsinthedentaloffice,includingdiabetesmellitusata76.8%rateofagreement.14

In2013,61.7%ofadultsbetweentheagesof18and64hadavisitwiththeirdentalprovider.15Forpatientswhoarenotutilizinghealth care servicesand visit a dental office for emergency situations,healthcarescreeningsmaybedoneatthesevisits.10

A prospective study was conducted within Co-lumbiaUniversityCollegeofDentalMedicineTriageClinictoexplorethedevelopmentandevaluatethe

performanceofaselectiveapproachtoidentifyun-diagnosedprediabetesanddiabetesinadentalset-ting.16Participants(n=601)wereselectedbasedononeself-reportedriskfactorfordiabetesandsubse-quentlyevaluatedutilizingaperiodontalexamandanA1cpointofcareinstrument.16Thestudyfindingsconfirmedtheapproachwaseffectiveinidentifyingindividuals(n=182)withpotentialundiagnoseddia-betesandprediabetesandreferringthemtoaphysi-cianforevaluation.16Theresearchersconcludetheirmodelofidentificationshouldbefurtherexploredbydentalprofessionalsandvalidatedindiversedentalpopulations.16

Ina studybyGencoetal,11generaldentistryandperiodontalspecialtypracticesincludingacom-munitydentalclinic,utilizedtheAmericanDiabetesAssociationRiskTestandapointofcareinstrumenttomeasure hemoglobin A1c among 1,022 partici-pants.17Theyidentifiedindividuals(n=416)withpo-tentialdiabetesorprediabetesandreferredthemtoaphysicianforfurtherevaluation.17Thestudydem-onstrated dental screening feasibility for diabetesandprediabetes,aswellasacceptanceamongden-tal staff, patients and their physicians.17 AlthoughtheGencoetalstudyhadnotablefindings,duetovariousbarriersincludinglackofinsurancecoverageforscreeningsinadentalsetting,andpatient’slackof compliance for follow-up after screening in pri-vatedentalpractices,theauthorswerehesitanttorecommenddiabetesscreeningsintraditionaldentalsettings.17

An8 itemsurveyof randomly selectedpatientsfromaNewJerseyDentalSchoolandseveralprivatepractice clinics (n=470) was conducted regardingpatientattitudestowardchairsidemedicalscreeninginadentalsetting.18Theresponsesofthemajorityof the participantswere favorable towards havingadentistperformscreeningforheartdisease,highbloodpressure,diabetes,humanimmunodeficiencyvirusinfectionsandhepatitisinfection.18

Across-sectionalstudyconductedbyCreanoretal utilized a 1-page questionnaire among patientswithin2primarycaredentalclinicsand16generalpracticesinSouth-WestEngland.19Thesurveywasdesigned to determine attitudes toward chairsidemedicalscreenings, includingdiabetes,amongpa-tientsattendingappointmentsatprimarycareden-talclinicsandgeneraldentalpractices.19Atotalof626 surveys were completed from 18 sites at an87%rateofagreementfortheimportanceofden-tistsscreeningformedicalconditions.19

As part of The Dental Practice-Based ResearchNetwork, a study in28 communitydental practic-es recruited 498 patients to test the feasibility ofscreeningforabnormalrandombloodglucoselevelsusingglucometersandfinger-sticktesting.20Among


the participants, greater than 80% liked the ideaand62%wouldrecommendtheirdentisttoothers,ifbloodglucosetestingwasavailable.20

ThepurposeofthispilotstudywastoimplementtheAmericanDiabetesAssociationdiabetesrisktestto identifypatientsat risk forundiagnosed type2diabetes in an educational dental hygiene settingandtodeterminetherateofcomplianceandresultswhen a point-of-care A1c screening was recom-mended.


reSultS

This descriptive study consisted of a purposivesample of patients at an academic dental hygieneclinic. Permission to utilize the validated diabetesrisktestwasgrantedbytheAmericanDiabetesAs-sociation.TheAmericanDiabetesAssociationdiabe-tesrisktestquestionnaireincludedage,sex,historyof gestational diabetes, family history of diabetes,physicalactivityandweight.Ascoreof5orhigheronthediabetesrisktestindicatedanincreasedriskfordevelopingtype2diabetes.Inadditiontothe7questions,2yes/noresponsequestionswereinclud-ed.Thefirstquestioninquiredofapreviousdiagno-sisofhighbloodsugar,borderlinediabetes,predia-betesordiabetestype1or2.ThesecondquestionwaspresentedattheendoftheAmericanDiabetesAssociation risk test, and inquired of participant’swillingnesstohaveafingersticktomeasure2to3monthaveragebloodglucose,iftheirrisktestscoreindicated increased risk for type 2 diabetes (≥5).Consideringhealthliteracylevels,thetermA1cwasomittedfromthesecondquestion,andreplacedwithbloodsugar.Twoprincipalinvestigatorsand1clinicstaff member, all registered dental hygienists, ad-ministered the study informed consent forms, theA1c tests and completed follow-up referral letters.Dental hygiene students administered a NationalCash Register carbonless 2-page paper version oftheAmericanDiabetesAssociationdiabetesrisktest.

Eligibilitycriteriaforthestudyincludedallpatientswho presented to the clinicwhowere 18 years oroldernotpreviouslydiagnosedwithprediabetesordiabetes.Exclusioncriteriaincludedparticipantswithapreexistingdiagnosisofhighbloodsugar,border-linediabetes,prediabetes,ordiabetesmellitustype1ortype2.Theuniversity’sinstitutionalreviewboardensured the protection of the subjects engaged inthisstudy.

During appointment check-in, study personnelprovided patients an implied consent form whichexplainedthestudy,andparticipants inagreementself-completed the American Diabetes Associationdiabetesrisk test.Once therisk testwascomplet-ed, dental hygiene students identified participantsdeterminedtobeatincreasedriskfordiabetesand

alertedstudypersonnel.Participantswhoscoreda5orgreaterandindicatedyestohavingtheiraveragebloodglucosemeasuredhadtheirA1ctestedviaapoint of care instrument, the DCA Vantage™. TheDCAVantage™was found tomeet the acceptancecriteria of theNationalGlycohemoglobinStandard-ization Program certification criteria of A1c instru-ments, making it equivalent to laboratory-basedmethods.21,22ParticipantswithA1cindicativeofpre-diabetesordiabetesbasedontheAmericanDiabetesAssociationguidelines,5.7%orgreater,referredtotheirprimaryphysicianforfurtherassessment.5Ad-ditionally,acopyofthecompletedAmericanDiabe-tesAssociationrisktest,theresultsoftheA1ctest,andanaccompanyingletterexplainingpatient’sriskweremailedtothephysicianofrecord.

