Abstract
During the last century, the role of dental hygienists as leaders in the recognition, prevention, and treatment of oral diseases has grown, reflecting the ever-evolving knowledge base of the profession. The American Dental Hygienists’ Association (ADHA) has contributed to and supported research that has formulated the scientific basis for the profession to inform education and practice. Progress has been made across multiple priority areas identified on the National Dental Hygiene Research Agenda, including educational research examining the impact of curriculum models on teaching and learning; health services research projects documenting workforce issues and cost-effectiveness of practice models; and public health initiatives expanding access to care to provide oral health care services for diverse patient populations. The Journal of Dental Hygiene, established in 1927, has played a significant role in disseminating scientific evidence to the global dental hygiene and professional communities. Collaborative efforts both within dental hygiene and externally with interprofessional partners and key stakeholders have positively contributed towards building the research infrastructure to support the profession. The number of dental hygienists who are actively engaged in research has increased, as has the value for research as part of the research culture. Focused research priorities and training efforts have encouraged collaborations across the globe to conduct and promote the science supporting dental hygiene education and practice. Development, testing and validation of theoretical frameworks is essential to drive all professional activities. Building a community of scholars who will continue to define the dental hygiene discipline through scholarship is critical to promote a scholarly identity for the profession.
- Dental hygienists
- dental hygiene research
- scholarly identity
- research agenda
- interprofessional collaboration
- theoretical frameworks
INTRODUCTION
Dental hygiene is defined as the science and practice of recognition, prevention and treatment of oral diseases and conditions as an integral component of total health. This includes assessment, diagnosis, planning, implementation, evaluation, and documentation.1 The American Dental Hygienists’ Association (ADHA) advocates for equitable, comprehensive, evidence-based, interprofessional, preventive, restorative and therapeutic care for all individuals.2 As oral health care professionals, dental hygienists are educated to deliver quality care based on sound science and in accordance with the highest set of ethical practice standards.3
A discipline encompasses the generation of knowledge that is applied by the profession into practice.4,5 The ADHA has supported the conduct of research to grow the body of knowledge unique to the discipline of dental hygiene, the translation of this knowledge into educational models and curriculum and practice standards, and more recently, the development and testing of theoretical frameworks.6,7 To this end, the ADHA supports basic science and applied research in the investigation of health promotion/disease prevention and theoretical frameworks which form the basis for education and practice. All research efforts should enhance the profession’s ability to promote the health and well-being of the public.8 Promotion of the scientific basis for dental hygiene practice requires a strong research infrastructure.9
BUILDING A RESEARCH INFRASTRUCTURE
The establishment of a research infrastructure is essential to purposefully and systematically build the scientific knowledge base. This infrastructure facilitates the conduct of research and the dissemination of the findings for translation into educational curricula and to ultimately inform practice. There are five essential and interrelated elements of a research infrastructure used in the health professions:10
A critical mass of researchers/scientists
Research priorities that produce clinically relevant knowledge
Communication systems that promote linkages among researchers and increase access to research findings
Funding mechanisms to support research
Demonstrated value for research and its relationship to practice
The following sections highlight progress made in addressing each of these essential elements. A summary of historical progress made towards advancing the dental hygiene research infrastructure is found in Table 1.
100-Year History of Dental Hygiene Research*
Critical Mass of Researchers
An important component of a research infrastructure is to put programs in place to train new researchers to purposefully grow the number of dental hygienists who actively engage in research.9 These efforts cannot be accomplished by any one organization or institution alone: this work requires concerted, coordinated, and dedicated efforts by those who are invested in advancing the profession.
