Assessment of Pathology Instruction in U.S. Dental Hygiene Educational Programs

Discussion

This study assessed pathology instruction in dental hygiene programs from 2 different perspectives: examining the instruction of pathology content and surveying directors of both entry-level and advanced practitioner programs as to their perceptions of their graduates' preparation to perform particular dental hygiene services. Results indicated that 29% of respondents from entry-level programs strongly agreed and 53% agreed that their graduates were adequately prepared to meet the complex medical and oral health needs of the public. All respondents of advanced practitioner programs strongly agreed that their graduates were adequately prepared for that role.

The curricula of entry-level programs varied as to the extent of general and oral pathology instruction. This is not surprising as CODA does not dictate specific credit hours, clock hours or format of instruction to meet accreditation standards. Their requirements are general and currently allow considerable flexibility and latitude in structuring and implementing educational curricula and assessing outcomes of the educational process. While this philosophy has stimulated curricular innovation, with excellent academic results, some programs may have benefitted from more stringent requirements from CODA.

Combining general and oral pathology into 1 course, often also covering systemic pathology content, seems popular. The general pathology content includes basic pathologic processes, such as inflammation, infection and immunity, and the application of these processes to specific organ systems. These applications are often considered to be systemic pathology. A strong background in general and systemic pathology is essential to be adequately prepared to recognize risk factors for systemic diseases and oral manifestations of systemic diseases. Multiple studies have shown the link between periodontitis and systemic diseases, such as diabetes and cardiovascular disease. However, this relationship between periodontal disease and systemic disease is complex and requires a fundamental knowledge of pathological mechanisms.¹⁶

The emphasis of programs on oral pathological conditions is evident in the number of clock hours of oral pathology content. Accordingly, more respondents agreed that their students were adequately prepared in the dental hygiene services, which are based on oral pathology content. This content may be more directly related to clinical dental hygiene, such as identifying oral lesions. Oral cancer, its common oral sites and risk factors, is a substantial part of oral pathology. These concepts are also taught in the initial dental hygiene clinical course, where students learn how to conduct comprehensive extraoral and intraoral examinations.

Instruction in conducting oral cancer risk assessments occurred in both the oral pathology course and in the lecture and clinical components of the clinical courses. Most respondents agreed that their students are adequately prepared to identify risk factors for oral cancer. Adequate preparation in this service may be overly optimistic, considering the results of one study of graduate dental hygienists, which demonstrated that only 16% correctly identified 11 out of 14 risk factors.⁸ Generally, respondents agreed more positively about the preparation of their graduates in clinical experiences than in didactic material. Because in this study the majority of pathology instructors were dental hygienists with training in pathology, perhaps there is greater emphasis on clinical aspects of pathology instruction. Clinical procedures, such as intraoral and extraoral examination and medical history, are repeated with each clinic patient, so the high percentage of adequate preparation for these procedures is not surprising. On the other hand, only 74% of graduate dental hygienists in the previously mentioned study responded that they were adequately trained to provide oral cancer examinations.⁸ That study differed from the current study, in that it surveyed dental hygienists as to their preparation, while the current study questioned program directors as to their perceptions of the preparation of their graduates.

Graduating dental students have been surveyed as to their perceptions of their oral cancer education. In one study the students perceived a lack of requisite knowledge and skills, which would be necessary to incorporate oral cancer detection procedures into their oral health care delivery.¹⁷ In a similar study dental students perceived that they were not adequately trained to perform biopsies or to interpret pathology reports, although they felt comfortable performing the oral cancer examination.¹⁸ Dental students, as well as dentists, have been assessed as to their knowledge of common sites for oral cancer. As examples, only 55% of students at one dental school knew the most common sites for oral cancer,¹⁹ and only approximately half the dentists in a nation-wide survey knew the 2 most common intraoral sites of cancer.²⁰ This leads one to speculate as to what factors are important in improving comprehension and retention of pathology instruction.

In the current study, the format of didactic instruction in the pathology courses included the traditional modes of lectures, but with a greater emphasis on new technology. Lecture was the most commonly utilized instructional format in the responding dental hygiene programs with a variety of other useful adjunct educational tools incorporated into the curriculum (e.g. YouTube, student-led discussions and online weekly activities.) Several research studies have probed the effectiveness of various educational models. Digital teaching elements were reported to enhance student learning using pen-technology, YouTube, and virtual conferencing in organic and biochemistry courses, as well as using virtual microscopy to study pathological images.^21,22 Medical students' retention rates of instructional material improved with the use of interactive software and multimedia tutorials, as compared to lecture format.^23,24 Multimedia instruction in health professions education is equal or more effective than traditional instruction for attainment of knowledge, skill and performance, as evidenced by a literature review.²⁵

The curricula of all 3 advanced practitioner programs use audio-visual materials and histological and clinical images of lesions, emphasizing the importance of being able to recognize, as well as understand, the underlying mechanisms of pathological lesions. Patient case studies were another popular educational resource. Studying these case studies provides excellent opportunities for the students to apply their knowledge of general, systemic and oral pathology to hypothetical patients, as well as to practice making decisions as how best to treat their future patients, who may have complex medical and dental needs. Utilized more fully, these educational resources would strengthen the pathology instruction in the entry-level programs.