The questionnaire responses were entered intoelectronic format viaMicrosoft Excel. Aquality as-sessmentwasundertakenbywhicharandomsam-ple ofwritten surveyswere audited for data-entryerror.Theanalysisincludeddescriptivestatisticsus-ingfrequencypercentiles,withWaldandExactBino-mial95%CIcalculatedforselectedvariables.Asso-ciationsbetweenselectvariableswereassessedviacontingencytablesandFisher’sExactTest.Themainanalysisuseddatafromallpatientswhoparticipatedinthesurveywhodidnothaveknownpre-existingdiabetes conditions (n=159). To assess robustnessof study results tomissing data, sensitivity analy-seswereperformedvia full case analysis (n=145)andmeanimputationformissingvalues(n=159).AllstatisticalanalyseswereperformedinSTATA®statis-tics/dataanalysissoftwareversion11.2.

The study profile of solicited study patients isshowninFigure1.Atotalof179of458solicitedpa-tientsagreedtoparticipateinthestudy(compliancerate39%,Binomial95%CI:35to44%),with25ofthe179studyparticipants reportedknownpre-ex-istingprediabetesordiabetesconditionsanddidnotmeet study criteria. As per theAmericanDiabetesAssociationdiabetesrisktest,64ofthe154partici-pantswithoutpre-existingconditionsincludedintheanalysiswereat increasedrisk for type2diabeteswithanat-riskprevalenceof42%(Binomial95%CI:34to50%).Ofthe64participantswhoweredeter-minedatrisk,36reportedtheywouldtaketheA1c,5reportedtheywouldnot,and23didnotreportananswer.Oncethe64at-riskpatientswereinformedoftheirriskscoreaspertheAmericanDiabetesAs-sociation diabetes risk test by research personnel,41patients tooktheA1c testoffered.(Compliancerate64%,Binomial95%CI:51to76%).

Table I shows descriptive statistics of the studypopulation included in the analysis (n=154). Themajority of patientswere female (66%), 50 years


TotalSurveyPopulation(n=154)

Gender,n(Percentfemale) 101(66%)Age,years

<40,n(Percent)40to49,n(Percent)50to59,n(Percent)≥60,n(Percent)

43(28%)11(7%)28(18%)72(47%)

Directfamilymemberwithdiabetesyes,n(Percent)no,n(Percent)missing,n(Percent)

49(32%)102(66%)3(2%)

Previoushighbloodpressurediagnosisyes,n(Percent)no,n(Percent)missing,n(Percent)

46(30%)105(68%)3(2%)

Physiciallyactivityyes,n(Percent)no,n(Percent)missing,n(Percent)

31(20%)121(79%)2(1%)

Table I: Demographic Characteristics ofStudyPopulation

TotalA1cTestsAdminister(n=41)

MeanA1c,(95%Cl)* 5.82%(5.70%,5.96%)A1cRangedistributionsNormal(A1c<5.7%),n(Percent) 14(34.15%)

Increaseddiabetesrisk(5.7%≤A1c<6.5%),n(Percent)

25(60.98%)

Diabetes(A1c≥6.5%),n(Percent) 2(4.88%)

TableII:A1cTestResults

Figure1:AssociationsbetweenDemograph-icsandComplianceforA1cScreening

ofageorolder(65%),reportednophysicalactivity(79%),didnothaveaprevioushighbloodpressurediagnosis (68%) and did not have a direct familymemberwithdiabetes(66%).Associationsbetweendemographics and response to take the A1c areshown inFigure1.Nostatisticallysignificantasso-ciationswerefoundbetweendemographicvariablesandpatient responses to taketheA1ctest.Of the41patientswhodidreceivetheA1ctest,themeanA1cwas5.82%(95%CI5.70to5.96%),asshowninTableII.AspertheAmericanDiabetesAssociationparameters, themajorityofpatients (61%)scoredanA1cbetween5.7%and6.5%indicatingincreasedriskfordiabetes.5

DiScuSSion

AmongtheundiagnosedpatientswhoparticipatedintheAmericanDiabetesAssociationrisktest,42%werefoundtobeatincreasedriskfordiabetesandwerethenreferredtotheirphysicianforfurthereval-uation.EvenwithoutA1ctesting,administeringtheAmericanDiabetesAssociationrisktestwasfoundtobeabeneficialhealthpromotiontoolforidentifyingpatientsatriskfordevelopingdiabetes.

Therewasa64%rateofagreementamong thehigh-riskgrouptohavetheirA1ctested.Theadmin-istrationoftheAmericanDiabetesAssociationdiabe-tesrisktestcreatedanopportunityfordialoguebe-tweenthepatientandtheoralhealthcareprovider.Moreover,theutilizationofthediabetesrisktestin

adentalsettingmayprovideincentiveforfollow-upwithaphysician.Basedonthepointofcareinstru-ment,themajority(61%)hadanA1cinthepredia-betesordiabetesrange.AlthoughapointofcareA1cassay is not recommended for a diagnosis of pre-diabetesordiabetes,anA1ctestshouldbedoneina laboratoryusingamethodmeetingNationalGly-cohemoglobin Standardization Program andDiabe-tesControlandComplicationsTrialcertificationandstandards; itmayserveasaconvenientscreeningtool and improve patient compliance for physicianfollow-up.7Patientswereprovidedwithawrittenre-ferralandtheprincipalinvestigatorssentacopyoftheAmericanDiabetesAssociationdiabetesrisktestalongwithalettertothephysicianofrecordforfur-therpatientevaluation.


TherateofparticipationamongpatientswhotooktheAmericanDiabetesAssociationdiabetesrisktestmaybeexplainedby the lengthof time it takesapatient to receivepreventativedentalhygieneser-vicesinaneducationalsetting.Relyingonthefrontofficeand/ordentalhygienestudentstoadministertheAmericanDiabetesAssociationdiabetesrisktestat the start of the patient appointmentwas not areliablemethodofadministration.IncorporatingtheAmerican Diabetes Association diabetes risk testalongwithotherriskassessmentsconductedduringthedentalhygieneprocessofcaremayimprovetherateofcomplianceandreinforcetheassociationbe-tweendiabetesandperiodontitis.