Historically, the primary responsibility for training new researchers has fallen to graduate dental hygiene programs. At the time of this writing, there are 17 graduate programs in the United States. Unfortunately, several programs have closed within the past decade. The emphasis placed on research training in existing graduate programs is inconsistent. While all include didactic coursework in research methodology, few require completion of original thesis research, but have opted for lesser-intensive research-related projects, such as a Capstone project, as a requirement for graduation. Among the current graduate programs, a heavy emphasis has been placed on preparing future educators to fill ongoing vacancies in academia. Thus, new faculty who are hired to teach in undergraduate and master’s degree programs are graduates of these programs, entering academic careers that require participation in scholarly activities, including conducting their own original research, for which they may be inadequately prepared. Their lack of experience presents another challenge when they are expected to mentor student research projects, which become understandably restricted in scope and based on faulty methodology, thus limiting the possibility of a meaningful contribution via publication. These problems are further confounded by the lack of mentorship and dedicated time for faculty research, all of which constrain efforts towards achieving a critical mass of researchers. This training pipeline, as it currently exists, cannot support much-needed efforts to increase the numbers of dental hygienists who are actively engaged in research.
In 2021, ADHA collaborated with the American Dental Education Association (ADEA) to develop criteria designed to guide graduate dental hygiene program aims and outcomes, broadening the scope of the curriculum and updating core competencies for graduates of these programs.11 To meet program aims, “graduate education must socialize students to a research culture so they engage in scholarly pursuits.”11 For the first time, the need for doctoral level programs in graduate dental hygiene education was addressed by both professional associations.
Over the past ten years, advocacy for doctoral education has increased, given greater awareness about the need for dental hygienists to have more advanced research skills and productive lines of research as core qualifications to become academic scholars, to participate in and lead interprofessional healthcare teams, create novel models of quality care delivery, and to affect change at the policy level.12-15 Obtaining the terminal degree in the field is among the hallmarks of a true profession, and dental hygiene must move forward with efforts to create this educational curriculum.16 In 2005, ADHA published “Dental Hygiene: Focus on Advancing the Profession”, a document that included the goal of establishing the doctoral degree by 2025.15,17 Models of doctoral program curricula have been proposed and published, including a professional pathway (Doctor of Science in Dental Hygiene) and an academic pathway (Doctor of Philosophy).13,17,18 Many other allied health professions have transitioned to the professional doctoral degree for entry-level into practice. Both dental hygiene educators and dental hygiene graduate students report perceived values for and the support of creation of the doctoral degree.19,20 In the interim, the number of dental hygienists with doctoral degrees has markedly increased; however, these degrees have been granted in fields outside of the dental hygiene discipline.
Other organizations continue to support the development of researchers to encourage engagement in research. In 1995, the International Association for Dental Research (IADR) established the Oral/Dental Hygiene Research Group in recognition of the increasing numbers of dental hygiene researchers and their unique bodies of work.6 Today, the group has been renamed as the Oral Health Research Group, and has broadened its membership to include other professionals, but still remains the professional home for many dental hygiene investigators. Between 2009 to 2017, the National Center for Dental Hygiene Research and Practice (NCDHRP) partnered with ADHA and the Canadian Dental Hygienists’ Association (CDHA) to host a series of global dental hygiene research conferences, where training programs for researchers were consistently provided. Ongoing collaborative efforts are needed to build the critical mass of dental hygienist researchers.
Research Priorities that Produce Clinically Relevant Knowledge
Research agendas are used to identify priorities and related funding initiatives and serve as working documents to guide efforts to advance the body of knowledge systematically and purposefully. Agendas should reflect national health objectives so that research findings are used to ultimately improve the health of the public. To monitor progress made while addressing and identifying priorities takes a significant amount of commitment by the professional community at large: stated objectives must be embraced by all dental hygienists, especially by practitioners who provide the greatest representation of the profession to the public.21 The tenants of practicing with an evidence-based philosophy requires that practitioners use current research to support their decision-making and adopt the use of best practices for the delivery of quality care to their patients.
Identified priorities drive research in all facets of the profession. Examples include educational research that leads to curricular changes in and a better understanding of teaching and learning strategies; health services research to study cost-effectiveness of different practice models on improving access to care and the value and quality of delivered care; and public health initiatives that aim to address health promotion and disease prevention on the population level. Research priorities should continually evolve, requiring frequent re-examination and updating of the agenda. Tracking progress made on addressing the research agenda can be challenging. However, efforts have been made to assist with this process by linking grant funding opportunities from the ADHA Institute for Oral Health (IOH) with identified priorities, and by requiring funded investigators to submit their research for publication in the Journal of Dental Hygiene (JDH). Also, authors who publish in the JDH must identify how their work supports the research agenda. Similar actions have been taken by the CDHA with the Canadian Foundation for Dental Hygiene Research and Education grant program and for authors who publish in the Canadian Journal of Dental Hygiene (CJDH).