Students from some entry-level programs may not be prepared, as evidenced by 5% of the respondents that strongly disagreed with each of the perception statements. One can only speculate as to the reasons creating these negative evaluations of the pathology instruction at the respondents' institutions. There could be budgetary problems or difficulty in recruiting a qualified, conscientious pathology instructor. Perhaps the students are entering the program without an adequate scientific background to be able to comprehend pathologic concepts. Programs in educational settings that limit their length are said to struggle to incorporate new content and technology into their over-crowded curriculum.²⁶ Examining the curricula of the advanced practitioner programs may provide examples to offer ideas for strengthening the pathology curriculum at these institutions.

The advanced practitioner programs were developed to help serve the underserved population and improve access to care. Furthermore, Mertz and colleagues confirmed that RDHAP practices were successfully “improving access to care, particularly for minority, medically compromised and disabled populations.”²⁷ Both types of advanced practitioner have been able to meet the needs of this population because they are legally able to practice unsupervised in residential care facilities, public health clinics and with homebound patients. In the current study, the statement whether graduates are prepared to practice unsupervised, if it were legally allowed, elicited many undecided responses. This may indicate that the directors of entry-level programs have not formulated their opinions on this controversial issue. Perhaps they are not aware of what unsupervised practice entails, so they could not evaluate the students' preparation for it. Unsupervised can have multiple meanings, often based upon the scope of practice of individual states. Direct access may be a better term, as defined in a recent document: dental hygienists being “allowed to initiate treatment, based on their assessment of a patient's needs without the specific authorization of dentists, to treat the patient without the presence of a dentist, and to maintain a provider-patient relationship.”²⁸ In 2001, ADHA developed a policy which stated that “dental hygienists who are graduates of accredited dental hygiene programs are competent to provide services without supervision.”²⁹ This situation would increase the opportunities to care for the underserved population.

The major limitations of this study involve the lack of definition or clarification of terms used in the questionnaire. In the questionnaire no definitions of pathology were provided, and all statements related to pathology instruction were written specific to either general pathology or oral pathology, with no mention of systemic pathology. Directors who are familiar with the term, systemic pathology, may have been confused as to how to address the statements related to student preparation based on the students' instruction in general pathology, because students may have been prepared for the task, not based on general pathology content, but on systemic pathology content. Another undefined term was “adequate preparation.” Respondents may have interpreted this expression with various meanings of student proficiency. The intent was the extent of preparation for students to be deemed competent, defined by CODA as “the level of knowledge, skills, and values to begin the practice of dental hygiene.”⁶ However, it is not clear whether respondents interpreted this in the same manner. “Training in pathology” was another ambiguous expression, not defined in the questionnaire. The authors intended that it would be interpreted as advanced education; even so, advanced education could have a broad range of educational possibilities, from completion of one continuing education course to being board certified in oral pathology. The authors neglected to formulate a question addressing these options, so the interpretation of the respondents is not known. Consequently, no data were collected to base a recommendation of the most appropriate qualification of an educator who would provide the majority of pathology instruction.

Clock hours may have been a weak choice to assess the amount of pathology instruction in the curriculum. Reporting clock hours may have required respondents to do the calculations, which could contribute to either an over or under estimate of classroom time. The authors assumed that program directors would have been familiar with reporting clock hours, as completion of the biannual survey of didactic clock hours requires listing of the clock hours, which provide instruction in the required content areas, such as general and oral pathology.³⁰ The wide variation in clock hours may have been due to the lack of clear pathology terms in the survey, causing the directors to interpret the questions differently.

Another limitation of this study is the low response rate (38%). Although the quick response time and ease of electronic surveys makes electronic surveys desirable to use, they tend to have lower response rates than mailed surveys.^31,32 Internet surveys also have a higher proportion of incomplete questionnaires.³³ While in the current study, 174 (52%) questionnaires were started, only 130 (38%) were completed. A few program directors requested to forward the research questionnaire to the pathology instructor, so these surveys may have been started by the program director, but not finished by the pathology instructor. As the population of electronic mail user increases, electronic surveys may become more popular and the user more likely to respond.³⁴