National data indicate the incidence and preva-lence of prediabetes and diabetes is on the rise.1Type2diabetesisamanageablediseasewithearlydiagnosis.Themajorityofadultpatientshaveanan-nualvisitwithadentalprovider,andimplementationof theAmericanDiabetesAssociationdiabetes risktestcanhelptoidentifypatientsatincreasedriskfordiabetes.Thetoolcouldbeutilizedinanydentalset-tingtoprovidepatientswithimportanthealthinfor-mation,potentiallyimprovinghealthpromotionanddiseaseprevention.3Largescaleclinical trialsneedtobeconductedtoassessfeasibility,acceptanceandcost-effectivenessofscreening inadentalascom-partedtoamedicalsetting.

Healthscreeningsaremorecost-effectivethanthetreatmentofdiseaseandcouldpotentiallyeasetheeconomicburdenofdiabetescare.4Additionally,im-plementationofahealthscreeningtoolwithinaden-talsettingcouldprovideanopportunitytoincreasecollaborationamongdentalandmedicalproviders.

concluSion

acknowleDgmentS

Utilization of the American Diabetes Associationrisktestassistedinidentifyingtype2diabetesatriskpatients,andprovidedanopportunitytodiscussdia-betesinadentalsetting.Moreover,utilizationofthediabetesrisktestinadentalordentalhygieneset-tingmayprovideincentiveforfollow-upwithaphy-sician.Ashealthcareproviders,dentalprofessionalshave a responsibility to raise diabetes awareness.Futureresearchregardingdiabetesassessmentinadental settingmustbe conducted tobetter under-standthevalueofscreeninginadentalsetting,andtoinvestigateifthisformofscreeningleadstoim-proveddiagnosisandmanagementofdiabetes.

Lori J. Giblin, RDH, MS, is an Assistant Professor, Forsyth School of Dental Hygiene, MCPHS University. Lori Rainchuso RDH, MS, is an Associate Professor and Graduate Program Director, Forsyth School of Dental Hygiene, MCPHS University. Andrew Roth-man, MS, EIT, is a doctoral candidate at Harvard School of Public Health and Adjunct Faculty at For-syth School of Dental Hygiene, MCPHS University.

TheauthorsthankMCPHSUniversityforthefund-ing of this project through a faculty developmentgrant.SpecialthankstoLoryLibby,RDH,MS,forherclinicalassistance.

A study limitation included lack of patient-phy-sician followup todetermineconfirmationofdiag-nosis. Additionally, the authors recognize this wasarelativelysmallsamplepopulationinonelocationandthereforenotgeneralizable.

1. DanaeiG,FinucaneMM,LuY,etal.National,region-al,andglobaltrendsinfastingplasmaglucoseanddiabetesprevalencesince1980:systematicanalysisofhealthexaminationsurveysandepidemiologicalstudieswith370country-yearsand2.7millionpar-ticipants.Lancet.2011;378(9785):31-40.

2. WorldHealthOrganization.WorldHealthOrganiza-tionFactSheetNo.312.2011.

3. NationalCenterforChronicDiseasePreventionandHealthPromotion.NationalDiabetesStatisticsRe-port.CentersforDiseaseControl.2014.

4. DallTM,YangW,HalderP,etal.Theeconomicbur-den of elevated blood glucose levels in 2012: di-agnosed and undiagnosed diabetes, gestationaldiabetesmellitus,andprediabetes.Diabetes Care.2014;37(12):3172-3179.

5. American Diabetes Association. Diagnosis andclassification of diabetes mellitus. Diabetes care.2014;37(Suppl.1):S81-S90.

6. The InternationalExpertCommittee. InternationalExpert Committee report on the role of the A1Cassayinthediagnosisofdiabetes.Diabetes Care.2009;32:1327-1334.

7. AmericanDiabetesAssociation.Standardsofmedi-calcareindiabetes--2015.Diabetes Care.2015;38Suppl1:S1-S94.

8. United States Department of Health and HumanServices.HealthyPeople2020.2014.

9. TeeuwWJ,GerdesVE,LoosBG.Effectofperiodontaltreatmentonglycemiccontrolofdiabeticpatients:a systematic review and meta-analysis. Diabetes Care.2010;33(2):421-427.

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10.ChappleIL,GencoR,workinggroup2ofthejointEFP/AAPworkshop.Diabetes and periodontal dis-eases:consensusreportoftheJointEFP/AAPWork-shoponPeriodontitisandSystemicDiseases.J Peri-odontol.2013;84(4Suppl):S106-12.

11.PageRC,EkePI.Casedefinitionsforuseinpopula-tion-basedsurveillanceofperiodontitis.J Periodon-tol.2007;78(7Suppl):1387-1399.

12.MartinJA,PageRC,KayeEK,HamedMT,LoebCF.Periodontitisseverityplusriskasatoothlosspredic-tor.J Periodontol.2009;80(2):202-209.

13.EkePI,PageRC,WeiL,Thornton-EvansG,GencoRJ.Update of the case definitions for population-based surveillance of periodontitis. J Periodontol.2012;83(12):1449-1454.

14.Laurence B. Dentists consider medical screeningimportantandarewillingto incorporatescreeningproceduresintodentalpractice.J Evid Based Dent Pract.2012;12(3Suppl):32-33.

15.NationalCenterforChronicDiseasePreventionandHealth Promotion. Behavioral Risk Factor Surveil-lance System. Prevalence and Trends Data, OralHealth.CentersforDiseaseControlandPrevention.2016.

16.Lalla E, Kunzel C, Burkett S, Cheng B, Lam-ster IB. Identification of unrecognized diabetesand pre-diabetes in a dental setting. J Dent Res.2011;90(7):855-860.

17.GencoRJ, SchifferleRE,DunfordRG, FalknerKL,HsuWC,BalukjianJ.ScreeningfordiabetesmellitusindentalpracticesAfield trial. J Am Dent Assoc.2014;145(1):57-64.

18.GreenbergBL,GlickM.Assessingsystemicdiseaseriskinadentalsetting:apublichealthperspective.Dent Clin North Am.2012;56(4):863-874.

19.CreanorS,MillwardBA,DemaineA,etal.Patients’attitudestowardsscreeningfordiabetesandothermedicalconditionsinthedentalsetting.Brit Dent J.2014;216(1).

20.Barasch A, Safford MM, Qvist V, et al. Randombloodglucosetestingindentalpractice:acommu-nity-based feasibility study fromTheDental Prac-tice-Based Research Network. J Am Dent Assoc.2012;143(3):262-269.