The ADHA National Dental Hygiene Research Agenda (NDHRA) was first conceptualized in 1993 as a working model for guiding research efforts to purposefully expand the profession’s body of knowledge, encourage collaborative research and to guide education and practice.22 The agenda was validated through use of a Delphi survey method by the National Center for Dental Hygiene Research (now NCDHRP).23 This agenda was updated in 2001 by the ADHA Council on Research in response to the 2001 U.S. Surgeon General’s Report “Oral Health in America” and Healthy People 2010 objectives, and from input gained through discussions at the 2000 ADHA National Dental Hygiene Research Conference.24,25
In 2006, a second Delphi study was conducted to re-examine the 2001 categories and topics to determine whether these priorities reflected current global health care issues as well as other issues that impacted the profession.26 As a result of the study, the third iteration of the ADHA NDHRA was adopted in 2007. The latest update to the NDHRA was presented in 2016 to improve usability of the research agenda document across the profession, incorporating input from the IFDH, the CDHA and the NCDHRP.27 There is an ongoing need to update the ADHA NDHRA to reflect current priorities.
The five primary objectives proposed with the original ADHA NDHRA remain relevant and applicable today:22,27
To give visibility to research activities that enhance the profession’s ability to promote the health and wellbeing of the public.
To enhance research collaboration among members of the dental hygiene community and other professional communities.
To communicate research priorities to legislative and policy-making bodies.
To stimulate progress toward meeting national health objectives.
To translate the outcomes of basic science and applied research into theoretical frameworks to form the basis for dental hygiene education and practice.
Communication Systems that Link Researchers and Increase Dissemination of Research Findings
Networks for researchers to communicate scientific findings with key stakeholders, the public, and with other researchers are essential components of an infrastructure. Dental hygiene researchers must become more visible to the public, including special interest groups representing a variety of patient populations, to external professional organizations, to strategic professional working groups, and to federal agencies. Increased visibility grants dental hygienists a seat at the table, providing opportunities to collaborate and translate research outcomes to improve access to care, promote best practices with the provision of dental hygiene services, obtain funding to support research efforts, and to have a voice to inform policy change.
The most recognized source for dental hygiene research is the JDH, established by ADHA in 1927. It was named the Journal of the American Dental Hygienists’ Association when ADHA membership was approximately 400 dental hygienists. The ADHA’s commitment to publish a refereed journal composed of original research articles is significant to establishing the identity and uniqueness of the dental hygiene profession. Currently, the JDH is one of three primary research publications in the world specifically for dental hygiene and has been vital for the growth of the profession.
In the early 1990s, the purpose of the JDH was updated to include a clear statement that the publication is a refereed and scientific publication. Content was redirected to focus exclusively on new knowledge that contributed to the theory and practice of dental hygiene through original research, literature reviews, and theoretical articles. In the 2000s, sections were added to the journal to reflect the article focus including Critical Issues in Dental Hygiene, Innovations in Education and Technology (now Innovations in Dental Hygiene Education), Linking Research to Clinical Practice, Short Reports, and Research (original research articles) providing a platform for different types of scholarship, reflecting a changing profession. The JDH is currently published bi-monthly online and is indexed in PubMed and other allied health databases. The JDH will need to continue to adapt to future trends in scholarly publishing, but it will remain essential for dental hygiene’s professional identity and growth.