21.Lenters-WestraE,SlingerlandRJ.Sixofeighthemo-globinA1cpoint-of-care instrumentsdonotmeetthegeneralacceptedanalyticalperformancecrite-ria.Clin Chem.2010;56(1):44-52.

22.ShephardMD,GillJP.Theanalyticalqualityofpoint-of-care testing in the ‘QAAMS’model fordiabetesmanagement inAustralianaboriginalmedical ser-vices.Clin Biochem Rev.2006;27(4):185-190.


Research in medical settings reports that pa-tients’ satisfaction with their provider is an im-portant predictor of theirwillingness to return forfollow-up visits, their cooperation with treatmentrecommendationsandthelikelihoodthattheyrec-ommendtheirprovidertootherpatients.1-3Severalstudiesindentistryhaveshownsimilarfindings.Forexample,Pateletalconcludedthattherelationshipwithaperiodontistwasrelatedtopatients’decisiontoacceptarecommendationtohavesurgicaltreat-ment.4 Inglehart et al documented that the levelof satisfaction with their dentist affected whetherandhow longpatientshadusedabitesplint theyhadreceivedbecausetheysufferedfrombruxism.5Numerousotherstudiesprovidedadditionalsupportfor the importance of dental patients’ satisfactionwith their provider, for reducing patients’ dentalfearandanxiety,forincreasingtheirconfidenceintheirdentist,andforachievingmorepositivetreat-mentoutcomes.6-14

Oneaspectofapatientvisit thatwas identified

DoWaitingTimesinDentalOfficesAffectPatientSatisfactionandEvaluationsofPatient-ProviderRelationships?AQuasi-experimentalStudyMaritaRohrInglehart,Dr.phil.habil;AlexanderH.Lee,BS;KristinG.Koltuniak,BS,RDH;TaylorA.Morton,RDH,BS;JennaM.Wheaton,RDA,RDH,BSDH

AbstractPurpose:Spendingtimeinwaitingroomspriortodentalvisitsisnotuncommonfordentalhygienepa-tients.Theobjectivesweretodetermineifthelengthofapatients’waitingtimeaffectedtheirsatisfactionwiththeappointmentandtheirevaluationoftheirprovider.Inaddition,thepatient’slevelofeducationandwhetherthedentalvisitisafirstvisitwillbeexaminedtodetermineiftheseaffectedtheoutcome.Methods:Surveydatawerecollectedfrom399adultpatientswhocameforregularlyscheduledvisitstoadentalschoolclinic.Thepatientsrangedinagefrom19to93years(mean=52years;SD=16.9).For29%ofthepatients,thisvisitwasthefirstvisitwiththisprovider.Results: Thepatientswhoseproviderswereearly(n=65)weremoresatisfied,morelikelytoplantofollowtheirprovider’srecommendationandevaluatedtheirrelationshipwiththeirprovidermoreposi-tivelythanpatientswhoseproviderswereontime(n=283),whilethepatientsinthe“late”group(n=32)showed themostnegative responses toallquestions.Patients fromhighereducationalbackgroundsweremostnegativeintheirresponseswhentheirproviderswerelate.Patientswithafirstvisitwhoseproviderswerelatehadthemostnegativeevaluationsofthepatient-providerrelationship.Conclusion:Longwaitingtimespriortoascheduleddentalappointmenthaveanegativeeffectonpa-tients’satisfactionwiththeirvisit,theevaluationsofthepatient-providerrelationshipandthepatients’intentionstoreturn.Keywords:dentalhygienists,dentists,patients,dentist-patientrelationships,patientappointment,pa-tientsatisfaction,patientschedule,patientcompliance,patientcooperationThisstudysupportstheNDHRApriorityarea,Health Promotion/Disease Prevention: Assessstrate-giesforeffectivecommunicationbetweenthedentalhygienistandclient.

research

introDuctionashavinganegativeeffectonpatients’satisfactionwiththeirproviderwasthe lengthoftimethepa-tientsspentinawaitingroom.Thisrelationshipwasdocumentedforpatientsinmanydifferentmedicalsettings,suchaswhenseekingcareinemergencyrooms,receivingchemotherapytreatment,visitingaprimarycareprovider,oragynecologist,obste-trician or other medical specialists.15-20 In dentaloffices, patients’ dissatisfaction with long waitingtimeshavebeendocumentedaswell.21-23However,no study so far explored how the exact length ofthepatient’stimeinthewaitingroomwouldaffecttheirsatisfactionwiththeirprovider,theirintentionstocooperatewithtreatmentrecommendationsandtheir intentions to return for future dental visits.Thefirstobjectiveofthisstudyistoexploreifhav-ingalongwaitingtimeversusnothavingtowaitorhavingadentistwhoisearlyaffectsapatient’sre-sponsetotheirprovidersandtheirintendedtreat-mentcooperation.

Inadditiontoexploringthisrelationshipingen-


eral,itisalsointerestingtoreflectwhethercertaingroups of patients will respond to longer waitingtimes more negatively than other groups of pa-tients.Onepotentialmoderatingfactorcouldbethepatient’s level of education. Research found thatthereisageneralrelationshipbetweenpatientsat-isfactionandlevelofeducation.Patientswithlowerlevelsofeducationwereonaveragemoresatisfiedwiththeirmedicalcareandprovidersthanpatientswithhigher levelsofeducation.24-26 In thecontextofexploringtheeffectsoflengthofwaitingtimeondental patients’ satisfaction, these earlier findingsmightnotonlyresultinthepredictionthatlessedu-catedpatientswouldbemoresatisfiedthanbettereducatedpatients,buttheremightbeadifferentialeffectofwaiting time length in thesegroups.Thesecondobjective is toexplorewhetherapatient’slevelofformaleducation(moreprecisely,theyearsofschoolingtheyhadreceived)willdifferentiallyaf-fecttheirsatisfactionasafunctionofthelengthoftheirwaitingtime.It ishypothesizedthatpatientswith more formal education will be less satisfiedthanpatientswith less formaleducation,andthatthiseffectwouldbeespeciallylargewhenpatientshadalongwaitingtime.

A second moderating factor might be whethera dental visit is a patient’s first encounterwith aprovider or whether a patient has an already es-tablishedrelationship.Atanewpatientvisit,den-talcareprovidersdonotonlyneedtoassurethatthey collect all the necessary medical and dentalinformation to provide safe and the best possiblecare for a patient, but they also have to developgoodrapportwithapatient.Thequestionishowthelengthofwaitingtimeaffectsanewpatientversusanestablishedpatient’sresponsetotheirproviders.


Thisresearchwasdeterminedtobeexemptfromoversightby theInstitutionalReviewBoard for theHealthandBehavioralSciencesattheUniversityofMichiganinAnnArbor.

Respondents:AnaprioripoweranalysiswiththeprogrampackageG*Power3.1.2wasconductedtocomputetheneededsamplesizegivenalpha=0.05,the power=0.95 and amediumeffect size of 0.20whenusingaunivariateofanalysis to test forsig-nificantdifferencesintheaverageresponsesofre-spondentswhoseproviderwasearly,lateorontime.Theresultshowedthatasamplesizeof390patientswasneeded.Datawerecollectedfrom399regularlyscheduledadultdental/dentalhygienepatients.TableIshowsthatthesamplewasquiteheterogeneousinregardtogender,ageandyearsofeducation.Therewereapproximatelyequalnumbersofmale(n=196)and female (n=203) patients. The patients rangedin age from19 to 93 years (mean=52 years) and

theiryearsofeducationrangedfrom6to30years(mean=14years).

Procedure:Thepatientswereinformedaboutthestudywhen they arrived for a regularly scheduledappointmentinthewaitingroomareaofaMidwest-erndentalschool.Iftheyagreedtorespondtoaself-administered survey after their appointment, theyreceivedthesurveyandavoucherforfreeparkingduring the visit from the research assistant. Theyrespondedtotheanonymoussurveyaftertheirap-pointment and returned it in a sealed envelope totheresearchassistant.Thereturnofthesurveywasseenasgiving implicitconsent.Nowrittenconsentwasrequiredbecausethesurveywasanonymous.

Materials: A survey instrument was developedby the research teamand thenpilot testedwithagroupof10patients.Thepilotdatashowedthatthequestionswereeasytounderstandandthatonlyfor-mattingchangeswereneeded.Thefinalsurveycon-sistedof4setsofquestions.Thefirstsetaskedthepatientsaboutsomebackgroundcharacteristicssuchastheirgender,age,yearsofeducationandwhetherthisdentalvisitwastheirfirstvisitwiththisprovider.Part2consistedof2questionsrelatedtothelengthoftheirwaitingtime.Question1inquiredaboutthelengthofthewaitingtimeinminutesandQuestion2askedthepatientstoindicatecategoricallyiftheir

Backgroundcharacteristics

FrequenciesorMean

PercentorSDtoRange

GenderMaleFemale

196203

49%51%

Age Mean:52years

16.8719to93years

Yearsofeducation Mean:14years

2.766to30years

DentalvisitinformationFirstvisittodentalschool

YesNo

36363

9%91%

FirstvisitwiththisstudentYesNo

117282

29%71%

Lengthofwaitingtimeinminutes Mean:9 10.91

0to75minutesWaitingtime-Providerwas:

EarlyOntimeLate

6629834

17%*75%9%

TableI:BackgroundCharacteristicsofStudyParticipants

*Percentagesmightnotaddupto100%duetorounding


Satisfactionwithappointment 1and2 3 4 5 MeanSD

Satisfactionwithdentalvisittoday* 2% 2% 13% 83% 4.770.60

Ienjoyedthevisittoday** 3% 11% 23% 64% 4.460.84

Ifeltcomfortabletoday** 2% 3% 20% 75% 4.680.65

Ilearnedmoreabouthowtokeepmyteethhealthy** 3% 5% 15% 77% 4.660.77

Index“Satisfactionwithappointment”(alpha=0.763) 4.640.55

Evaluationsofrelationship

Myproviderwaswellprepared 1% 3% 11% 85% 4.790.57

Myproviderwelcomedmeinafriendlymanner** 1% 1% 9% 90% 4.870.44

Myproviderexplainedwhatwouldbedonetoday** 1% 1% 10% 88% 4.850.47

Myprovidertooktimetolistentome** 1% 1% 11% 88% 4.850.47

Itrustmyprovidertogivegoodtreatment 1% 2% 11% 87% 4.840.48

Iplantofollowmyprovider’srecommendations** 1% 3% 13% 84% 4.780.58

Iplanonreturningtothisprovider** 1% 1% 10% 88% 4.850.46

Ifeelmyprovidervaluesmytime** 1% 3% 10% 87% 4.810.54

Index“Evaluationofrelationship”(alpha=0.962) 4.830.45

*Answersrangedfrom1=notatallto5=verysatisfied**Answersrangedfrom1=stronglydisagreeto5=stronglyagree

TableII:Patients’SatisfactionandRelationship-RelatedResponses

studentproviderwasearly,ontimeorlatefortheirappointment.

Thethirdsetofquestionswasconcernedwiththepatients’satisfactionwiththeappointment.Thefirstofthese4satisfactionquestionsaskedaboutthepa-tient’s“Satisfactionwiththedentalvisittoday,”withanswers ranging from1=Not at all to 5=Very sat-isfied.ThreeadditionalquestionshadaLikert-styleanswerformat.Theyconsistedofthestatements“Ienjoyed the visit today,” “I felt comfortable today”and “I learnedmore about how to keepmy teethhealthy.”Answersrangedfrom1=Stronglydisagreeto5=Stronglyagree.TheCronbachalphainter-itemconsistencyreliabilitycoefficientforthesefouritemswas0.763.

The final set of questions consisted of 8 Likert-typequestionsconcerningthepatients’evaluations

oftheirrelationshipwiththeirproviderandtheirre-sponsesrelatedtocooperatingwiththeirprovider’srecommendations (“I plan to follow my provider’srecommendations”) and their likelihood to returntotheprovider(“Iplantoreturntothisprovider”).Theseanswersalsorangedfrom1=Stronglydisagreeto5=Stronglyagree.TableIIprovidesanoverviewofthewordingofthesestatements.TheCronbachal-phainter-itemconsistencyreliabilityindexforthese8itemswas0.962.