Communicating research activities traditionally occurs during annual meetings of professional societies and at research conferences during scientific sessions featuring oral and poster presentations. Several ADHA research conferences have been held over the years, the first of which was held in Denver, Colorado in 1982, followed by conferences in 1987, 1994 and 2000 (Table I). In 2009, the NCDHRP strategically partnered with ADHA and CDHA to publish the first proceedings of the North American Dental Hygiene Research Conference held in Bethesda, Maryland, disseminating research findings presented at the conferences through dual publication in JDH and the CJDH.28
As subsequent conferences expanded to global audiences in 2012, 2014 and 2017, so did the reach of the proceedings.29-31 In addition, a commemorative issue of the JDH was published in 2013 to highlight dental hygiene research to date and future directions.32
A current excellent example illustrating the importance of collaborative research and dissemination of findings occurred between ADHA and the American Dental Association (ADA) Health Policy Institute. During the COVID-19 pandemic, these organizations studied both dental hygienists and dentists, gathering practice trend data and mental health challenges during the pandemic. Over a span of one year, seven papers were published that highlighted findings from their collaborative investigations.33-39
Technology now affords opportunities for greater dissemination and discourse through webinars, podcasts, and on-demand learning. Using live, online platforms, ADHA and ADA collaborators informed clinicians about how to navigate the pandemic in real time, disseminating current research findings directly into the hands of the users where information was needed most. Platforms continue to evolve to assist clinicians with obtaining evidence-based information to support practice decisions and to locate resources related to research. The ADHA has introduced CE Smart, an online learning platform that offers comprehensive continuing education courses and tracks CE credits. The platform also includes evidence-based webinars, which are later converted into on-demand courses available in the CE Smart catalog.40 The DHNet, created and hosted by the NCDHRP, links clinicians with resources that support dental hygiene research, evidence-based practice, education and community outreach.41
Funding Mechanisms to Support Research
Collaborative efforts are needed to create opportunities for dental hygienists to obtain the funds necessary to conduct research. In addition, mechanisms to secure and dispense funds are necessary to ensure equitable disbursement and accountability for spending.9 To date, professional dental hygiene organizations have been instrumental in establishing funding paths for students and early career investigators.
The primary objective of the ADHA IOH fountation is to advance the dental hygiene profession and enhance the availability of oral care through student scholarships, research grants, and community service grants. The IOH is dedicated to improving overall public health by promoting awareness of and ensuring access to high-quality oral health care for all individuals. In pursuit of its mission, IOH aims to:
Empower dental hygienists to enhance public health by offering community service grants
Support advancements in the dental hygiene profession through research grants
Enhance access to educational programs for dental hygienists through scholarships
The IOH Research Grant Program facilitates various forms of research, including original studies, developmental projects, and qualitative and quantitative investigations. Funding is prioritized for projects supporting the NDHRA. Proposals for IOH funding should develop or expand upon the dental hygiene body of knowledge; promote the public’s oral health by improving dental hygiene education and practice; and/or support the delivery of quality oral health care.42
The Canadian Foundation for Dental Hygiene Research and Education also offers a grant program for members of the CDHA who must also be registered dental hygienists within Canada. This grant funds a one-year research project that will advance the dental hygiene body of knowledge and, ultimately, enhance the oral health and well-being of Canadians. Proposals must align with the CDHA’s Dental Hygiene Research Agenda.43
The NCDHRP offers a research grant program to dental hygiene graduate students to support thesis or capstone project research. The purpose of this grant program is to support research that addresses the oral health of the public with a focus on prevention and the translation of research evidence so that it is meaningful and useful for the public and dental hygiene education and practice.44
These organizations and small “internal” grant programs available at many academic institutions allow dental hygienists to obtain seed monies to collect pilot data, establish an area of expertise, and build a funding track record, all of which are necessary to successfully apply for and obtain federal monies for larger projects.9 Grant programs available through private foundations and industry are also potential sources for funding.
Demonstrated Value for Research and Its Relationship to Practice
Each of the infrastructure components previously described emphasize the fundamental value that the profession must place on research.9 Strategies to increase visibility of research help to underscore its importance and value in relation to professional activities. Recently, ADHA has begun to highlight research in emailed announcements to its membership, grouping articles by “themes” to increase the visibility of the research published in the JDH. Multiple organizations, including ADHA, ADEA, CDHA, IADR and NCDHRP are committed to increasing research visibility to promote the culture of research among dental hygienists.