Statistical analyses: The datawere entered intoSPSS(Version21).Descriptivestatisticssuchasper-centages, means, standard deviations and rangeswereprovidedtogiveanoverviewoftheresponses.Inferential statisticswereused to compare the re-sponsesofsubgroupsofpatients.Multivariateanaly-ses of variance (MANOVA)with the 3 independentvariables “Lengthofwaiting time” (with the3 lev-


reSultS

TableIshowsthat196maleand203femalepa-tientsparticipated in this study. Thepatientswereonaverage52yearsold(range19to93years)andhadanaverageof14yearsofeducation(range6to30 years),with 151 patients having a high schooldiplomaorfeweryearsofeducationand221havingmoreyearsofeducationthanahighschooldiploma.Ninepercentofthepatientsreportedthatthiswastheirfirstvisit to thedentalschool,and29%indi-cated that itwas the first visitwith this particularstudentprovider.Whenthepatientswereaskedhowlongtheyhadtowaitinthewaitingroomarea,theaverage answer was 8.59minutes (range 0 to 75

els:Providerwaslate,ontimeorearly),“Education”(≤12yearsofeducationvs.>12yearsofeducation),and“Typeofvisit”(firstvs.repeatvisit)andthede-pendent variables satisfactionwith appointment (4items)andevaluationsor relationshipwithprovid-er(8items)werecomputed.Anindex“Satisfactionwith the appointment’ andan index “Evaluationofthepatient-providerrelationship”werecalculatedbyaveragingtheresponsestothesingleitemsinthese2 item sets. The inter-item consistency of these2scaleswasdeterminedwithCronbachalphacoeffi-cients.Univariateanalysesofvariancewiththeinde-pendentvariable“Waitingtime,”“Levelofeducation”and “First vs. not first visit” and the 2 indices asthedependentvariableswereconducted.Alevelofp<0.05wasacceptedassignificant.

minutes).Inresponsetothequestionwhethertheirproviderhadbeenearly,ontime,or late,17%re-portedthattheirproviderwasearly,75%thattheirprovider was on time, and 9% that their providerwaslate(TableI).

The vastmajority of patients was very satisfiedwith their dental visit (83%), agreed strongly thattheyenjoyedtheirvisit(64%),hadfeltcomfortable(75%), and had learnedmore about how to keeptheirteethhealthy(77%)(TableII).Whenasatis-faction indexwasconstructedbyaveragingthere-sponsestothese4items,theaverageresponsewas4.64ona5-pointscalewith5beingthemostsat-isfied response.The responses to the8 items thatmeasuredthepatients’evaluationsoftheirrelation-shipwiththeirproviderandtheirintentionstofollowtreatmentrecommendationsandreturnforafollow-upvisitwerealsoverypositive.Again,over80%ofthe respondents strongly agreed that their provid-erwaswellprepared;welcomedtheminafriendlymanner, explained what would be done, and tooktimetolistentothem.Over80%alsotrustedtheirprovider,plannedonfollowingtheprovider’srecom-mendationsandonreturningtotheprovider,andfelttheirprovidervaluedtheirtime.Whenanindexwasconstructedbasedontheaverageoftheresponsestothese8items,theaverageresponsewas4.83.

Thefirstobjectivewastocomparetheresponsesofpatientswhohadreportedthattheirproviderhadbeenearly,ontimeorlate.TableIIIshowsthatthe

Satisfactionwithappointment Waitingtime-Providerwas:Early Ontime Late

Satisfactionwithdentalvisittoday?# 4.96 4.80 4.21***Ienjoyedthevisittoday.## 4.70 4.44 4.06**Ifeltcomfortabletoday.## 4.82 4.68 4.39**Ilearnedmoreabouthowtokeepmyteethhealthy.## 4.79 4.66 4.33*Index“Satisfactionwithappointment” 4.81 4.64 4.25***EvaluationsofrelationshipMyproviderwaswellpreparedformyvisit. 4.89 4.81 4.47**Myproviderwelcomedmeinafriendlymanner.## 4.89 4.89 4.69*Myproviderexplainedwhatwouldbedonetoday.## 4.89 4.87 4.56**Myprovidertooktimetolistentome.## 4.91 4.87 4.53***Itrustmyprovidertogivegoodtreatment. 4.86 4.86 4.63*Iplantofollowmyprovider’srecommendations.## 4.88 4.81 4.50**Iplanonreturningtothisprovider.## 4.89 4.87 4.63*Ifeelmyprovidervaluesmytime.## 4.89 4.85 4.34***Index“Evaluationofrelationshipwithprovider” 4.89 4.85 4.54***

TableIII:AverageResponsesofPatientswhoseProvidersWereEarly,OnTimeorLate

*p≤0.05;**p≤0.01;***p≤0.001#Answersrangedfrom1=notatallto5=verysatisfied##Answersrangedfrom1=stronglydisagreeto5=stronglyagree


<HS

>HS

5

4.5

4

3.5Early OnTime Late

Figure1:AverageSatisfactionwiththeAp-pointment of Patientswhose ProviderwasEarly,OnTimeorLatebyLevelofEducation

FirstVisit

NotFirstVisit

5

4Early OnTime Late

Figure2:AverageEvaluationofthePatient-ProviderRelationshipofPatientswhosePro-viderWasEarly,OnTimeorLatebyFirstvs.NotFirstVisitwithThisProvider

patientswhoseproviderwasearlyweresignificantlymore satisfied with their dental visit than the pa-tients whose provider were on time, and that theleast satisfied patients were those whose providerwaslatefortheappointment(4.96vs.4.80vs.4.21;p<0.001).Thesamepatternofresponseswasalsofound in theanswersto thestatements“Ienjoyedthe visit today,” “I felt comfortable today” and “Ilearnedmoreabouthowtokeepmyteethhealthy.”Ineach instance,patientswhoseproviderwas latewere leastpositive in their responses,and thepa-tients whose provider were early weremost posi-tive(MANOVA:F(4/754)=5.15;p<0.001).Aunivari-ateanalysisofvariancewiththedependentvariable“Satisfaction with appointment” index showed thesameoverallpatternofresponses.

TableIIIalsoshowsthatthe3groupsofrespon-dentswhose providerswere early, on time or latedifferedinthesamewayintheirevaluationsoftheirrelationship with their provider. For each of the 8statements,patientswhoseproviderhadbeen lateweresignificantly lesspositiveabouttheirrelation-shipthanpatientswhoseproviderswereearlyorontime(MANOVAF(16/742)=2.51;p=0.001).

Inadditiontocomparingtheresponsesofpatientswhoseproviderswereearly,ontimeorlate,itwasalso explored how the patients’ level of educationaffectedtheresponsesof these3groups.Figure1shows the average level of satisfaction of patientswithlower(12yearsorless)vs.higher(morethan12years)levelsofeducationineachofthe3wait-ingtimegroups.Thisfigureshowsthatpatientswitha lower level of education were more satisfied ineachofthe3groupsthanpatientswithhigherlev-elsofeducation(4.82vs.4.48;p<0.001).Inaddi-tion,patientswithahigherlevelofeducationwhoseprovider was late were on average least satisfiedwith their appointment (mean: 4.07) compared to

allothergroups(p<0.01).TableIVprovidesthede-tailedinformationconcerningtheeffectsof levelofeducationonsatisfactionandproviderevaluationsofpatientsinthe3groups.Patientswithlowerlevelsofeducationhadmorepositiveaverageoverallevalu-ationsof their relationshipwith theirprovider thanpatients with higher levels of education (4.91 vs.4.71;p<0.01).Whiletheinteractioneffectsbetweenthefactors“Waitingtime”and“Levelofeducation”werenotsignificantformostoftheevaluationitems,the average responses to the item “I feel thatmyprovidervaluesmytime”showedagainthatpatientswithhigherlevelsofeducationwereleastpositiveinresponsetothisitemcomparedtoallothergroups.

Thefinalquestionwaswhetherthefactthatapa-tienthadafirstvisitwithaprovideraffected theirresponses to whether their provider was early, ontimeorlate.Figure2showsthattheaverageover-allevaluationsofpatientswhoseproviderhadbeenlate and for whom this visit was a first visit wereleastpositive(Mean:4.40),whiletheresponsesofpatientswithafirstvisitwhoseproviderwereearlyweremost positive (Mean: 5.00) compared to theevaluationsofallotherrespondents.TableVshowsthatthefactthatapatienthadafirstvs.notafirstvisitwithaproviderdidnotaffecthowsatisfiedtheywere, how much they enjoyed the visit and howcomfortabletheyfelt.However,patientswithafirstvisitagreedlessstronglythattheyhadlearnedmoreabouthowtokeeptheirteethhealthythanpatientsforwhomthisvisitwasa repeatvisit. Inaddition,patientswhosawprovidersforthefirsttimeagreedless strongly that theirproviderwaswell preparedfortheirvisit,welcomedtheminafriendlymanner,explainedwhatwouldbedoneduringthevisit,tooktimetolistenandvaluedtheirtimethanpatientsforwhomthisvisitwasnotafirstvisitwiththisprovid-er.Patientswithafirstvisitwhoseproviderwaslatehad the least positive response to the statements


Satisfactionwithappointment ≤HSvs.>HS

WaitingtimeTotal

Early Ontime Late

Satisfactionwithdentalvisittoday?#≤HS 5.00 4.78 5.00*** 4.83***>HS 4.91 4.80 3.95 4.74

Ienjoyedthevisittoday.##≤HS 4.77 4.58 4.78 4.63***>HS 4.63 4.35 3.86 4.34

Ifeltcomfortabletoday.##≤HS 4.80 4.78 4.78 4.78>HS 4.83 4.62 4.32 4.62

Ilearnedmoreabouthowtokeepmyteethhealthy.##

≤HS 4.90 4.73 4.89 4.77**>HS 4.69 4.60 4.14 4.57

Index“Satisfactionwithappointment”≤HS 4.87 4.72 4.86** 4.82***>HS 4.76 4.59 4.07 4.48

Evaluationsofrelationship

Myproviderwaswellpreparedformyvisit.≤HS 4.93 4.82 4.88 4.85*>HS 4.85 4.79 4.41 4.76

Myproviderwelcomedmeinafriendlymanner.##≤HS 4.93 4.89 4.88 4.90>HS 4.85 4.88 4.68 4.86

Myproviderexplainedwhatwouldbedonetoday.##≤HS 4.93 4.90 4.88 4.91*>HS 4.85 4.85 4.50 4.82

Myprovidertooktimetolistentome.##≤HS 4.97 4.89 4.88 4.91*>HS 4.85 4.85 4.45 4.81

Itrustmyprovidertogivegoodtreatment.≤HS 4.93 4.87 5.00 4.89**>HS 4.79 4.84 4.55 4.81

Iplantofollowmyprovider’srecommendations.##≤HS 4.97 4.86 4.75 4.87*>HS 4.79 4.76 4.45 4.74

Iplanonreturningtothisprovider.##≤HS 4.97 4.87 5.00 4.90**>HS 4.82 4.87 4.55 4.83

Ifeelmyprovidervaluesmytime.##≤HS 4.97 4.90 5.00*** 4.92***>HS 4.82 4.81 4.18 4.75

Index“Evaluationofrelationshipwithprovider”≤HS 4.95 4.88 4.91 4.91**>HS 4.83 4.83 4.47 4.71

TableIV:AverageResponsesofPatientswithHighSchoolorFewerYearsofEducationvs.WithMoreYearsthanHighSchoolEducationwhoseProvidersWereEarly,OnTimeorLate


“Myproviderexplainedwhatwouldbedonetoday”and“Myprovidertooktimetolisten”comparedtoallotherrespondentgroups.

DiScuSSion

Patients’satisfactionwiththeirmedicalanddentalvisits and their provider is crucial for theirwilling-nesstocooperatewithtreatmentrecommendations,theirwillingnesstoreturnforafollow-upvisitandtorecommendaprovidertootherpatients.1-5Whilealackoftreatmentcooperationultimatelymightaffect

patients’health,notreturningforfollow-upappoint-ments and not recommending a provider to otherpatients can clearly affect the success of a dentalpractice.5 Avoiding situations that negatively affectpatients’satisfactionisthereforecrucial.Theresultsof this study showed that letting patients wait fortheirappointmentsandnotbeingontimeaffectstheirsatisfactionnegatively.Managingappointmenttimescarefullyisthereforeimportant.However,therearetimeswhenpatientsmighthavetowaitduetoun-foreseenevents.Thewaythesesituationsarebeingmanaged seem to determine ultimately howmuch