Clinicians are becoming more aware of and have a willingness to adopt an evidence-based philosophy of practice; however, open access to published research is a barrier to widespread adoption. Refereed journals in dental hygiene must address the open access issue to help overcome obstacles with finding current research to support best practices. In the interim, dental hygiene investigators are encouraged to translate their research findings through presentations at professional meetings, webinars, podcasts, and by publishing articles in peer-reviewed clinical news magazines, all of which have widespread reach to practicing clinicians.
The ADHA has promoted student research recognition and visibility through several programs with the assistance of corporate funding. The graduate dental hygiene student research competition is held during the ADHA Annual Conference and presentations are open to the membership. The ADHA/Sigma Phi Alpha student journalism award was created to recognize excellence in student research manuscripts in three categories, undergraduate, graduate, and doctoral. Competition winners are invited to submit their manuscripts for consideration for publication in the JDH.
THEORETICAL FRAMEWORKS
Theory development is essential to a discipline as it provides a framework for understanding, guides practice, predicts outcomes, supports continuous improvement and fosters professional identity and unity. It enables professionals to navigate complex challenges, make informed decisions, and contribute to the advancement of their field. Prior to the early 1990s, dental hygiene did not significantly explore theoretical models. However, Darby and Walsh introduced a paradigm for the discipline of dental hygiene science during that time.45 This paradigm included key concepts such as the client, environment, health/oral health, and dental hygiene actions. The ADHA embraced this paradigm, leading to a more refined definition of dental hygiene as a discipline. This shift recognized that dental hygiene involved the study of phenomena and allowed for the advancement of knowledge through research and theory development, moving beyond a mere list of duties.46,47 The theoretical frameworks for dental hygiene are found in Table II.48-60
Dental Hygiene Theoretical Frameworks
The ADHA supports the need for further development of the theoretical basis for the growth of the profession and ultimately, to become a unique discipline.6,46 As conceptual models continue to evolve, practitioners can select an approach to client care that is both scientifically grounded and aligned with their personal philosophies. The practice of dental hygiene must be based on sound science.6,61-63 Despite the unique and distinctive aspects of the process of dental hygiene care described by these models, to date, there are few studies that have used these conceptual frameworks as the basis for the research, and far fewer that have attempted to test and validate these theories. Moving forward, theory testing and validation should be prioritized.
CREATING A SCHOLARLY IDENTITY
Advancements in the development of the dental hygiene discipline are crucial to enhance its impact on interdisciplinary research and improve oral health in the general population. Walsh and Ortega recognized that embracing a scholarly and interdisciplinary approach to dental hygiene research empowers the dental hygiene profession to play a significant role in national and international efforts to prevent oral diseases and promote overall health.12
Having a community of scholars and a scholarly identity are vital to this progress as they provide the structure for collective growth, knowledge sharing, and advancement. A community of scholars fosters collaboration and networking among professionals, enabling the exchange of ideas, research collaboration, and innovation within the dental hygiene profession. A scholarly identity is critical to the profession as it drives the advancement of the discipline, promotes evidence-based practice, enhances professional credibility, promotes continuous learning and growth, and facilitates collaboration among professionals.12
A scholarly identity encompasses several key characteristics. It involves having a comprehensive understanding of the dental hygiene discipline, recognizing its interconnectedness and interdependence with other related disciplines. It also entails a lifelong commitment to the advancement of dental hygiene knowledge by actively engaging in research and asking meaningful research questions that address the core issues of the discipline. Dental hygiene research scientists use evidence to support their viewpoints, drawing upon existing research and the work of other scholars in both dental hygiene and other disciplines. They recognize the importance of situating their own findings within this broader context, highlighting the relevance and implications of their work. Finally, a scholarly identity involves the dissemination of research findings through scientific publications, ensuring that new knowledge reaches and contributes to the larger scientific community and knowledge base.12
Developing a scholarly identity involves three key strategies: coursework, socialization into the culture of scholarship, and high-quality mentored scholarship. For coursework, it is important to not only focus on research methods but also gain a critical knowledge of dental hygiene’s research priorities and interdisciplinary approaches. Socialization into the culture of dental hygiene scholarship involves integrating course work with the standards and values of the discipline, emphasizing the importance of asking questions central to dental hygiene’s perspective. Professional socialization and peer interaction play significant roles in fostering a scholarly identity. Lastly, high-quality mentored scholarship is crucial, where graduate learners develop original research projects, write theses or capstone projects, and defend their work orally and in writing. Mentors guide and support learners, match them with other appropriate mentors, and help them participate in scholarly activities, such as scientific writing and oral presentations.