Satisfactionwithappointment Firstvs.NotFirst

Waitingtime-Providerwas:Total

Early Ontime Late

Satisfactionwithdentalvisittoday?#First 4.88 4.79 4.08 4.73

NotFirst 5.00 4.80 4.37 4.80

Ienjoyedthevisittoday.##First 4.42 4.47 4.00 4.40

NotFirst 4.86 4.43 4.21 4.48

Ifeltcomfortabletoday.##First 4.63 4.67 4.31 4.62

NotFirst 4.93 4.68 4.53 4.70

Ilearnedmoreabouthowtokeepmyteethhealthy.##First 4.46 4.63 4.15 4.54*

NotFirst 4.98 4.68 4.47 4.71

Index“Satisfactionwithappointment”First 4.59 4.64 4.13 4.52

NotFirst 4.94 4.65 4.39 4.65EvaluationsofRelationship#

Myproviderwaswellpreparedformyvisit.First 4.70 4.77 4.38 4.71*

NotFirst 5.00 4.18 4.56 4.83

Myproviderwelcomedmeinafriendlymanner.First 4.70 4.89 4.62 4.81*

NotFirst 5.00 4.89 4.78 4.90

Myproviderexplainedwhatwouldbedonetoday.First 4.70 4.86 4.31* 4.76***

NotFirst 5.00 4.88 4.78 4.89

Myprovidertooktimetolistentome.First 4.74 4.86 4.31* 4.77**

NotFirst 5.00 4.87 4.72 4.88

Itrustmyprovidertogivegoodtreatment.First 4.74 4.85 4.54 4.79

NotFirst 4.93 4.86 4.72 4.86

Iplantofollowmyprovider’srecommendations.First 4.74 4.77 4.46 4.73

NotFirst 4.95 4.82 4.56 4.82

Iplanonreturningtothisprovider.First 4.74 4.85 4.54 4.79*

NotFirst 4.98 4.88 4.72 4.88

Ifeelmyprovidervaluesmytime.First 4.74 4.80 4.15 4.71**

NotFirst 4.98 4.86 4.56 4.86

Index“Evaluationofrelationshipwithprovider”First 5.00 4.49 4.40* 4.61

NotFirst 4.87 4.88 4.57 4.85

TableV:AverageResponsesof PatientswithaFirst vs.NotaFirstVisit to theDentalSchoolClinicswhoseProvidersWereEarly,OntimeorLate


the length of waiting affects patients’ satisfaction,atleastintheshortterm.Researchinmedicalset-tingsfoundthatwhenmedicalcareproviderswerelate for theirappointmentwithapatient,spendingmoretimewiththepatientduringtheappointmentcouldmoderatethenegativeeffectsofalongwaitingtime.19,27,28

Theresultsofthisstudyshowedthatpatientchar-acteristicsmightalsoaffectthedegreetowhichlon-gerwaitingtimesaffectpatients’satisfaction.Whilepreviousresearchclearlydocumentedthatpatients’

levelofeducationwasrelatedtotheirtreatmentsat-isfaction,24-26 this is the first study that documentsthat patients’ level of education might moderatetheirresponsestolongerwaitingtimes.Inaddition,thereissomeevidencethatwhetheradentalvisitisanewpatientvisitcouldfurthermoderatepatients’responses. Future studies could explore whetherother patient characteristics such as patients’ agemightalsoaffectresponsestolongerwaitingtimes.29

Inadditiontoconsideringhowlongerwaitingtimesaffect patients’ responses, it is also noteworthy to


concluSion

acknowleDgmentS

Basedonthesefindings,itcanbeconcludedthatthe length of time patients have towait in await-ing room area for their dental care provider nega-tively affects their level of satisfactionwith the ap-pointment, their evaluations of the patient-providerrelationshipaswell as their intentions to cooperatewiththeproviders’recommendations.Thesenegativeeffectsonpatients’levelofappointmentsatisfactionareespeciallysevereforpatientswithhigherlevelsofeducation.Inaddition,ifaproviderislateforafirstvisitwithanewpatient,itcanbeexpectedthatthepatients’ overall evaluations of the patient-providerrelationshipswill be least positive compared to theevaluationsofallotherpatientgroups.

Marita Rohr Inglehart, Dr. phil. habil, is a Profes-sor, Department of Periodontics and Oral Medicine, School of Dentistry & Adjunct Professor, Department of Psychology, College of Literature, Science & Arts, University of Michigan. Alexander H. Lee, BS, is a Re-search assistant, University of Michigan – School of Dentistry. Kristin G. Koltuniak, BS, RDH, is a dental hygienist in private practice of Dr. Diana Wolf Abbott, DDS, MS, PC, in Rochester Hills, MI. Taylor A. Morton, RDH, BS, is a dental hygienist in private practice at Children’s Dental Specialists in Warren, NJ. Jenna M. Wheaton, RDA, RDH, BSDH, is a dental hygienist in private practice at Shortt Dental in South Lyon, MI.

WewanttothankChukwukaAkunne,GopaldeepKaur,ElizabethLyandPaulYoonfortheirhelpwithcollectingthedataandpreparingthedataforanaly-sis.

consider that research showed that providers’ sat-isfactionwithanappointmentwasalsolowerwhentheycouldnotprovideon-timecarefortheirpatientsandthepatientshadtowait.18Runninglateforap-pointmentsmightinducestressthataffectspatient-provider interactions and providers’ professionalqualityoflife.Insummary,longerwaitingtimesforpatientsarenotonlylikelytoresultinreducedpa-tientandprovider satisfaction inagivensituation,butmightaffectthesuccessofapracticeinthelongrun.

Thisstudyhadseverallimitations.First,thedatawerecollectedinadentalschoolsettingwhereden-tal care is relatively lessexpensive,but takes lon-ger than in a private office. Answers to the ques-tionconcerningthepatients’ intenttoreturnmightbeaffectedbythefactthattheywereseekingden-tal treatment for a reduced price. In private prac-ticesettings,patients’intentionstoreturntoapro-vider, especially if a dental visit is their first visit,might therefore bemore affected by their level ofsatisfactionwithanappointment.Second,giventhatthesedatawerecollectedinadentalschool,thepa-tientsmight bemore likely to come from a lowersocio-economicbackground.Future researchmighttherefore consider patients’ economic situation inconnectionwiththeir levelofeducationasafactorthatmightdeterminethepatients’responsestolongwaitingtimes.Third,nodatawerecollectedconcern-ingwhetherthesepatientsweretreatedbydentalordentalhygienestudents.Itisthereforenotpossibletoanswerthequestionwhetheralongerwaitingtimeforanappointmentwithadentalhygienistvs.aden-tist would affect patients’ responses differentially.Finally,alldependentvariableswereassessedwithpatients’responsestoasurvey.Infuturestudies,itwould be interesting to collect objective data suchaswhetherpatientsactuallyreturntoaprovideraf-terhavinghadtowaitforalongtime.Inaddition,severalpossiblevariables thatmighthaveaffectedtheoutcomessuchastheprocedureperformedandtheamountofexperienceoftheproviderwerenot

includedandshouldbeconsideredinfuturestudies.Assessingpatients’responsesatlaterpointsintimecouldalsobehelpfulbecauseitwouldclarify ifthefindingsinthisstudyholdupovertime.

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