Developing a scholarly identity has traditionally been the responsibility of graduate education programs. Currently, with no doctoral programs in dental hygiene, masters level programs have been contributing to this effort. This requires coursework in research methodology and statistics used for data analysis. Graduate learners should be encouraged to think critically and develop the values, behaviors, and attitudes necessary to assume a career in research scholarship. When possible, students should pursue original research for a thesis project, defend the project, present their research at national or international meetings, and submit a paper for publication in peer reviewed journals. These activities must be done under the careful supervision of a dedicated mentor(s).
Developing a scholarly identity in any discipline can pose challenges. One is the lack of recognition and support for scholarly pursuits within the dental hygiene profession, which may discourage dental hygienists from actively engaging in research and scholarly activities. Another challenge is the limited availability of resources and mentorship opportunities for aspiring scholars, hindering their growth and development. Additionally, in academia, the pressure to balance clinical practice skills and numerous academic responsibilities can pose significant challenges in establishing a strong scholarly identity. Overcoming these challenges requires a supportive environment, access to resources, and a commitment to prioritizing scholarly endeavors.64
Furthermore, a scholarly identity must be nurtured. Even if students are well prepared and graduate having conducted original research, it does not mean they will continue in these research pursuits.65 For example, the state of academia places an increased emphasis on efficiently producing entry level graduates, often leaving insufficient time for faculty to pursue scholarly activities. Furthermore, faculty may face challenges with obtaining adequate resources and mentoring to support their work. Professional associations have been, and can continue to be, a resource for mentorship, helping aspiring scholars on their journey of developing their scholarly identity and becoming part of a community of scholars.
There is a critical need for doctoral programs in dental hygiene, especially in light of current challenges in the oral health care delivery system. Dental hygiene leaders and scholars are needed to work with interdisciplinary teams to conduct high-level research and represent the discipline’s perspective in oral health care. While graduate programs at the master’s level have made an impact, these programs are relatively compact, often lacking the time needed for the graduate student to become well-versed in different theories and methodologies while developing an in-depth expertise in an area of research interest.
RECOMMENDATIONS FOR THE FUTURE
While considerable progress has been made to expand the knowledge base of dental hygiene, there is a need to create a framework for ongoing and future research efforts to advance the discipline. Collaborative efforts with professional organizations such as the ADHA, academic partners, and key stakeholders from public health, private industry and other healthcare professionals are critical for success. Recommendations for consideration by the dental hygiene community for inclusion in future updates to the ADHA NDHRA are presented in Table III.
Proposed Recommendations for Priorities for Updates to the ADHA National Dental Hygiene Research Agenda
CONCLUSION
Throughout the last century, considerable progress has been made with expanding the dental hygiene knowledge base and dissemination of research findings. Notable efforts have helped to build the critical research infrastructure needed to support the growth of the profession. Continuing efforts are needed towards building a critical mass of investigators who are actively engaged in research. Research priorities must be identified and funded so these investigators can produce clinically relevant knowledge to address national health objectives and support the delivery of quality care to improve the oral health of the public. Theory development is essential to expand the scientific basis for the dental hygiene discipline and to promote the development of a scholarly identity for the profession. Moving forward, increased collaboration with professional organizations, academic institutions and strategic alliances will be vital to the expansion of a unique body of knowledge and the evidence base to inform education and practice.
Footnotes
NDHRA priority area: Professional development: Education (interprofessional education)
DISCLOSURES
Ann Eshenaur Spolarich was a previous Chair of the Data and Safety Monitoring Board for the National Institute of Dental and Craniofacial Research and previously served as Associate Director of the National Center for Dental Hygiene Research and Practice. No outside funding was received for this paper.
- Received August 7, 2023.
- Accepted August 21, 2023.
- Copyright © 2023 The American Dental Hygienists’ Association
